Multidisciplinary Handoffs Improve Perceptions of Communication

DOI: 10.1542/hpeds.2014-00052014;4;311Hospital Pediatrics

Lauren G. Solan, Connie Yau, Heidi Sucharew and Jennifer K. O'TooleMultidisciplinary Handoffs Improve Perceptions of Communication

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BRIEF REPORT

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AUTHORSLauren G. Solan, MD,1 Connie Yau, BA,1 Heidi Sucharew, PhD,2 and Jennifer K. O’Toole, MD, MEd1,3

1Divisions of Hospital Medicine and2Biostatistics and Epidemiology, and 3Pediatric Residency Training Program, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio

KEY WORDS communication, duty hour standards, handoff, multidisciplinary, pediatric

ABBREVIATIONSACGME: Accreditation Council for Graduate Medical EducationCCHMC: Cincinnati Children’s Hospital Medical CenterEMR: electronic medical recordUPO: unanticipated patient occurrence

www.hospitalpediatrics.orgdoi:10.1542/hpeds.2014-0005

Address correspondence to Jennifer K. O’Toole, MD, MEd, Cincinnati Children’s Hospital Medical Center, Division of Hospital Medicine MLC 9016, 3333 Burnet Ave, Cincinnati, OH 45226. E-mail: [email protected]

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154 - 1663; Online, 2154 - 1671).

Copyright © 2014 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.

This abstract was presented at the Pediatric Academic Societies Meeting, April 28—May 1, 2012 (Boston, MA) and at the Pediatric Hospital Medicine Meeting, July 19–22, 2012 (Cincinnati, OH).

Multidisciplinary Handoffs Improve Perceptions of Communication

abstractBACKGROUND: Communication errors during handoffs are a leading cause of sentinel events. The Accreditation Council for Graduate Medical Education 2011 duty hour standards (DHS) increase the frequency of handoffs.

OBJECTIVE: The goal of this study was to determine if a multidisciplinary group handoff bundle improves communication while working within the 2011 DHS.

METHODS: During 1-month pilot programs of the 2011 DHS, 2 groups were observed. Group A adopted a multidisciplinary group handoff bundle, including presence of residents and charge nurses, a standardized mnemonic in verbal and written form, and resident training. Group B received only a mnemonic pocket card. Residents completed preintervention and postintervention Likert scale surveys to assess handoff perceptions. Within-group preintervention to postintervention changes were analyzed by using the signed rank test. Measuring communication errors, an institutional tool was used to track unanticipated patient occurrences (UPOs) postintervention for both groups.

RESULTS: Signifi cant improvements for the preintervention to postintervention surveys regarding the perceptions of quality of handoffs received, effective and effi cient delivery of handoffs, comfort in giving handoffs, and handoff practices focusing on safety (all, P ≤ .05) were observed in group A. There were no signifi cant changes in group B. Overall, 17% of collected group A UPO forms and 11% of group B UPO forms had at least 1 UPO recorded. The most common reason for a UPO was unaddressed nursing concerns.

CONCLUSIONS: A multidisciplinary group of residents and charge nurses and a handoff bundle was associated with improved resident perceptions of handoffs and communication within the 2011 DHS.

Handoffs are transitions in patient care that occur between members of a patient’s care team. Two systematic reviews of the handoff literature reinforced that little has been done to demonstrate handoff best practices, there is great diversity in handoff characteristics, and there is a scarcity of evidence to support any one particular practice.1,2 The Joint Commission’s report on quality and safety recog-nizes the variability in practice and calls health care providers to “implement a standardized approach to ‘handoff’ communications including an opportunity to ask and respond to questions.”3

In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) mandated changes in duty hour standards (DHS) restricting the number of sequen-tial hours residents can work,4 resulting in concerns that transitions of patient care and patient safety may suffer.5–7 With these new DHS and ever-increasing turnover

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of residents, the frequency of handoffs and variability within them has been a focus of attention.5,7,8 Because of the aforementioned concerns, there has been substantial interest in evaluat-ing the effects of handoffs on patient safety and adverse events.9,10

Only 1 recent study demonstrated a signifi cant decline in medical errors and adverse events postimplemen-tation of a resident handoff bundle, which included a handoff mnemonic, computerized tool, and communica-tion training.11 Other studies have addressed communication concerns by emphasizing communication train-ing for staff,12 but they were unable to show an effect on patient safety. There is no evidence in the literature evaluat-ing the implementation of a multidisci-plinary handoff among residents and nurses, let alone in the context of the new 2011 resident DHS.

Given the signifi cance of communica-tion errors, the lack of standardization of handoffs across institutions, and the ACGME mandate to provide training in teamwork, communication, and transi-tions of care,4 we developed a multi-disciplinary group handoff bundle at our institution while working within the new 2011 DHS. We hypothesized that implementation of a multidisci-plinary handoff between residents and nurses, in combination with a stan-dardized handoff mnemonic, would improve communication surrounding handoffs in the setting of the 2011 DHS.

METHODSThis study was a nonrandomized pre-intervention to postintervention trial of 2 handoff processes in the setting of the 2011 DHS. It was approved by the institutional review board of Cincinnati

Children’s Hospital Medical Center (CCHMC).

Setting

CCHMC is a free-standing, academic children’s hospital with a large pedi-atric residency training program with >180 residents among categorical and combined programs. General pediat-ric patients are typically admitted to 1 of 2 inpatient units, each of which is staffed by 1 charge nurse.

Study Participants

This study occurred during 2 separate month-long pilot programs of the 2011 DHS, before the mandated implemen-tation in July 2011. The fi rst pilot took place in January 2011 on 4 general pediatric inpatient teams (group A) and the second in April 2011 on 2 sub-specialty inpatient teams (group B). Group A participants included pedi-atric and medicine-pediatric residents as well as family medicine residents rotating from outside institutions. Only pediatric and medicine-pediatric resi-dents participated in group B. These 2 months were chosen for the study based on adequate resident staffi ng numbers allowing for compliance with the 2011 DHS. Residents were preas-signed to rotate in either month in July 2010. Consent forms were distributed to all residents in both group A (23 residents) and group B (11 residents). Consent was implied with completion of data collection forms.

Intervention: A Multidisciplinary Group Handoff Bundle

A multidisciplinary group handoff bundle was implemented for group A requiring that interns, senior residents, and charge nurses be present at the 8:00 PM handoff every evening. Interns were instructed to lead the handoff as they normally would. Senior residents

were instructed to supervise and pro-vide oversight as needed. Charge nurses from the team’s primary unit were given the responsibility of providing updates in patient status and inquiring about dis-charge and contingency planning when otherwise not shared.

Another component of the handoff bundle was a standardized mnemonic, known as “SAFETIPS,” which was used during verbal and written handoffs (Fig 1).13 Residents in group A received pocket cards illustrating the mnemonic and a training session on how to use the mnemonic. This brief 30-minute resident training session focused on use of a standardized mnemonic in both verbal and written format and changes to the overall handoff process dur-ing the study period. Study investiga-tors collaborated with members of the Information Technology Department at CCHMC to change the electronic medi-cal record (EMR) handoff document to refl ect the SAFETIPS mnemonic.

In contrast, group B did not use the multidisciplinary group hand-off bundle, and charge nurses did not attend the evening handoffs in group B. Senior residents were given

FIGURE 1 Adapted SAFETIPS mnemonic card. DOB, date of birth; DNR, do not resuscitate; MRN, medical record number; NPO, nothing by mouth.




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the option of attending the intern-to-intern handoff, but it was not required. Participants were given SAFETIPS pocket cards without training. In addi-tion, the written handoff document remained housed in a Microsoft Word document, separate from the hospital EMR and subject to variability. Table 1 illustrates the study design and hand-off structures of each group.

Data Collection Tools and Procedures

The 2 groups were each followed up for a 1-month period. Residents completed preintervention to post-intervention surveys to assess their perceptions of handoff processes. The surveys were developed de novo by the study team and reviewed by experts in research and education from the Division of Hospital Medicine and the residency program. The sur-veys used a 5-point Likert scale (1 = very poor, 5 = very good) to assess resident perceptions of the new 2011 DHS in terms of the quality of handoffs received, effective and effi cient deliv-ery of handoffs, comfort in giving a handoff, and handoff practices focus-ing on safety. The survey was distrib-uted via e-mail with a hyperlink to an electronic survey platform.14

To measure success of handoffs and quantify lapses in communication, we used an unanticipated patient occur-rence (UPO) tracking tool. The UPO tracking tool (Fig 2) was developed during another safety initiative at our

institution as a way to track commu-nication errors in the handoff process that represent potential triggers for adverse events or as a precursor to safety events; however, it has not been formally validated. This form was fi lled

TABLE 1 Characteristics of the Study Groups and Handoff Structure

Characteristic Group A Group B

Group characteristics Study period January 2011 April 2011 No. of teams 4 2 Team composition General pediatric inpatient Cardiology and pulmonology inpatient No. of residents 23 11 Resident work hours design 2011 ACGME DHSa 2011 ACGME DHSa

Handoff group structure Charge nurse at handoff Yes No Senior resident at handoff Yes Rarely (not required)

Handoff mnemonic Pocket cards Yes Yes Posted on workstations Yes No Documentation Embedded in EMR Stand-alone electronic Microsoft Word document Training Yes Noa Compliant with ACGME standards: interns restricted to work ≤16 hours, seniors to 24 hours + 4 hours of care transitions; 80-hour workweek.

FIGURE 2 UPO tracking form. IVF, intravenous fl uids; MRT, medical response team; PEWS, pediatric early warning score.




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out by residents after completion of an overnight shift as a means of reporting errors in communication that affected patient care during their shift. The overnight residents recorded UPOs that they identifi ed in ≥1 patient. The tool was collected the following morn-ing by a research assistant.

Statistical Analyses

Resident preintervention to postinter-vention survey responses within the same group were analyzed by using the signed rank test. The number and proportion of UPO forms with at least 1 reported UPO event were presented according to group. Given the inherent differences between groups A and B, analysis occurred within each group, and results were not directly com-pared between groups.

RESULTSPreintervention and postinterven-tion surveys were completed by 19 (83%) of the 23 residents in group A and by 7 (64%) of the 11 residents in group B. The mean ± SD daily com-bined census among all 4 teams dur-ing the study month for group A was 33.7 ± 7.8 patients per day; among the 2 teams during the study month for group B, it was 39.6 ± 8.0 patients per day. Preintervention to postinterven-tion survey changes were observed in group A, with signifi cant improvements

in perceptions of the quality of handoffs received, effective and effi cient delivery of handoffs, comfort in giving a handoff, and of handoff practices focusing on safety (all, P < .05), resulting in a median paired difference (post minus pre) of 1 for all 4 questions. In group B, there were no signifi cant preintervention to postintervention changes in responses, resulting in a median paired difference of 0 for all 4 questions (Table 2).

For group A, there were 10 (17%) of 60 total forms with at least 1 recorded UPO. Of the 10 UPO forms, 1 had 7 UPOs, 4 had 2 UPOs, and 5 had 1 UPO, for a total of 20 UPOs for group A. The most common reason for a UPO was nursing concerns not conveyed, fol-lowed by unexpected code/medical response team activation, incorrectly ordered medication/intravenous fl u-ids, inadequately conveyed parent concerns, and unanticipated transfer to the PICU (descending order). In group B, 3 (11%) of 28 total forms had at least 1 UPO recorded. Two forms had 1 UPO, and 1 form had 3 UPOs, for a total of 5 UPOs for group B. Nursing concerns not conveyed during hand-off were again the most common reason for a UPO, followed by lack of notifi cation of abnormal vital signs/examination fi ndings and inadequately conveyed parent concerns (descend-ing order).

DISCUSSIONOur bundled intervention including interns, senior residents and charge nurses present at the handoff, a stan-dardized mnemonic used in both writ-ten and verbal handoffs, and resident training on use of the standardized mnemonic signifi cantly improved resi-dent perceptions of handoffs and com-munication while working within the 2011 DHS. We found that sharing of a mnemonic alone, without additional training, verbal or written standardiza-tion, or presence of a multidisciplinary team did not improve resident percep-tions of handoffs and communica-tion. A recent study found improved resident confi dence in handoffs after standardization of the written hand-off document15; however, our study is novel in its inclusion of a multidisci-plinary team of physicians and nurses at handoff.

Communication errors during hand-offs have been identifi ed by the Joint Commission, ACGME, and other accrediting bodies as areas of weak-ness in our current health care sys-tem requiring intensive examination and timely intervention. This fi nding is especially true as the nation contin-ues to adjust to the 2011 DHS, which increase the number of handoffs between residents. Interpretation of the UPO results are challenging given

TABLE 2 Resident Preintervention to Postintervention 1-Month Follow-up Survey Responses

Question Group A (n = 19) Group B (n = 7)

Preintervention Postintervention Δ Postintervention – Preintervention

Preintervention Postintervention Δ Postintervention – Preintervention

Quality of handoffs received 3 (3, 4) 5 (4, 5) 1 (1, 2)* 4 (3, 4) 4 (3, 5) 0 (0, 0)Effective and effi cient delivery of handoffs

4 (3, 4) 4 (4, 5) 1 (0, 1)* 4 (4, 4) 4 (4, 4) 0 (0, 0)

Comfort giving a handoff 3 (3, 5) 5 (4, 5) 1 (0, 2)* 4 (4, 5) 4 (4, 5) 0 (0, 0)

Handoff practices focus on safety

3 (3, 4) 4 (4, 5) 1 (0, 2)* 4 (3, 4) 4 (3, 4) 0 (0, 0)

Data are presented as median (25th, 75th percentile) for Likert scale scores ranging from 1 = very poor to 5 = very good. *Signed rank test P < .05 for paired preintervention to postintervention differences.




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the many differences between groups A and B and that this information was only collected postintervention; how-ever, the common reasons for commu-nication errors based on the UPO form are apparent and potentially infl uential for targeting of future interventions.

We acknowledge several limitations to our study. The study was conducted over short periods of time at 1 institu-tion, making the generalizability of our results uncertain. In addition, the UPO tool has not been validated, making the results diffi cult to generalize and, as a self-report tool, minor UPOs may have been overlooked. Our sample size of residents was small. There are also inherent differences between the 2 groups, especially in terms of patient complexity, length of stay, and acuity, making direct comparisons between the 2 groups challenging. By sharing the mnemonic with group B, we also cannot strictly divide and compare the groups as having all or none of the bundle but rather by having all or some of the bundle. An additional limitation is that the study subjects and inves-tigators were not blinded; therefore, there is a potential for response bias for both survey and UPO outcomes.

CONCLUSIONS The 2011 ACGME DHS have garnered a great deal of attention because of the direct effect of increasing the number of handoffs in care between residents. Results from previous stud-ies on resident handoffs and commu-nication lend insight into the complex nature of this topic and have dem-onstrated varying success. However, most of these studies focused on the use of discrete interventions such as a standardized handoff sheet or use

of a mnemonic, whereas none has involved the implementation of a mul-tidisciplinary group handoff bundle.2 Our study demonstrated statistically signifi cant improvements in resident perceptions of handoffs and com-munication with the implementation of a multidisciplinary group handoff bundle in the setting of the 2011 DHS. These fi ndings suggest that the inclu-sion of nursing staff and presence of a multidisciplinary care team at the time of handoff in conjunction with a stan-dardized handoff mnemonic, resident training, and embedding the written handoff document into the EMR can improve communication and overall satisfaction of care team members. We were unable to directly compare groups A and B due to inherent differ-ences in patient and team composition and could not draw conclusions about the impact on patient safety through measurement of UPOs. Additional pro-spective studies are necessary to further evaluate the feasibility of long-term sustainment of these interven-tions and to elucidate the effects these interventions have on patient safety and medical errors.

REFERENCES

1. Riesenberg LA, Leitzsch J, Massucci JL,

et al. Residents’ and attending physicians’

handoffs: a systematic review of the

literature. Acad Med. 2009;84(12):1775–1787.

2. Foster S, Manser T. The effects of patient

handoff characteristics on subsequent care:

a systematic review and areas for future

research. Acad Med. 2012;87(8):1105–1124.

3. The Joint Commission releases improving

America’s hospitals: a report on quality and

safety. Jt Comm Perspect. 2007;27(5):1, 3.

4. Accreditation Council for Graduate Medical

Education (ACGME). Common program

requirements for pediatrics. Available at:

www.acgme.org/acgmeweb/Por tals/0/

dh_dutyhoursCommonPR07012007.pdf.

Accessed May 14, 2012.

5. Mueller SK, Call SA, McDonald FS,

Halvorsen AJ, Schnipper JL, Hicks LS.

Impact of resident workload and handoff

training on patient outcomes. Am J Med.

2012;125(1):104–110.

6. Petersen LA, Brennan TA, O’Neil AC, Cook

EF, Lee TH. Does housestaff discontinuity of

care increase the risk for preventable adverse

events? Ann Intern Med. 1994;121(11):866–

872.

7. Starmer AJ, Spector ND, Srivastava R, Allen

AD, Landrigan CP, Sectish TC; I-PASS Study

Group. I-pass, a mnemonic to standardize

verbal handoffs. Pediatrics. 2012;129(2):201–

204.

8. Helms AS, Perez TE, Baltz J, et al. Use of an

Appreciative Inquiry Approach to Improve

Resident Sign-Out in an Era of Multiple Shift

Changes. J Gen Intern Med. 2011; (Oct):14.

9. Kitch BT, Cooper JB, Zapol WM, et al.

Handoffs causing patient harm: a survey of

medical and surgical house staff. Jt Comm J

Qual Patient Saf. 2008;34(10):563–570.

10. Horwitz LI, Moin T, Krumholz HM, Wang L,

Bradley EH. Consequences of inadequate

sign-out for patient care. Arch Intern Med.

2008;168(16):1755–1760.

11. Starmer AJ, Sectish TC, Simon DW, et al.

Rates of medical errors and preventable

adverse events among hospitalized children

following implementation of a resident

handoff bundle. JAMA. 2013;310(21):2262–

2270.

12. Deering S, Johnston LC, Colacchio K.

Multidisciplinary teamwork and com-

munication training. Semin Perinatol. 2011;

35(2):89–96.

13. Shaughnessy E. Pediatric resident sign-out

education. Available at: www.mededportal.

org/publication/8321. Accessed July 12,

2012.

14. Survey Monkey. https://www.surveymonkey.

com/. Accessed December 1, 2010.

15. Payne CE, Stein JM, Leong T, Dressler DD.

Avoiding handover fumbles: a controlled

trial of a structured handover tool versus

traditional handover methods. BMJ Qual Saf

2012;21(11):925–932.



DOI: 10.1542/hpeds.2014-00052014;4;311Hospital Pediatrics

Lauren G. Solan, Connie Yau, Heidi Sucharew and Jennifer K. O'TooleMultidisciplinary Handoffs Improve Perceptions of Communication

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Multidisciplinary Handoffs Improve Perceptions of Communication