2017 HSC Section 2 - Practice Management

Hospital reported that 59% of residents could

identify

1 patient harmed because of problem-

atic handoffs, and 12% reported that the harm

was major.

Due to the complexities of health care environ-

ments and the substantial variation in clinical

practice between different specialties, efforts to

standardize the handoff process have been met

with resistance, with creation of various handoff

tools of questionable applicability and sustainabil-

ity. In addition, evaluation of the handoff process

lacks a unifying structure. In a recent study,

Mohorek and Webb

suggested using the linear

model of communication as a conceptual frame-

work for handoff research. The handoff process

is a linear transition of information from one per-

son to another person or group, many of whom

may not have participated in this patient’s care

before and may have less career experience with

the medical/surgical situation. The linear commu-

nication model, when used as a framework, allows

researchers to identify 3 separate areas in which er-

rors occur: transmitter (message encoding), chan-

nel, and receiver (signal decoding).

A recent editorial in the

Journal of Graduate Med-

ical Education

recommended studying handoffs

within an established framework.

The aim of this

study was to evaluate handoffs in surgical services

in the context of a communication framework to

identify factors that adversely affect the handoff

process. Once these factors are delineated clearly,

a targeted intervention to improve handoff effec-

tiveness could be developed.

METHODS

Study population and setting.

A prospective,

single-institution study was conducted to evaluate

the process of handoff of surgical patients at a

tertiary care teaching hospital. The conceptual

framework published previously for handoffs using

communication theory was used to develop evalu-

ation tools for the source (resident giving the

handoff), receiver (resident receiving the hand-

off), and observer.

The observers in this study were involved in the

development of the evaluation tools, and consensus

was achieved through an iterative process. Our

residency program implemented a night-float sys-

tem to address patient care needs in the setting of

work hour restrictions. General surgery residents at

the Medical College of Wisconsin Affiliated Hospi-

tals were observed giving and receiving patient

handoffs at the evening shift change during a

6-month period. Handoffs were observed in 3

settings. The first setting was the handoff to the

night-float residents, which included 3 surgical

oncology services, a colorectal surgery service, a

vascular surgery service, and the minimally invasive

general surgery service. This handoff took place in a

remote room reserved for patient handoffs.

Given the voluntary nature of this study, resi-

dents were allowed to decline participation in the

study entirely or participate intermittently. There-

fore, data were collected for services individually,

rather than the night-float handoff collectively as

one large handoff of the 6 services. We could not

therefore evaluate differences in handoff quality

for those occurring earlier versus later in the

handoff process.

The second setting was the trauma service

handoff, which took place in the physician work-

room next to the nurses’ station and included the

2 services of trauma surgery and acute care surgery.

The third setting was the surgical intensive care

unit service, which occurred in the surgical inten-

sive care unit. Residents of different postgraduate

year levels were observed during the study period.

The handoff was usually provided by one resident,

the “source,” and was received by 2 residents, the

“receivers,” a senior and a junior resident.

This quality-improvement study was approved

by the institutional review board (IRB). Partici-

pants in the handoff process provided written

consent. As part of the informed consent process

for the IRB, all participants received an e-mail

announcement as well as a group announcement

describing the project design, objectives, and

methods. This announcement included discussing

the questions in

Fig 1

that were used to evaluate

the handoff process.

Measures.

Trained observers included 1 medical

student, 2 senior residents, and 1 surgery faculty

member. The observers did not participate in the

handoff process. Junior residents gave handoffs in

person, whereas senior residents provided hand-

offs either in person or via telephone. We had no

standardized tools for the handoff process,

although all residents had received instruction

on handoffs, including several handoff templates

and mnemonics. Physicians discussed typically the

level of acuity of patients, pertinent history, active

problems, hospital course, and action plans. Eval-

uation forms for the source, receiver, and observer

were developed based on our linear model of

communication published previously.

Observers utilized a standardized form to iden-

tify distractions, including number of extraneous

staff entering or leaving the room, background

conversations, side conversations unrelated to pa-

tient care, interruptions due to pager beeps,

ARTICLE IN PRESS

Surgery

2016

Hasan