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. Author manuscript; available in PMC: 2025 Oct 1.
Published in final edited form as: J Surg Res. 2024 Aug 29;302:715–723. doi: 10.1016/j.jss.2024.07.111

Evaluation of a Novel Emergency General Surgery Handover: A Prospective Feasibility Study

Lauren D Hostettler 1, David M Kline 3, Justin B Moore 4,5, Chandylen L Nightingale 6, Preston R Miller III 2, Andrew M Nunn 2, Samuel P Carmichael II 2
PMCID: PMC11490366  NIHMSID: NIHMS2020732  PMID: 39214063

Abstract

Background.

High quality health information handovers are critical to optimal patient care and trainee education. The purposes of this study were to assess the feasibility of implementing an EGS morning handover and to explore its impact upon markers of clinical care.

Materials and Methods.

This prospective feasibility study was conducted at a single academic tertiary care medical center following implementation of a novel EGS morning handover process. We assessed organizational perspective through a two-part anonymous survey delivered to the EGS service staff (n=29) and collected feasibility metrics daily at the morning handover meetings. Exploratory clinical metrics of quality improvement were compared between parallel five-month periods pre- and post-implementation of the handover. Data were compared by descriptive statistics.

Results.

One hundred and seventeen patients from March 1, 2022 – July 31, 2022, and 185 patients from March 1, 2023 – July 31, 2023, were identified pre- and post-handover implementation, respectively, with an increase in time to operating room posting by 49% (95% CI: 1.03, 2.14) and no statistically significant change in length of stay. The average duration of the formalized EGS morning handover was 14 minutes (95% CI: 12:18, 15:42) having an average of 12 questions asked (95% CI: 9.98, 14.02) and an average attendance of 70% from essential personnel. Eighty-four percent of post-implementation survey responses indicated positive regard towards the new EGS handover.

Conclusions.

The implementation of an Emergency General Surgery morning handover is feasible, necessitating further studies to define the impact of the EGS morning handover upon clinical outcomes.

Keywords: EGS, Handover, Morning Report, Implementation Evaluation, Feasibility, Framework

Introduction

Medical errors are among the top five leading causes of death in the United States, indicating the need for safety frameworks to mitigate preventable morbidity and mortality.1 While the concept of medical error is complex, communication lies at the root of 67% of medical errors.2 For instance, transfer of patient care information in noisy environments or incomplete transfer of information during change of patient care personnel may lead to loss of critical details, delays in care, and patient dissatisfaction. The limitation on cumulative duty hours for residents has led to a transition towards shift schedules and a subsequent increased volume of patient care handovers, thereby increasing opportunity for communication error. The implementation of formalized patient care handovers (i.e. morning report, sign out, and handoff) have strived to optimize data transfer across teams and medical services in the face of such challenges.3,4 These exchanges, described as the processes of transferring clinical care, information, and responsibility of a patient from one departing provider to an oncoming provider, represent a vulnerable period for transfer of critical health information and an opportunity to ensure the appropriate information is conveyed to the incoming medical team.2,5 Formalized handovers have been implemented and studied in the contexts of certain medical specialties with notable improvements in patient care and outcomes.3,6–9

Acute Care Surgery (ACS), comprised of trauma, emergency general surgery (EGS), and critical care patients, has deployed formal handover procedures in 35% of programs in the United States.2,10 Though ACS service lines commonly co-manage EGS and trauma, EGS has historically not been included in formalized handovers, resulting in incomplete appraisal of formal handovers in this context. In 2020, the Eastern Association for the Surgery of Trauma identified handovers (titled Transitions of Care/Handoffs) among their Practice Management Guidelines currently under development, highlighting their significance on a national level of practice and galvanizing the implementation of a formal EGS handoff.20 The purposes of the present study were to 1) assess perceived gaps in the informal patient handover (IPH) by conducting an initial survey within our EGS service line and 2) prospectively assess the feasibility of implementing of a formalized patient handover (FPH) to provide a reproducible framework that reduces inadequate patient handover for EGS patients. We hypothesized that it is feasible to implement a formalized morning handover for EGS and secondarily explored potentially immediate, measurable consequence on patient outcomes of time to OR posting and hospital length of stay.

Methods

Study Development and Framework

We queried the National Library of Medicine using a search optimization strategy (Appendix A) to identify studies associated with an EGS morning handover or morning report, and to assess gaps in the literature. This strategy was guided by a medical librarian.

To produce a rigorous and reproducible framework for the feasibility implementation study, we modeled our design using the Implementation and Evaluation Science PRISM (practical, robust implementation and sustainability model) framework (Fig. 1) following IRB approval from the Wake Forest University School of Medicine (IRB00093555).11 Our framework identified the new formalized EGS patient handover as the “intervention” with the two target recipients being the organization (EGS staff) and the patients. The intervention, an EGS Formalized Patient Handover (FPH), was defined as a meeting during which a resident presents the overnight patients admitted, consulted, receiving intervention, or whose status changed overnight to the incoming day team (attendings, fellows, residents, and Advanced Practice Providers) according to the guidance provided during implementation rollout (Fig. 2). Metrics were collected from three data sources to quantify implementation feasibility. The three data sources included 1) a two-part pre- and post-EGS FPH implementation survey, 2) daily-collected EGS FPH data, and 3) a chart review of EGS patients from a selected 5 months prior to and 5 months following the FPH implementation. STROBE and STaRI checklists for a cross-sectional based study and for reporting implementation studies, respectively, were completed.12,13 No harm was deemed to potentially befall surveyed EGS staff nor de-identified chart reviews, and the need for informed consent was formally waived by the IRB.

Figure 1.

Figure 1.

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Modified PRISM (Practical and Robust Implementation and Sustainability Model) framework from Dissemination and Implementation Models in Health11.

Figure 2.

Figure 2.

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Acute Care Surgery Morning Report Guidelines for Trauma and EGS Morning Handovers.

Collection of Data

We constructed a two-part series of voluntary surveys to be delivered to all levels of the EGS medical team (Appendix B). The surveys assessed multiple points of EGS provider experiences and opinions regarding the former Informal Patient Handover (IPH) structure and the EGS FPH implemented in January 2023. The surveys were optimized using the Delphi method prior to their delivery via email using the RedCap electronic survey research platform.21, 22 The first survey served the purpose of assessing the regard, response, and consensus towards the informal handover as well as to assess the generalizability of the knowledge gap we had identified. The second survey was administered six-months post-implementation of the FPH in June 2023, and included the same questions previously asked about the IPH (i.e., EGS provider experiences and opinions) but were instead about the novel formalized EGS FPH. Staff who were open to discussing the topic further were encouraged to do so in exit interviews (Appendix C). Survey data were collected using RedCap and compared using descriptive statistics.

The second set of data was collected daily at the EGS FPH for three months (May 2023 – July 2023) to assess the feasibility of the implementation. Feasibility was determined by three a priori benchmarks: availability of resources (such as time and venue), meeting the assessed need or adding value, and evaluating the practicality by assessing staff buy-in. The metrics for these benchmarks included timeliness and attendance of essential staff, number of questions asked, types of questions asked, number of changes in patient management plans, and the number of new tests or assessments ordered during the EGS FPH (resources, practicality, and value added). The “essential staff” whose attendance and timeliness was collected included 6 specific roles: EGS Resident presenting the overnight patients, Trauma Resident presenting the overnight patients, EGS Attending, Trauma Attending, TICU Attending, and overnight Attending. Metrics were consolidated and assessed via descriptive statistics through calculations of means and confidence intervals.

Lastly, in exploring early indications of quality improvement in patient care, we compared EGS patients in parallel five-month periods prior to and after the EGS FPH. Group A included weeknight admitted EGS patients from March 1, 2022 to July 31, 2022 (n=139), and Group B included weeknight admitted EGS patients from March 1, 2023 to July 31, 2023 (n=213), with flex months before and after the implementation of the FPH in January 2023 to account for adjustments surrounding the change. The two groups were compared for differences in the length of stay (in hours) and time to OR posting (in hours) as early exploratory observations for potential quality improvement in patient care using two-sample t-tests of the natural log of the collected values. If length of stay was not appropriately or completely captured, the patients were excluded (2022 n=22; 2023 n=28). For patients with multiple operations following admission, only the time to OR posting from admission until the first operation was considered. If time to OR posting was the same as admission time or if the OR posting time was not recorded, the patients were also excluded (2022 n=45, 2023=54). This left 117 patients in Group A and 185 in Group B for analysis in length of stay, and 94 patients in Group A and 159 patients in Group B for analysis in time to OR posting.

Results

Survey

The first survey was delivered to 67 EGS Service staff members with 29 individuals completing the survey (43% response rate). Sixty-two percent of participants in the first survey agreed or strongly agreed with the fact that there was a need to improve the IPH. Thirty-one percent of participants agreed or strongly agreed that IPHs were consistent in providing details of HPI, diagnostics, and plan. Sixty-six percent agreed or strongly agreed that they felt the time commitment to the IPH was manageable and appropriate. However, participant comments suggested that additional time was required following an IPH to review charts for completeness.

The second survey was delivered to the same group of 67 EGS Service staff members, with 20 individuals completing the survey (29.8% response rate) and a post-hoc exclusion of one response due to the respondent disclosing that they were not a part of the EGS service line. Eighty-four percent of EGS staff indicated that they were overall satisfied with the new EGS FPH with “strongly agree” or “agree.” Seventy-nine percent of participants also agreed or strongly agreed that the EGS FPHs were consistent in providing details of HPI, diagnostics, and plan, compared to the 31% in the first survey. Ninety percent of participants strongly agreed that the information provided for EGS patients during the FPHs impacted their plan of care. Seventy-four percent of participants also agreed or strongly agreed that the EGS FPH is patient-safety focused. Still, 52.6% of participants agreed that there was a need to improve the EGS FPH (Fig. 3). Comments surrounding room for improvement mostly pertained to making the process more efficient as to spend more time on complex admissions and cases, rather than spending excess time on more routine EGS cases and limiting non-medical conversation. Comments also noted that a challenge with making the process more efficient could be the loss of educational discussion, which was an element of the FPH positively described as “outstanding” and making the overall experience “far superior to what [was] in place prior.”

Figure 3.

Figure 3.

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Two-part anonymous survey of the EGS Service Line concerning the informalized EGS Handover and the new, formalized EGS Handover, respectively.

Five exit interviews were conducted following the second survey. These interviews predominantly indicated positive regard for the EGS FPH highlighting two benefits of the implementation repeatedly. The first benefit was the discussion of patient management and plans with multiple attendings being present. Interview feedback described multiple opportunities for loss of information transfer between night and day services with the informal handover. For the EGS FPH all caregivers were present at the same time not only for the handover of patient care information, but also to allow for the discussion of the future care pathway. This led to the second most stated benefit being learning opportunities for all in attendance. With attendings for the Trauma, EGS, and Critical Care services present, attending-level patient care discussion was regularly observed by other team members, leading to opportunities for learning through observation and engagement. Moments of correction or adjustment following errors could also be addressed during the FPH, providing group learning opportunities. Following insight from multiple attendings and learning opportunities as the two most stated benefits to the FPH, direct communication between all caregivers, discussion of patient care management, and prioritizing action items were additionally noted benefits (Fig. 4).

Figure 4.

Figure 4.

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Perceived Benefits of the Formalized EGS Morning Handover.

Feasibility

The average duration of the EGS FPH was 14 minutes alone (95% CI: 12:18, 15:42) and 31 minutes (95% CI: 27:44, 34:16) in combination with the previously established formal Trauma Patient Handover with a range of 3–31 minutes (EGS alone), and 5–60 minutes (EGS and Trauma combined). The absence of essential staff was considered in attendance tracking with an average of 70% attendance (95% CI: 59%, 81%). Sixty-five percent of FPHs had significant tardiness with significant tardiness being measured as an arrival after 50% of the average EGS meeting duration (> 7 minutes into the meeting). This study did not assess indications for tardiness or absence.

Early Clinical Implications Exploration

During EGS Morning Handovers, the medical team discussed the patients’ status, care, and next steps, asking additional questions surrounding these items as needed. An average of 12 questions (95% CI: 9.98, 14.02) were asked per EGS Morning Handover (Fig. 5). Most of the questions were pertinent to patient care since arrival and/or their current status, followed by patient history. The volume of questions changed proportional to the duration of the EGS Morning Handover. Next steps and clarification questions comprised 29.5% overall (Fig. 5). New orders were requested an average of 0.28 times (95% CI: 0.14, 0.42) with a range of 0–2 new orders per meeting over the span of the three-month data collection period. Plans changed an average of 1 time (95% CI: 0.68 to 1.32) per handover with a range of 0–5 plan changes.

Figure 5.

Figure 5.

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Content Breakdown of questions and discussion taking place during the formalized EGS Handover.

The average length of stay, measured in hours, of EGS patients increased from 2022 to 2023 by 32% (mean ratio: 1.32, 95% CI: 0.96, 1.82). The average time to OR posting increased from 2022 to 2023 by 49% (mean ratio: 1.49, 95% CI: 1.03, 2.14) (Fig. 6). The natural log of the values assessed in the two-sample t-tests indicated a statistically significant increase in time to OR posting (p = 0.0319), and no statistical significance in length of stay (p = 0.0795).

Figure 6.

Figure 6.

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Box and Whisker Plot of the Natural Log of the Length of Stay and Time to Operating Room Posting from March 1 to July 31, 2022 and March 1 to July 31, 2023.

Discussion

Formal and organized patient care handovers have proven effective in minimizing medical errors in patient care. However, there is substantial heterogeneity in practice, with FPHs often remaining unadopted. In the wake of this national recognition, our study is the first to assess the feasibility of implementing an EGS FPH, constructed on an established framework with additional exploration of early clinical implications. We found that there was an overall increase in satisfaction from the EGS service line six months following the implementation of a FPH from the previously existing IPH and that the EGS service line had increased confidence in the consistency and type of information exchanged at handoff. Identified benefits included direct communication with team members and learning opportunities throughout the formal discussion of patients and their care regardless of insignificant clinical impact.

This study demonstrated that the implementation of an EGS FPH is logistically feasible. With the addition of the 14-minute average EGS FPH to the previously existing Trauma FPH, the weekly time spent in EGS FPH did not pose an additional threat to work hour restrictions incorporating multiple aspects of otherwise delayed decision-making into the FPH. This is evidenced by an average of 12 questions being addressed within those 14 minutes, saving chart review on the back end. Buy-in was not immediate, with the primary concern being the additional time requirement of a FPH. However, six months following implementation, the second survey illustrated that the perspective on the FPH time commitment had shifted with 70% of surveyed EGS staff agreeing that the time commitment is manageable and appropriate. The cost of fourteen minutes in exchange for twelve questions that develop the medical decision-making capacity of trainees and increase their confidence in managing the care of patients on their service is an affordable cost and feasible option.

Another component to the discussion of time commitment was that of attendance and timeliness. Even with a mandatory FPH, traumas and emergencies continue to occur, and operations extend into the time frame set apart for FPH, leading to absence or tardiness. Additionally, as in any place of employment, there is excused and unexcused tardiness and absence. This obstacle was addressed with a mandatory attendance policy, but the FPH still experienced tardiness and/or absence.

Suggestions for future formalized EGS Morning Handover implementation efforts include a formalized handover training at rollout inclusive of all levels of the EGS service, the establishment of mandatory attendance expectation (to be determined by each institution), and a set of guidelines for discussion. The standardization of handovers via checklists has been applied in other contexts, as it ideally prevents loss of information (via the Swiss cheese model, where multiple layers of safeguards, each with its own weaknesses [holes], prevent adverse events by ensuring the holes do not line up and let an error through).23 However, this may also hinder the clinical decision-making development of learners and open dialogue of patient care management. Current conversation in the literature surrounding checklist standardization indicates equipoise in this area.8,14–18 One study by Date, et al. suggested that handovers are a learned skill, as they observed the difference between junior-level and senior-level handover differences.19 In agreement, we believe education at rollout to be essential with the level of standardization to be further assessed.

Some studies have indicated promising quality improvement in their assessment of patient care following the implementation of FPHs.6,8,9,18 For this analysis, however, the unanticipated outcome was the impact of the EGS FPH on the time to OR posting and length of stay of the patients following the FPH implementation. We did not expect for there to be a significant delay in time to OR posting. From the conception of the analysis, these data points were intended to be exploratory outcomes, and our interest was simply to look for early clinical impact. To fully evaluate this finding further analysis would be needed, as no regression analysis was conducted on these data points, and many things could influence the time to OR posting and length of stay, such as more effective triaging during the EGS FPH leading to fewer emergent OR postings, staffing shortages, operating room shortages, or equipment shortages. Without studying these variables directly, this study cannot speak to their impact on time to OR posting or length of stay.

Limitations to the study include the inherent obstacles in surveys such as undetermined generalizability, recall bias, and non-response error. We observed a decrease in response rate from the pre-implementation to the post-implementation surveys. A limitation to this could be if the most dissatisfied participants declined to complete the survey. We do not believe that to be the case, however, as those who did complete the survey still had constructive comments or ideas for improvement while still noting that overall, they were satisfied with the implementation. This led us to believe that those who did not respond were more likely to be neutral or unavailable rather than dissatisfied. Another limitation is that a limited sample size from the chart review may have impeded a complete assessment of the clinical implications of a FPH.

Conclusions

The implementation of a formalized Emergency General Surgery Morning Handover is feasible, especially if streamlined with guidance via handover parameters and mandatory engagement. Following a six-month post-implementation period, responses regarding the formalized EGS Morning Handover indicated high regard for the Morning Handover and highly positive post-implementation staff buy-in from the perspective of patient care and personal development. Measured clinical outcomes of EGS handover implementation unexpectedly indicated an increase in time to OR posting, indicating the need for future analysis with multiple adjustments.

Supplementary Material

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Acknowledgements

Funding-

The project described was supported by the Wake Forest Institute of Regenerative Medicine (student stipend), National Center for Advancing Translational Sciences and National Institutes of Health through Grants UL1TR001420 and KL2TR001421. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Footnotes

Disclosure- none.

Study Type: Prospective Feasibility Study

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

1
NIHMS2020732-supplement-1.pdf (154.3KB, pdf)
2
NIHMS2020732-supplement-2.pdf (197.9KB, pdf)
3
NIHMS2020732-supplement-3.pdf (376.5KB, pdf)

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