2017 HSC Section 2 - Practice Management

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Evaluating handoffs in the
context of a communication
framework
Hani Hasan, MD,a Fadwa Ali, MD,a Paul Barker, MD, a Robert Treat, PhD,b Jacob Peschman, MD,a
Matthew Mohorek, MD,a Philip Redlich, MD, PhD,a,c and Travis Webb, MD, MHPE,a Milwaukee, WI
Background. The implementation of mandated restrictions in resident duty hours has led to increased
handoffs for patient care and thus more opportunities for errors during transitions of care. Much of the
current handoff literature is empiric, with experts recommending the study of handoffs within an
established framework.
Methods. A prospective, single-institution study was conducted evaluating the process of handoffs for the
care of surgical patients in the context of a published communication framework. Evaluation tools for the
source, receiver, and observer were developed to identify factors impacting the handoff process, and inter-
rater correlations were assessed. Data analysis was generated with Pearson/Spearman correlations and
multivariate linear regressions. Rater consistency was assessed with intraclass correlations.
Results. A total of 126 handoffs were observed. Evaluations were completed by 1 observer (N = 126), 2
observers (N = 23), 2 receivers (N = 39), 1 receiver (N = 82), and 1 source (N = 78). An average
(±standard deviation) service handoff included 9.2 (±4.6) patients, lasted 9.1 (±5.4) minutes, and had
4.7 (±3.4) distractions recorded by the observer. The source and receiver(s) recognized distractions in
>67% of handoffs, with the most common internal and external distractions being fatigue (60% of
handoffs) and extraneous staff entering/exiting the room (31%), respectively. Teams with more patients
spent less time per individual patient handoff (r = 0.298; P = .001). Statistically significant intra-
class correlations ( P # .05) were moderate between observers (r $ 0.4) but not receivers (r < 0.4).
Intraclass correlation values between different types of raters were inconsistent (P > .05). The quality of
the handoff process was affected negatively by presence of active electronic devices (b = 0.565;
P = .005), number of teaching discussions (b = 0.417; P = .048), and a sense of hierarchy between
source and receiver (b = 0.309; P = .002).
Conclusion. Studying the handoff process within an established framework highlights factors that impair
communication. Internal and external distractions are common during handoffs and along with the
working relationship between the source and receiver impact the quality of the handoff process. This
information allows further study and targeted interventions of the handoff process to improve overall
effectiveness and patient safety of the handoff. (Surgery 2016;j:j-j.)
From the Division of Education/Department of Surgerya and Academic Affairs,b Medical College of Wisconsin; and
the Department of Surgery,c Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
HANDOFFS refer to a transfer of patient care be-
tween health care providers. This process includes
transfer of information and responsibility concern-
ing patient care. There is no doubt that a
successful and comprehensive handoff process is
important for quality and continuity of patient
care, but the quality of handoffs is affected by
many factors, including lack of standardized hand-
off tools, interruptions or distractions, variation in
experience of providers, information inaccuracies,
and communication or social skills.1
The implementation of mandated restrictions
of resident duty hours at academic institutions has
led to increased patient care handoffs and thus
more opportunities for errors during these impor-
tant transitions of care. Compliance with the duty-
hour restrictions can lead to an average of up to 15
handoffs per patient over a 5-day hospitalization.2
A recent survey of internal medicine and general
surgery residents at the Massachusetts General
The authors report no conflicts of interest or financial
disclosures.
Presented at the Academic Surgical Congress, Jacksonville, FL,
February 2–4, 2016.
Accepted for publication September 7, 2016.
Reprint requests: Fadwa Ali, MD, Department of Surgery, Med-
ical College of Wisconsin Affiliated Hospitals, 8701 Watertown
Plank Road, Milwaukee, WI 53226. E-mail:
0039-6060/$ - see front matter
2016 Elsevier Inc. All rights reserved.
SURGERY
ARTICLE IN PRESS Reprinted by permission of Surgery. 2017; 161(3):861-868.
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