Transitions in Care: Improving the Hand-off

1. Transitions in Care: Improving the Hand-off Penni Foster, PhD

2. A hand-off is the transmission of essential patient care information that occurs during a transition in responsibility from one provider to another. Hand-off

3. Inadequate hand-offs, including the omission of key information about a patient’s clinical condition and plan, have been associated with delays in diagnosis and treatment, inefficient and redundant work, and adverse patient outcomes. Horwitz et al. Consequences of inadequate sign-out for patient care. Archives of Internal Medicine. 2008. 168 (16): 1755-1760. Inadequate hand-offs and negative outcomes

4. Hand-offs occur when responsibility in care is transferred one professional provider to another, such as physician attendings, residents, and nurses. Who performs a hand-off?

5. A hand-off occurs each time in any of the following situations: • Move to a new unit • Transport to or from a different area of the hospital for care • Temporary assignment to a different physician or other provider (e.g., overnight/weekend coverage, rest breaks, meal breaks, changes in call) • Fixed changes in physician assignment (e.g., rotation change) • Discharge to another institution or facility Hand-offs must occur for every patient, including inpatients, emergency room patients, clinic patients, and observation patients. When should hand-offs occur?

6. Hand-offs should include specific and essential information: Patient name/DOB/ location Diagnoses/problems/impression Medical history and advanced directives Medications/fluids/diet Allergies Current labs and vitals Pending tests requiring follow up Specific treatments/protocols in place Past and planned procedures Plan for the next 24+ hours What information is included in the hand-off?

7. Residents surveyed reported being ill-prepared by the hand-off for events that occurred during call. Research shows that hand-offs are often unstructured, incomplete, error-prone, and adversely effected by noise, crowding, and interruptions. Manser T. Effective handover communication: An overview of research and improvement efforts. Best Practice & Research Clinical Anaesthesiology. 2011. 25 (2): 181–191. Threats to a quality hand-off

8. To improve patient safety, hand-offs (whether verbal or written) MUST include the following: • Interactive communication allowing for questions between giver and receiver • Limited interruptions • Up-to-date information • Verification process of repeat-back or read-back What can I do?