2017 HSC Section 2 - Practice Management

personnel entering and leaving the room was the

most common type of distraction. The frequency

of distractions during the handoff was highlighted

in other studies.

In a recent study of surgical handoffs at 3

University of California, San Francisco (UCSF),

teaching hospitals, distractions occurred in 48% of

handoffs.

Interestingly, the authors report that

pagers and patient-related telephone calls were the

most common distractions. In other studies, most

observed handoffs were interrupted

1 for every ser-

vice.

10,11

Our study also demonstrated that distrac-

tions negatively affect the quality and process of

delivery and reception of the handoff. Our linear

regression analysis shows that the process of handoff

delivery was negatively affected by the number of

side or teaching discussions and the number of

personnel entering or exiting the room.

We hypothesize that distractions affect the mo-

mentum of the handoff process and divert attention

from important, patient-related information. Con-

trary to our results, the UCSF study showed that

distractions increase the duration of the handoff

process but do not affect the quality of the handoff

process.

While the authors suggested that surgery

residents developed tolerance to distractions, the

UCSF study did not report any solicited feedback

from the residents providing or receiving handoffs

regarding whether they felt distractions impacted

the quality of the handoff process. The authors’ re-

sults were based solely on the observers’ evaluation

of the handoff process.

In our study, we surveyed both the source and

the receiver in addition to the observers. Identifying

distractions is important for quality improvement of

the handoff process, because the most common

distractions should be amenable to interventions.

Residency programs could encourage minimization

of side and teaching conversations during the

handoff process. Nursing personnel could also be

encouraged to minimize pages during handoff time

except for urgent, patient-related issues. Similar to

the sterile cockpit rule in the aviation industry that

requires pilots to refrain from nonessential activities

during critical phases of flights, including takeoff

and landing, hospitals can consider instituting a no-

page policy during handoffs.

10,12

In our study, the quality of handoff delivery was

rated significantly better by the observer when a

PGY-2 or higher level resident delivered the handoff

compared with a PGY-1 resident, despite the

receiver scores not showing a difference based on

the source PGY level. This finding has not been

reported previously. We hypothesize that the ability

to provide pertinent patient information and

identify potential complications or issues improves

with experience. Handling distractions during

handoffs may also require multitasking, a skill that

improves with experience. Prior studies have shown

that multitasking is a complex cognitive process

that improves with practice.

In an observed, simu-

lated handoff experience with need to handoff mul-

tiple patients, residents with prior training in

handoff or prior handoff experience achieved bet-

ter scores based on assessing their handoff delivery

using a 5-item checklist.

This finding suggests that

handoff training during medical school or begin-

ning of residency may be beneficial.

Our study demonstrated that the quality of

handoff delivery and reception is impacted posi-

tively by a good relationship between the source

and receiver. Furthermore, we identified this

relationship as an important predictor of the

quality of the handoff process. This observation

was supported by 2 findings: the presence of

hierarchy negatively affected the evaluation of

the handoff process, and the source-receiver rela-

tionship correlated directly with the overall hand-

off process score, both positively and negatively.

To our knowledge, prior handoff studies have

not examined the working relationship between the

handoff participants as a predictor of quality,

although our study of communication theory iden-

tified the relationship between the source and

receiver and hierarchy as important psychologic

distractions when relaying a message.

Developing a

hierarchy-free environment during handoffs, as well

as improving the source-receiver relationship,

should be further studied as a means for improving

communication and ultimately patient care.

When comparing the responses of different

participants, we identified 2 themes. Observers

were mostly congruent with one another, while

different participant types were mostly incongruent.

The observers only disagreed on the evaluation of

the handoff reception, likely due to the passive

nature of receiving information, making it difficult

for a third party observer to evaluate accurately.

In contrast, when comparing the source to the

receivers or observers, the observers agreed on the

overall presence of distractions, but the source/

receiver/observer gave divergent responses in terms

of type of distractions, evaluating the handoff de-

livery/reception process, and the handoff environ-

ment. The divergent responses occurred due to the

source and receiver being focused on their respec-

tive tasks during the handoff, while the observers

were focused on evaluating the process and account-

ing for distractions. Furthermore, our work suggests

that the source and receiver could be sensitive to

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