Patients receiving acute care typically go through different levels of care encountering numerous health care providers in the process. For example, a stroke patient who undergoes cranial surgery will be admitted into the PACU. Once stable, he is admitted into the medical-surgical unit and then discharged into long-term rehabilitation. Prior to being sent home, he is advised to see his primary care physician for follow-ups. Throughout the many transitions in each health care experience, handoffs occur between health care professionals working in each unit during changes in shift. Handoffs also take place between providers of one unit or level of care and another. A handoff is defined as “the process of transferring primary authority and responsibility for providing clinical care to a patient from one departing caregiver to one oncoming caregiver” (Ross, 2012, p. 361).
Handoffs essentially pertain to communication and errors and omissions therein may have disastrous outcomes for the patient. While it can be said that the patient’s chart contains pertinent information about his or her condition and needs, studies estimate that between 20-30% of information shared during handoffs are not documented in the chart (Patterson & Wears, 2010). With patients’ length of stay averaging 4.8 days, estimates show that handoffs occur at least 24 times and represent the same number of opportunities for ineffective communication (Riesenberg, Leitzsh & Little, 2009). In another study, it was found that seven out of eight handoffs were ineffective (Riesenberg, Leitzsh & Cunningham, 2010).
For this reason, handoffs have an impact on the continuity of care, patient safety, and care quality. The process can prevent redundancy and facilitate timely and appropriate interventions for current and emerging needs. However, handoffs often suffer from a lack of standardization. They are structured in different ways with varying levels of quality. For example, nurses typically conduct narrative and descriptive handoffs while physicians do so using bullets and a summary (Ross, 2012). Some provide complete and organized data and some give confusing information.
At the same time, there are factors that interfere with the recipient’s ability to comprehend and retain what is being communicated. Distractions in the environment, information overload, on-the-job pressure, stress, multitasking, language barriers, and cultural barriers also impede communication (Berkenstadt et al., 2008; Johnson et al., 2013). Relying on memory alone for both sender and receiver is also prone to errors and omissions. In addition, the attitudes of health care providers regarding handoffs also matter where a positive regard for it promotes the continuity of care (Wu et al., 2013). From a systems perspective, organizational culture shapes the way handoffs take place. A hierarchical relationship between nurses and physicians often hampers interdisciplinary collaboration that is made possible by effective communication. The lack of a safety culture further stifles initiatives for improvement.
The Joint Commission estimates that the root cause of around 80% of sentinel events is miscommunication during handoffs (Zhani, 2012). These errors include wrong-site surgery, medication errors, hospital-acquired infections, injurious falls, and failure to avert cardiac or respiratory arrest. Sentinel events result in the permanent disability of a patient or death (Wu et al., 2013). Specifically for transitions from hospital to home, a common issue is the lack of communication of patient information, especially pending diagnostic results, to the primary care provider. This is seen as a contributory factor to patient readmissions and is often a result of poor discharge planning. Since the development of guidelines and tools by the Commission, health care organizations have reported a reduction in readmissions by up to 50%, and a reduction in transfer time from the emergency department to inpatient wards by 33% (Zhani, 2012; Ross, 2012).
In this author’s health care organization, shift change handoffs between nurses were standardized in 2009 wherein nurses used the Situation, Background, Assessment, and Recommendation or SBAR format to organize the content of information during shift change handoffs at the nursing station. The practice was modified in late 2013. In terms of process, handoffs moved from the nursing station to the patient bedside and nurses were encouraged to make the process more interactive and meaningful through data validation and patient involvement. The practice update also required writing SBAR data on a form and referring to it during handoffs to organize the information, reduce errors or omissions, and prevent reliance on memory. Since 2009, the readmission rate has remained below the benchmark with no significant improvements on the average. However, small improvements were noted based on monthly trends since the guideline update last year. Following the practice update, nurses also complain about inadequate in-service education on the topic. Further, a review of the handoff policy reveals that it does not yet reflect the changes in practice. There was also no mention of the evidence base for the modifications.
Literature Review
Standardized Handoff Guidelines
Recognizing the importance of this process, the Joint Commission made the standardization of handoff communication a national patient safety goal in 2006 (Welsh, Flanagan & Ebright, 2010). The published guidelines, aimed at helping health care providers in the implementation, included interactive communications during handoffs wherein opportunities to ask questions or answer them are present (The Joint Commission, 2006). The guidelines also required that information be accurate and up-to-date. There should be minimal interruptions and verification processes must be in place. Moreover, handoffs should also represent opportunities for the review of pertinent data in the patient’s history.
In 2007, the World Health Organization (WHO) issued guidelines on handoff communication for consideration by its member states. Similarly, it called for standardization in all types of handoffs suggesting the SBAR technique as one approach. Besides having sufficient time to answer questions, limiting information to key patient data, and reducing interruptions, repeat back was also encouraged (WHO, 2007). Moreover, the guideline specifically emphasized the conduct of handoffs between different levels of care following discharge and between traditional and non-traditional health care providers. The WHO further recognized the need to consider in-service training and education.
The Agency for Healthcare Research and Quality also published a guideline specific for implementing a change to bedside handoffs among nurses (AHRQ, 2011). The guideline gives background information on handoffs and recommends three steps needed in change implementation. These include forming a team to lead the change, deciding on the best implementation method, and implementing and evaluating the change. A practical application of the guideline is provided in the form of a case study.
In 2012, the Joint Commission made available the Hand-off Communications Targeted Solutions Tool that assists organizations in evaluating the quality of handoffs from the perspective of senders and receivers (Zhani, 2012). The tool includes a valid and reliable instrument for measuring performance that is useful in quality improvement. It further assists in customizing measurements to ensure relevance for each type of transition or handoff. Modifiable templates of data collection forms also come with the tool. Last, the 2006 guidelines were enhanced with emphasis on the empowerment of the health care staff in developing solutions for ineffective handoffs. The tool was piloted in 11 hospitals and the product of a research project led by the Commission in collaboration with 10 other hospitals (Zhani, 2012).
The guideline, with the acronym SHARE, consisted of five essential solutions which reflect in part the WHO guidelines (The Joint Commission, 2012). Standardizing critical content means highlighting key information from the health history as well as providing a synthesis of patient data from different sources. Hardwiring entails the communication of expectations in conducting handoffs and must be supported by standardized tools, forms, strategies, and technology (The Joint Commission, 2012). Allowing opportunities to ask questions pertain to critical thinking on the part of the receiver in recognizing ambiguous, contradictory, or inadequate information. Data is validated by querying the sender and in the event of additional questions the sender should provide his or her contact information. Reinforcing quality and measurement pertains to committed leadership in establishing standardized handoffs by monitoring for compliance and promoting staff accountability over performance (The Joint Commission, 2012). Educating and coaching ensures a knowledgeable and skilled staff in the area of handoffs and the communication of performance feedback. The guideline was intended to be a model of the optimal handoff process that organizations can tailor based on their own needs and context.
Systematic Review of Standardized Handoffs
In a systematic review that included a search of five databases, Riesenberg, Leitzsh & Cunningham (2010) evaluated the evidence from 95 articles of which 75 pertained to barriers and 20 pertained to strategies that ensured the effectiveness of nursing handoffs. Seventy-six percent of these employed the SBAR method and were conducted within the context of quality improvement. Each study was subjected to quality assessment with scores that ranged from 10 to 16 signifying acceptable to high quality. Seventeen of the 20 articles, or 85%, scored 8 or below, the remaining three scored above 10 (Riesenberg, Leitzsh & Cunningham, 2010). Half of the studies found that the strategies employed were effective.
One hospital implemented shift change handoff at bedside and it helped family members understand the patient’s condition and needs better. The guideline used is available in the National Guideline Clearinghouse website with the title “Best evidence statement: Increasing patient satisfaction by moving nursing shift report to the bedside” (NGC, 2013). Another hospital shifted from oral and tape-recorded shift reports to walking rounds that elicited patient participation. The practice was rated as “very positive” by patients. Many of the studies on walking rounds also noted a reduction in staff nurse overtime. Once study investigated the accuracy of face-to-face and taped shift reports by comparing the information provided with the actual status of the client. It was found that there was a greater likelihood for omitted information in taped reports while there was higher probability of incongruent information in face-to-face reports (Riesenberg, Leitzsh & Cunningham, 2010). As such, improvements were needed for both methods. However, the advantage of face-to-face handoff is the opportunity to validate information.
One hospital implemented the recording of pertinent patient information in a binder found outside each patient’s room. Compliance with medical history recording improved by 55% and flow-sheet documentation compliance went up by 45% leading to 100% achievement in both measures (Riesenberg, Leitzsh & Cunningham, 2010). The recording of the date of intravenous catheter insertion further increased to 95% from 75%. In yet another facility, telephone handoff from the ED to the inpatient unit was replaced by written reports. Ninety-five percent accuracy and process completion was achieved in the first year following implementation which increased to 97% by the second year. The speedier handoff further led to a 20% increase in patient satisfaction (Riesenberg, Leitzsh & Cunningham, 2010). Another organization used a written report form in lieu of oral handover which led to improvements in the documentation of key information, saved time, and improved patient and staff satisfaction. In the last study, nurses were allowed access to physicians’ electronic sign-outs. The outcomes were enhanced interdisciplinary communication, better understanding of the patient’s condition, and improved capacity of nurses to anticipate changes in patients’ clinical status (Riesenberg, Leitzsh & Cunningham, 2010).
However, the reviewers noted the low quality of research on the effectiveness of strategies for structuring handoffs. Majority of the articles provided anecdotal evidence. Of the empirical studies, very small sample sizes of nurses for self-report surveys of compliance, perceived effectiveness, and rates of recall of information were used (Riesenberg, Leitzsh & Cunningham, 2010). Very small samples of handoff events were also used for observations. Those that concluded efficacy used evaluation tools that were not validated. There were conflicting results in several studies that investigated one mnemonic although there were differences in study settings. Overall, there is weak support in literature for the use of structured handoff mnemonics.
The researchers call for higher quality studies with larger samples in order to determine best practices. At the same time, they point out the difficulty of studying handoffs considering that they occur in different contexts. They suggest that there might not be one best practice that works for all situations and that a general set of strategies need to be adapted to particular settings not only for standardization but also to address specific barriers. Subsequently, the researchers summarized all the strategies found effective in the studies reviewed. These include improving the communication skills of nurses, standardizing handoffs whether these are done face-to-face or during walking rounds, and monitoring and evaluating the process. The strategies also include the use of technology, such as videotaping, and environmental modification. Education and training, staff participation, and leadership were strategies identified in literature as well. The variety of strategies reflects the complexity of the problem and justifies the use of multifactorial interventions.
The SBAR Approach to Standardized Handoffs
While the focus of the systematic review was on the process of standardizing handoffs, mnemonics such as the SBAR pertain to the actual content of communication. SBAR was first used by the U.S. Navy to minimize miscommunications and later adapted in the health care setting (Ross, 2012). It is the most commonly employed mnemonic in the literature. Situation pertains to what is currently going on with the patient, and background refers to the underlying circumstances of the patient’s medical condition. Both are objective information. Assessment is about what the outgoing nurse deems is the patient’s problem, and recommendation is what he or she considers as appropriate interventions. Both are subjective information. The format ensures that data is organized and include only the most important information. It has been shown to be acceptable and viewed as effective by the nursing staff. It is also associated with outcomes such as patient and staff satisfaction, reduced overtime, and shorter transition time (Riesenberg, Leitzsh & Cunningham, 2010).
Summary of Remaining Gaps in Knowledge
Most studies have dealt with the barriers to standardizing the handoff process. The body of evidence on strategies for achieving this goal is insufficient to allow the identification of best practices. Despite the state of the evidence, current guidelines represent the gist of what has been found to be effective in past studies and in recent pilots. High-quality studies are much needed most especially on the impact of standardized handoff on clinical outcomes such as readmission rates and sentinel events. Comparisons of different strategies to determine which is more effective, cost-efficient, and acceptable to the staff and patient, not just SBAR, are useful. Studies can also investigate tools for evaluating the current state of handoffs, the knowledge, skills, and attitudes of the staff, and the process of change planning, implementation, and evaluation.
Standardized Handoff Policy
Based on the literature review, the handoff policy in this author’s organization is supported by the literature as well as national and international guidelines. The elements of the policy include the process of conducting face-to-face shift-change handoffs at bedside with patient involvement, and the use of the SBAR to structure content with the support of data written on a form. However, the implementation of the policy update was somewhat ineffective because nurses presently complain of inadequate education. This scenario has a bearing on compliance and may be one reason why the impact of the policy update has been small. Another issue with the policy is that it does not reflect the change to bedside handoff and the use of a written form. The proposed policy is a revision of the existing one and contains the aforementioned updates as well as a provision on the need to provide sufficient in-service education to nurses. The revisions are in red font color. References are added as well to identify the evidence base for each provision. In recognition of the Joint Commission provision that direct care staff be empowered in structuring the handoff process and the emphasis on adapting policy within the context of a clinical setting (The Joint Commission, 2012), the policy will be limited to the medical-surgical unit.
Policy Revisions
Purpose
1. Implement standardized handoffs at change of shift (The Joint Commission, 2012; WHO, 2007; AHRQ, 2011).
2. Implement the conduct of handoffs at bedside with the involvement of the patient (AHRQ, 2011; National Guideline Clearinghouse, 2013; Riesenberg, Leitzsh & Cunningham, 2010).
Definitions
Standardized handoff. Face-to-face communication employing a prescribed content and process between nurses at shift change for the purpose of transferring key information for appropriate and safe patient care.
Change of shift. Transition from one nursing shift to another.
Bedside. The area surrounding the patient’s hospital bed.
Patient participation. Patient validation of the information being communicated; patient asks or answers questions for clarification.
Procedure (Medical-surgical Unit)
1. Prior to shift change, the outgoing nurse will complete the handoff form based on the SBAR format (WHO, 2007; Riesenberg, Leitzsh & Cunningham, 2010; Wu et al., 2013). He or she will rehearse how to communicate the information on the form to the incoming nurse.
2. The outgoing and incoming nurse will proceed to patient bedside (AHRQ, 2011; National Guideline Clearinghouse, 2013). Outgoing nurse informs the patient that a handoff will take place, briefly explains the process, and encourages the patient to ask or answer questions (Riesenberg, Leitzsh & Cunningham, 2010). Incoming nurse will introduce himself/herself. Outgoing nurse will hand off the patient verbally and will refer to the information on the handoff form (WHO, 2007; Riesenberg, Leitzsh & Cunningham, 2010; The Joint Commission, 2012).
3. The incoming nurse will validate the information with the outgoing nurse and the patient (Welsh, Flanagan & Ebright, 2010; Patterson & Wears, 2010). The incoming nurse repeats back the information (WHO, 2007; Riesenberg, Leitzsh & Cunningham, 2010; The Joint Commission, 2012).
Miscellaneous
1. Outgoing and incoming nurses will conduct the handoff with minimal interruptions from competing tasks or the environment (WHO, 2007; Riesenberg, Leitzsh & Cunningham, 2010).
2. All staff nurses must complete the in-service education and training on handoff communication, content, and process (The Joint Commission, 2012; WHO, 2007; Berkenstadt et al., 2008).
References:
Association of Healthcare Research and Quality (2011). Nurse bedside shift report implementation handbook. Retrieved from http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy3/Strat3 _Implement_Hndbook_508.pdf
Berkenstadt, H., Haviv, Y., Tuval, A., Shemesh, Y., Megrill, A., Perry, A., Ziv, A. (2008). Improving handoff communications in critical care: Utilizing simulation-based training toward process improvement in managing patient risk. Chest, 134(1), 158- 162. doi: 10.1378/chest.08-0914.
National Guideline Clearinghouse (2013). Best evidence statement (BESt): Increasing patient satisfaction by moving nursing shift report to the bedside. Retrieved from http://www.guideline.gov/content.aspx?id=47378&search=handoff+or+handover
Patterson, E.S., & Wears, R.L. (2010). Patient handoffs: Standardized and reliable measurement tools remain elusive. Joint Commission Journal on Quality and Patient Safety, 36(2), 52-61. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20180437
Riesenberg, L.A., Leitzsch, J., & Cunningham, J.M. (2010). Nursing handoffs: A systematic review of the literature, surprisingly little is known about what constitutes best practice. American Journal of Nursing, 110(4), 24-34. doi: 10.1097/01.NAJ.0000370154.79857.09.
Welsh, C.A., Flanagan, M.E., & Ebright, P. (2010). Barriers and facilitators to nursing handoffs: Recommendations for redesign. Nursing Outlook, 58(1), 148-154. doi:10.1016/j.outlook.2009.10.005.
World Health Organization (2007). Communication during patient hand-overs. Patient Safety Solutions, 1(3), 1-4. Retrieved from http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf
Wu, M., Lee, T., Tsai, T., Lin, K., Huang, C., & Mills, M.E. (2013). Evaluation of a mobile shift report system on nursing documentation quality. Computers, Informatics, Nursing, 31(2), 85-93. doi: 10.1097/NXN.0b013e318266cac3.
Conclusion
Handoffs are an important component of care. The process facilitates the transition of patients from one health care provider or level of care to another. Owing to the lack of structure and the presence of barriers to effective communication, handoffs represent opportunities for errors in information that contribute to a significant number of sentinel events. Evidence-based practice dictates that interventions be strongly supported by quality research findings. Current literature provides strong evidence on the barriers to effectiveness, but there is weak support for the effectiveness of strategies employed to standardize handoffs. In particular, the impact of standardized handoff on sentinel events has not been established.
Despite inadequate evidence, national and international guidelines have synthesized the positive findings of past studies providing frameworks that can be adapted. Based on what is known, handoff is a complex phenomenon influenced by various factors, often unique to a particular setting, and requires a tailored, multifactorial response. While it is clear that the provisions in the handoff policy of this author’s organization complies with national and international guidelines, albeit the lack of citations and references, staff education was overlooked. At the same time, recent practice updates have not been documented in the policy. The proposed policy revised the old version to include citations and references, practice updates, and staff education applicable to the medical-surgical setting.
Appendix 1
Structured Hand-off Policy
Purpose: Implement standardized handoffs at change of shift
Definitions:
Standardized handoff. Face-to-face communication employing a prescribed process between nurses at shift change for the purpose of transferring key information for appropriate and safe patient care.
Change of shift. Transition from one nursing shift to another.
Procedure (All Units)
1. During shift change, the outgoing and incoming nurse will share pertinent patient information face-to-face in the following format:
S – situation
B – background
A – assessment
R – recommendation
2. Outgoing and incoming nurses must conduct the handoff in the designated area in the nurses’ station.
3. Outgoing and incoming nurses will conduct the handoff with minimal interruptions from competing tasks or the environment
Appendix 2
SBAR Hand-off Form
References
Association of Healthcare Research and Quality (2011). Nurse bedside shift report implementation handbook. Retrieved from http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy3/Strat3 _Implement_Hndbook_508.pdf
Berkenstadt, H., Haviv, Y., Tuval, A., Shemesh, Y., Megrill, A., Perry, A., Ziv, A. (2008). Improving handoff communications in critical care: Utilizing simulation-based training toward process improvement in managing patient risk. Chest, 134(1), 158- 162. doi: 10.1378/chest.08-0914.
Johnson, F., Logsdon, P., Fournier, K., & Fisher, S. (2013). SWITCH for safety: Perioperative hand-off tools. AORN Journal, 98(5), 494-504. Retrieved from http://dx.doi.org/10.1016/j.aorn.2013.08.016
National Guideline Clearinghouse (2013). Best evidence statement (BESt): Increasing patient satisfaction by moving nursing shift report to the bedside. Retrieved from http://www.guideline.gov/content.aspx?id=47378&search=handoff+or+handover
Patterson, E.S., & Wears, R.L. (2010). Patient handoffs: Standardized and reliable measurement tools remain elusive. Joint Commission Journal on Quality and Patient Safety, 36(2), 52-61. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20180437
Riesenberg, L.A., Leitzsch, J., & Cunningham, J.M. (2010). Nursing handoffs: A systematic review of the literature, surprisingly little is known about what constitutes best practice. American Journal of Nursing, 110(4), 24-34. doi: 10.1097/01.NAJ.0000370154.79857.09.
Ross, J. (2012). Developing a better understanding of handoffs. Journal of PeriAnesthesia Nursing, 27(5), 360-362. Retrieved from http://dx.doi.org/10.1016/j.jopan.2012.07.010
Welsh, C.A., Flanagan, M.E., & Ebright, P. (2010). Barriers and facilitators to nursing handoffs: Recommendations for redesign. Nursing Outlook, 58(1), 148-154. doi:10.1016/j.outlook.2009.10.005.
World Health Organization (2007). Communication during patient hand-overs. Patient Safety Solutions, 1(3), 1-4. Retrieved from http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf
Wu, M., Lee, T., Tsai, T., Lin, K., Huang, C., & Mills, M.E. (2013). Evaluation of a mobile shift report system on nursing documentation quality. Computers, Informatics, Nursing, 31(2), 85-93. doi: 10.1097/NXN.0b013e318266cac3.
Zhani, E.E. (2012). Joint Commission Center for Transforming Healthcare releases tool to tackle miscommunication among caregivers. Retrieved from http://www.jointcommission.org/center_transforming_healthcare_tst_hoc/
