Patient Handoffs Among Residents and Physician Assistants

Purpose: The purpose of this guideline is to ensure that all communication handoffs among residents and physician assistants are standardized, and contain accurate information about a patients care, and ensure a seamless transition in management of the patient. A patient handoff is defined as a transfer of care between one caregiver and another (e.g. each evening, before a weekend, at the end of a rotation or between services). Scope: This guideline applies to all patient handoffs among residents and physician assistants. Procedure: Each patient handoff must be an interactive communication between the outgoing and incoming caregiver that includes both a written and verbal component. All handoffs require verbal communication, although not every patient needs to be discussed during that communication. In contrast, each patient requires a written sign-out. Each handoff should be performed as a face-to-face interaction whenever possible. If a face-to-face handoff is not feasible then it should occur via telephone. Email or voicemail by itself is not an acceptable manner of handing off. Handoffs should occur in a quiet, private place to minimize the possibility that information will be lost or overheard by those other than the intended recipients.

A. End of Shift Handoffs: This pertains to all end of shift patient handoffs performed by residents/ PAs within a service. A written sign-out should be given to an incoming caregiver and contain

pertinent information on every patient, including: patient name, date of birth, bed location, attending physician, reason for admission, past medical/ surgical history, current medications, allergies, current clinical status, recent important events, and a problem list or plan. Written sign-out should also include potential contingency plans for anticipated patient problems, code status, and health care proxy (with contact numbers). Finally, sign-out should contain tasks to be completed in if-then format.

Verbal sign-out should be given to the incoming clinician for patients who have

active clinical issues or have specific tasks to be accomplished during the period of care transition. A useful format for conducting verbal sign-out is SBAR, and should include at a minimum, the following information: Situation (identify patient, briefly state major problems), Background (pertinent information relevant to current care), Assessment (including anticipated problems) and Recommendations (to-do list in if-then format). Tasks to be completed should be verified by a read back by the incoming caregiver. Information or tasks that are not clear should be clarified prior to the outgoing clinician departing.

B. Service or Departmental Transfer/ Handoff

This pertains to all patient transfers by residents/ PAs, between different services or departments.

A written transfer note should be placed in the progress notes section of the patients chart. This transfer note should contain at least the following information: reason for admission, reason for transfer, admitting team/ attending physician, past medical/ surgical history (or a reference to the admission note), current clinical status/ physical exam, hospital course and plan (with current contingency plans) by system or problem with pending/ followup tests as needed, list of current consultants and family contact information with a summary of any discussions to date. As appropriate, the transferring services plan for ongoing follow-up should also be documented and verbally communicated to the accepting team.

Transfer orders should be written by the ACCEPTING team. The accepting

team will review the transfer note and will write the transfer orders. Additionally, the accepting team will write a brief accept note outlining any changes in the patients status or plan of care.

C. OR Patients not on a Surgical Service

This pertains to all patients going to the OR who are NOT currently on a surgical service (e.g. a medicine patient going for an orthopedic procedure)

The team who currently cares for the patient should initiate the discussion regarding the postoperative team for the patient. If there is disagreement between the residents as to the post-operative service then the attendings for both services should discuss and agree upon the most appropriate post-operative service for the patient.

A written sign-out should be given to the surgical team, including: patient

name, date of birth, bed location, attending physician, reason for admission, reason for surgery, past medical/surgical history, current medications, allergies, current clinical status, recent important events, and a problem list or plan. A verbal sign-out should also occur outlining current medical problems with plans for each of them as well as follow-up needs.

Post operatively the surgical service should verbally sign-out to the accepting

service (when the accepting service is not surgery), with at least the following information: patient name, location, procedure type, procedure outcome, complications, post-op tasks to be completed and plan for surgical follow-up. A brief operative note should also be placed in the chart that includes the procedure type, findings, and any complications.

Ongoing Monitoring:

It will be the responsibility of each residency program director, director of each PA service, or chief PA as appropriate to enforce and monitor compliance with this policy. If there are issues of recurrent non-compliance that cannot or are not being acted upon by the residency/ PA director, then it will be brought to the attention of the Chief Medical Officer for further action.