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distractions and the handoff reception process and
handoff environment (
P
>
.05) but agreed on the
handoff delivery process (
P
= .017;
Table V
). Com-
parison of different participant types (eg,
comparing an observer to a receiver or source)
showed divergence in responses (
P
>
.05).
Linear regression analysis determined that the
handoff delivery process was affected negatively by
the number of side discussions (
b
= 0.18,
P
= .046), the number of teaching discussions
(
b
= 0.42,
P
= .048), and by extraneous staff
entering/leaving the handoff room (
b
= 0.35,
P
= .04). Similarly, the handoff reception process
was negatively impacted by the number of side dis-
cussions (
b
= 0.26,
P
= .004), the number of
teaching discussions (
b
= 0.20,
P
= .044), the
presence of active, unrelated electronic devices
(
b
= 0.57,
P
= .005), and the sense of hierarchy
among handoff participants (
b
= 0.31,
P
= .002). The delivery (
b
= 0.83,
P
<
.001) and
reception (
b
= 0.75,
P
<
.001) processes were
affected positively by a good relationship between
the source and receiver (
Table VI
).
DISCUSSION
Patient handoffs have become an integral part
of patient care. The importance of this communi-
cation process has become evident in light of the
inception of duty-hour restrictions in 2003; in one
study, handoffs increased by 40%.
2
Intuitively,
handoffs in patient care present a risk of loss of vi-
tal information and, consequently, the potential
for adverse patient events. A large body of litera-
ture identifies flaws in patient handoffs, with at-
tempts to improve this process,
6
but the majority
of previous efforts have designed interventions
either empirically or based on feedback from focus
groups.
7,8
A systematic review of the literature by Abraham
et al
1
examined various handoff tools. In this re-
view, the majority of studies focused on effective-
ness of a tool as well as user satisfaction.
Furthermore, the theoretic basis of most studies
has been limited to some aspect(s) of the handoff
process (eg, information processing, cognition,
accountability). An editorial in the
Journal of Grad-
uate Medical Education
describes the magnitude of
the handoff problem and proposes a paradigm
shift in how research is done to improve handoffs.
5
Specifically, future research is recommended to
start with a conceptual framework based on previ-
ous research results.
This process is exactly what we sought to
accomplish with our project. Our group has
developed a conceptual framework utilizing
communication theory to study the handoff pro-
cess, break it down to its core elements, and
develop an intervention that targets these various
elements.
4
Our study may be the first in the litera-
ture that evaluates the handoff process in the
context of a comprehensive communication
framework. In our study, we evaluated specifically
the process of delivering and receiving patient
handoffs, not the content of the message being
delivered or received.
Our study demonstrated that distractions are
very common during surgery resident handoffs;
70% of residents providing handoffs reported a
distraction, while 66–75% of residents receiving
handoffs reported a distraction. According to the
observers, an average of 4.7 ± 3.4 distractions
occurred per service handoff. Extraneous
Table V.
Receiver 1 and receiver 2 comparison
using ICC (
N
= 39)
ICC
P
value
Any extraneous staff entering/
exiting room
0.216 NS
Background conversation by
extraneous staff (Y/N)
0.050 NS
Any side conversations by handoff
staff
0.027 NS
Any unrelated electronic devices on
during handoff?
0.257 NS
Rate handoff delivery (1–5)
0.234 .017
Rate handoff reception (1–5)
0.089 NS
NS
, Not significant (
P
value
>
.05).
Table VI.
Linear regression analysis of predictors
of handoff delivery/reception quality
Handoff delivery process
b
coefficient
P
value
Negative predictors
Number of side discussions
0.18 .046
Number of teaching discussions
0.42 .048
Extraneous staff
entering/leaving the
handoff room
0.35 .040
Positive predictors
Source-receiver relationship
+0.83
<
.001
Handoff reception process
Negative predictors
Number of side discussions
0.26 .004
Number of teaching discussions
0.20 .044
Presence of electronic devices
0.57 .005
Source-receiver hierarchal
barrier
0.31 .002
Positive predictors
Source-receiver relationship
+0.75
<
.001
ARTICLE IN PRESS
Surgery
j
2016
Hasan
et
al
99