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Participants in the handoff process, both the
source and the receiver, used a standardized paper
form to identify distractions and rate the quality of
the handoff process according to the same Likert
scale (
Fig 1
,
A
). Evaluation forms were completed
immediately following each service handoff. The
source and receiver were also asked if hierarchy/
chain of command served as a barrier for effective
communication at any point during the handoff
(Yes/No) and to evaluate the source-receiver rela-
tionship on a Likert scale (1–5, 5 = best;
Fig 1
,
B
). A subset of handoffs included 2 observers
and/or 2 receivers to assess rater consistency.
Statistical and data analysis.
Data analysis was
generated with SPSS software (version 21.0; IBM
Corp, Armonk, NY) with Pearson/Spearman cor-
relations and multivariate linear regressions. Re-
sults are reported as mean (±standard deviation)
for each individual service. Rater consistency was
assessed with intraclass correlations (ICC 2,1).
RESULTS
During a 6-month period, 126 handoffs were
observed by
$
1 trained observer; 23 handoffs
included 2 observers. An evaluation form was
completed by the source in 78 handoffs and by a
receiver in 82 handoffs. Two receivers completed
the evaluation form in 39 handoffs (
Table I
). The
majority of handoffs observed in this study were
part of the night-float system (92%). Seven percent
of handoffs were completed over the phone, with
the evaluation forms completed immediately and
returned to the authors.
The night-float team received handoffs from 6
separate services. An average service handoff
included 9.2 ± 4.6 patients and lasted
9.1 ± 5.4 minutes. Observers identified an average
of 4.7 ± 3.4 distractions per service handoff. Extra-
neous staff entering and leaving the room was
the most common type of distraction, occurring
1.5 ± 1.9 times per service handoff. Furthermore,
34% of
handoffs included background
conversations by extraneous staff, and 58% of hand-
offs were noted to have activated electronic devices
unrelated to the handoff or patient care (
Table II
).
The observers noted that some form of distrac-
tion occurred in nearly every handoff;
$
3 distrac-
tions occurred in up to 70% of handoffs;
$
6
distractions occurred in up to 35% of handoffs.
The number of patients per service was found to
inversely correlate with the amount of time spent
handing off each patient (Rs = 0.298,
P
= .001;
Fig 2
). In addition, the observer rating of the
handoff delivery directly correlated with amount
of time spent per patient (
P
= .048).
Evaluation forms completed by the source and
receiver(s) reported a distraction in up to 78% of
handoffs. Internal distractions, or “noise,”
occurred in up to 71% of handoffs, whereas
external distractions were noted in up to 44%
(
Table III
). Furthermore, the source and/or
receiver acknowledged
$
1 type of distraction
occurring in 78% of handoffs and 3 distinct types
of distractions in up to 37% of handoffs.
Fifty-four handoffs were delivered by a post-
graduate year (PGY)-1 resident, and the remainder
were delivered by a PGY-2 or higher resident.
There was no difference in duration of handoffs
(8.2 minutes for PGY-1 residents and 9.7 minutes
for more senior residents,
P
= .24). Similarly, there
was no difference in the number of distractions,
including side conversations by handoff providers
(
P
= .27), interruptions by extraneous providers
talking to handoff staff (
P
= .25), pager/phone in-
terruptions (
P
= .42), or number of teaching dis-
cussions (
P
= .74). In contrast, the quality of
handoff delivery was rated to be better by the
Table I.
Number of handoffs observed and
number of source/receivers completing the
evaluation form
Number of handoffs observed
126
Number of handoffs with 2 observers
23
Number of handoffs with source
completing the evaluation form
78
Number of handoffs with 1 receiver
completing the evaluation form
82
Number of handoffs with 2 receivers
completing the evaluation form
39
Table II.
Observer results per 1 service handoff
Mean (SD)
Duration of handoff (min)
9.1 (5.4)
Number of patients in handoff
9.2 (4.6)
Number of distractions counted,
N
(SD)
4.7 (3.4)
Number of extraneous staff entering/
exiting the room
1.5 (1.9)
Number of side conversations by handoff
staff
0.7 (1.1)
Number of pager beeps/phone calls
interrupting handoff
0.8 (1.1)
Number of handoff interruptions by
extraneous staff talking to handoff staff
0.6 (0.8)
Number of teaching discussions
0.2 (0.5)
Background conversations by extraneous
staff (% yes)
34
Were unrelated electronic devices on
during the handoff? (% yes)
58
SD,
Standard deviation.
ARTICLE IN PRESS
Surgery
j
2016
Hasan
et
al
97