Communication: Is There a Standard Handover Technique to Transfer Patient Care?

Effective communication is integral to patient safety, especially during high-risk periods where patients are transitioning to different care areas or to different providers. However, communication failures continue to occur; The Joint Commission (TJC) reports that the number one cause of anesthesia-related sentinel events is breakdown in communication.¹ The operating room (OR), the postanesthesia care unit (PACU), and the intensive care unit (ICU) are especially vulnerable to communication failures between providers; inadequate communication in the PACU has been shown to affect mortality and morbidity.^2,3 A review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS) indicated failure in communication as the second most common contributing factor to adverse events in recovery units.⁴ Indeed, observational studies have shown a direct correlation between poor handover and patient harm.⁵

Therefore, the handover process is critical to the safe care of the surgical patient. The handover is a transfer of not only information but also of professional responsibilities across teams.⁶ Ideally, a handover report is attended by surgical and anesthesia staff, a nurse, and a PACU or an ICU clinician, and relays information on the patient’s history, intraoperative events, and postoperative care plan. According to the American Society of Anesthesiologists, standard of care requires the presence of intraoperative anesthesia staff for monitoring during transport and verbal report.⁷ However, beyond this, there is a lack of consistent guidelines; reports are vulnerable to omission of pertinent information.⁸ A complete omission of information occurred in 57% of surgical malpractice claims⁹ and has been found to be one of the key factors in causing harm from miscommunication.⁸ The conditions of the perioperative environment, including time pressures, may influence the quantity and quality of data transferred during the handover.

Why is a Standardized Approach Needed?

TJC mandated that a standardized approach to handovers become a patient safety goal in 2006.¹⁰ By standardizing consistency in communication among providers, checklists have been used effectively to reduce morbidity and mortality in both medical and surgical settings.¹¹ Interventional studies in PACU have shown improvement in medical errors with the implementation of checklists.^12–15 In a multicenter handover intervention by Bigham and colleagues, a physical checklist decreased handover-related failures by 69% in a year.¹³ Another intervention using the “I-PASS Handover Bundle” by Starmer and colleagues led to a 23% relative reduction in overall medical errors and a 30% relative reduction in the rate of preventable adverse events.¹⁴

In addition to increased quantity of data transfer, checklist use is associated with improved nursing satisfaction and handover efficiency.¹⁶ Overall, a checklist accomplishes 2 goals: first, it provides a guideline to standardize information transfer; second, a physical checklist is used as a reminder to prevent omission of vital information.^17,18 This paper will discuss key challenges to handover communication, the need for standardization, and how best to implement and sustain quality improvement projects related to handovers.

Effective Communication

Effective communication is an integral component of patient safety. Because surgical patients undergo numerous transitions in care—from the preoperative environment, to the OR, to the PACU or ICU and then to the floor—their care must be handed over repeatedly from provider to provider, magnifying the potential for communication errors. In a review of surgical malpractice claims, up to 43% of communication breakdowns associated with patient injury occurred in connection to handovers.⁹ There are numerous challenges to effective communication during the handover process: distractions, recurring transfers of information with lack of standardization, and personnel dynamics.

Distractions

The literature related to patient harm as a result of distractions during perioperative handovers is conflicting. A study of surgical residents on a hepatobiliary service noted that distractions were present in 48% of handovers, characterized by pages, telephone calls, nonrelevant conversations, and general noise; however, although distractions increased the length of the handover process, these distractions did not impact handover quality.¹⁹ In contrast, Nagpal and colleagues found that distractions occurred in one-third of postoperative handovers. Distractions were a major contributor to handover failure, which was defined as incomplete transfer of information and omission of important tasks.²⁰ Interruptions during handover can certainly impact the quality of the handover and the satisfaction of both the delivering and receiving providers.

Transfer of Information

In many institutions, the transfer of information during the hand-over remains significantly unstructured. Lorinc and colleagues studied handovers between the OR and neonatal ICU and noted that there was significant variability in team members present, expectations of those team members, and information transferred. Interestingly, in patients who were more critically ill, there was a greater number of interruptions and the handover length was shorter and less thorough.²¹ Similarly, Mistry et al²² found that barriers to safe handovers included inconsistent participation of both receiving and delivering teams, poor standardization of information content, and multiple interruptions.

Because of such variability, there is significant potential for information loss during the handover procedure. One study found that many elements of patient care may not be communicated on handover to the PACU, including administration of vasopressors, fluids, and blood products, and insertion of arterial and central access. Many items that practicing anesthesiologists deemed “necessary in handover” were reported less than half of the time, and “type of surgery” was only reported 4% of the time.¹⁷ Similarly, Smith et al³ observed handovers in the PACU and noted that important events were often omitted. Production pressures may limit the time allotted to the handover, resulting in incomplete transfer of data.

The handover itself is comprised of information giving on the part of the delivering team and information seeking and verifying on the part of the receiving team. Manser et al²³ found that the greatest percentage of time during handover was spent in information giving, but assessment of the patient with predictions about the patient’s course may be more helpful to the receiving team. Indeed, time allotted during the handover to ask and answer questions may be valuable not only in the care of the patient but also in provider satisfaction. Standardization of handovers can decrease the incidence of lost information, reduce task errors, and improve teamwork and nurse satisfaction.²⁴

The quality of the handover may be compromised by the ready availability and accessibility of detailed intraoperative information in the electronic health record (EHR). Providers may deem the handover less important, given that much of the clinical information is already documented in the EHR. However, verbal face-to-face communication is fundamental in clinical discussion.²⁵ An official handover provides not only the overarching skeleton that the EHR can be used to supplement but also an opportunity for an interactive discussion about the patient that includes subjective input and observations not found in the EHR.^7,26 In addition to verbal communication, written notes and printed handouts can be helpful in preserving critical information.²⁷

Personnel Dynamics

Handovers occur among providers of different disciplines and training levels: anesthesiologist to anesthesiologist, anesthesiologist to anesthesiology trainee, anesthesiologist to PACU nurse, and many more. The effective transfer of information depends, in large part, on the communication skills of both the delivering and the receiving teams. However, historically, only 8% of medical schools in the United States teach how to conduct a proper handover.²⁸ There is evidence that there may be implicit status asymmetry in handovers between physicians and nurses, and that such hierarchy may prevent people from speaking up when something is wrong.^9,29,30 This so-called “authority gradient,” which occurs when team members have differing levels of professional stature or expertise, has been linked to severe errors including wrong-site surgery and even patient death.^31,32 In addition, the fast-paced and large volume nature of surgical care may result in teams who work together infrequently, exacerbating the authority gradient and producing unfamiliarity and the reluctance to speak up.

Each type of provider may have their own expectations about what is needed in the handover, based on what information they need to take care of the patient in the next phase of care. For example, nurses may focus more on the “big picture,” while physicians focus on critical details.³⁰ In addition, given the variable backgrounds of the delivering and receiving teams, it is possible that the receiving team member may not interpret the information in the same way as the delivering team member. The handover quality may vary considerably depending on the experience and training level of the delivering team member. Therefore, it may be helpful to bridge the gap between the 2 disparate teams by using a common “language”—for example, using a mnemonic such as SBAR (Situation, Background, Assessment, and Recommendation), or I-PASS, (Illness Severity, Patient Summary, Action List, Situational Planning, and Synthesis by Receiver).^30,33

Given such differences in training, baseline communication skills, and perceptions in status, simulation may provide an opportunity to standardize communication during the handover procedure. A pilot study of anesthesia residents found that omission of information was significantly decreased after simulation training and that these gains were sustained a year later.³⁴ Simulation may help team members define who needs to be present at the handover. Interprofessional teams, including nurses, anesthesia providers, respiratory therapists, and others, may benefit from the simulation setting to gain familiarity with one another and with each discipline’s particular role during the handover process.

Standardization in Perioperative Handovers

“Uncontrolled variation is the enemy of quality

—W. Edwards Deming³⁵”

Standardization of the handover may reduce potential harm during transitions of care. Encouraged by TJC since 2006,¹⁰ handover standardization may include the use of protocols, checklists, mnemonics, digital programs or apps, or other cognitive aids.³⁶ Standardization can be applied to the entire process by which care is transferred from one provider or team to another (ie, including the physical transfer of a patient with equipment and monitors from the OR to the ICU), or it can be applied to portions of the process, such as information transfer between the anesthesia provider and the ICU physician.

A number of studies have now been published evaluating interventions to improve perioperative handovers.^{12,15,37–42} Nearly all of them have included some sort of structured process and/or a standard tool. Standardization reduces unnecessary variation; despite individual clinicians’ assertions that their unique approaches to routine tasks are warranted, a significant portion of variability in practice is unnecessary.^43,44 By reducing unnecessary variation, processes become more reliable and more efficient; critical steps are more often adhered to and fewer steps are omitted.

What is the Best Way to Standardize?

To date, there is neither evidence nor consensus on the best way to standardize perioperative handovers. One of the first and most cited methods included a Formula 1 pit crew analogy, as described by Catchpole et al.¹⁵ Other widely accepted mnemonics, such as SBAR⁴⁵ or I-PASS,^14,33 have been used for information transfer, as have more granular checklists and mnemonics.^46,47

How to standardize and what to include in the standard process is best determined at an institutional or a unit-based level, with buy-in and involvement from all disciplines involved in the care transition. For example, if focusing on standardizing OR to PACU handovers, a group of attending anesthesiologists, anesthesia residents, nurse anesthetists, OR nurses, PACU nurses, nursing assistants, and surgical team members should be convened to determine how to standardize the handover process in a practical way that accommodates everyone’s needs. The act of standardizing the process will bring together viewpoints that may not otherwise be recognized, and may be more valuable than the details of the process itself.¹⁹ Some structured tools should be integrated to assist with information transfer, but the use of a checklist or mnemonic is likely more important than which checklist or mnemonic is used.

What Can We Learn From Other Industries?

Perioperative settings are high-risk areas. Handovers must occur while maintaining vigilant, uninterrupted care of the patient, often in noisy, chaotic environments filled with auditory and visual distractions, some related to patient care (patient monitors and alarms), and others not (loud music, conversations). Although other handover scenarios in medical care allow practitioners to step away from direct patient care during the handover, allowing focus and limiting distractions, this is simply not always possible during perioperative care. We may be able to learn from other high-risk industries where the handover of critical tasks is also performed without breaking from continuous responsibility.

Like perioperative personnel, air traffic controllers must maintain attention while transitioning from one person to another at the end of a shift. The Federal Aviation Administration has published standards for transfer of responsibility for air traffic controllers that outline the importance of a structured process to promote safe handovers.⁴⁸ The guideline recognizes that handovers are a time of increased workload and seeks to provide a method of reducing the mental workload by creating a standard process for shift changes, with outlined responsibilities for both the incoming and the outgoing personnel. Incoming personnel are asked to review the current situation before beginning the handover and use of checklists is encouraged. The requirement for an in-person verbal handover with opportunity for the relieving personnel to ask questions and have them be completely answered is explicitly stated in the guideline, along with a clear statement declaring that transfer of responsibility has occurred. The outgoing personnel also have responsibility to review the situation after the handover to make sure that all is well before leaving.

Common Elements for Standardized Perioperative Information Transfer

Although it is difficult to prescribe an exact process for each institution to follow for perioperative handovers, there are a number of guiding principles that are likely to be helpful in developing a standardized process. Completion of urgent tasks before beginning the handover, limiting distractions and interruptions, encouraging direct communication between providers (a “warm” handover), requiring that all relevant team members be present, and eliminating nonrelevant discussion during the handover are all important. Closed-loop communication and creating an opportunity for receiving providers to ask and answer questions can help team members create a shared mental models of the aspects of care that are most critical. Perhaps most importantly, use of a checklist or cognitive aid to assist in information transfer can standardize communication so that important elements are not missed.^20,49–51 Each institution will differ in specific elements to include in any perioperative handover. Some common postoperative handover checklist elements are provided in Table 1.

Table 1.

Common Postoperative Handoff Checklist Elements

Patient demographics

Patient identification (Name, Date of Birth, Medical Record Number)

Age

Diagnosis

Surgical procedure

Medical history

American Society of Anesthesiologists Physical Status

Pertinent previous medical history

Cardiac (coronary artery disease, heart failure, hypertension, arrhythmia)

Pulmonary (asthma, chronic obstructive pulmonary disease)

Neurological (transient ischemic attack/cerebrovascular accident, Parkinson)

Liver disease

Kidney disease

Metabolic disease (diabetes)

Infectious diseases (human immunodeficiency virus, hepatitis C)

Psychiatric disease

Substance use (alcohol, tobacco, drugs)

Anesthesia risks (malignant hyperthermia, postoperative nausea, and vomiting)

Allergies

Medications

Preoperative vital signs

Operative anesthetic management

Location and size of intravenous access

Invasive monitoring

Drugs

Premedications (sedatives, enhanced recovery pathway medications)

Antibiotics

Induction agents, maintenance of anesthesia

Opioids/pain control

Vasoactive drugs

Bronchodilators

Muscle relaxants and reversal agents

Antiemetics

Procedure-related drain care, restrictions on positioning

Anesthetic course

Difficulties with intravenous access

Airway management, including ease of intubation

Intraoperative hemodynamic instability

Electrocardiographic changes

Relevant intraoperative laboratory values

Fluid balance

Amount and type of intravenous fluid

Blood loss and any blood product transfusions

Estimated fluid losses including urine output

Postoperative management and course

Laboratory tests or imaging required in PACU

Post-PACU disposition (home, inpatient floor, ICU)

ICU indicates intensive care unit; PACU, postanesthesia care unit.

Reproduced with permission and originally published in Agarwala et al.⁵²

Implementation of Standardized Handovers

Challenges

A number of challenges are inherent in the implementation of any effort to improve perioperative handovers. Because handover settings can vary, transferability and generalizability may be challenging. For instance, the postoperative transition of care of a cardiac surgical patient from the OR to the cardiac surgical ICU will bear little resemblance to the signoff of the obstetric patients with an active labor epidural at the change of shift, but the same anesthesia provider may be involved in both transitions of care during a given week or month.^53,54 The challenge lies in recognizing which elements are essential to any handover and therefore transferable, versus which elements ought to be tailored to the specific environment. It is difficult to reap the benefit of standardization if a tool must be substantially altered to fit the common clinical scenarios.

Sustainability is another challenge. The intervention itself needs to be simple to execute and reinforced in preexisting systems—for instance, through incorporation of a checklist into the EHR or distribution of the checklist throughout the perioperative area. Further, efforts to onboard new providers will need to be outlined so that improvements achieved are not phased out over time as workforce turns over.

Finally, and perhaps most importantly, culture must be changed. Indeed, factors associated with a less successful implementation of quality improvement efforts include a lack of institutional commitment to improving patient safety, lack of leadership support for the program, absence of an institutional champion, and provider resistance.⁵⁵ Culture change begins with the development of the program and engagement of key stakeholders. I-PASS borrowed from the business literature in leveraging Kotter’s⁵⁶ 8-step model for transformational change, including establishing a sense of urgency, building a powerful coalition of leaders, creating the vision, communicating the vision, empowering others to act on the vision, planning for and creating short-term wins, consolidating improvements, and institutionalizing new approaches.⁵⁷ As health care providers, we can learn effective ways to enact change management from business and other spheres.

Handover Training

The cornerstone of implementing any successful handover program is training the practitioners. Education often occurs in traditional forums, such as grand rounds presentations or faculty development workshops.⁵⁷ To improve consistency from one training session to the next, it is important that trainers themselves are adequately trained. Videos or online training programs may be used to ensure that each group of trainees receives the same messages. Hands-on sessions incorporating practice handovers and role playing will reinforce the core elements of the handover program. Furthermore, ongoing peer review and direct observation by faculty or trainers is essential to ensure that the benefits reaped by a program are sustained over time.⁵⁷

Checklists are a common and effective component of a handover program.^{12,16,18,37,58} Embedding these tools in the handover environment allows the checklist to be readily utilized and adhered to. Examples include printing posters of the checklist or wallet-sized cards that can be hung from individual identification tags. When possible, incorporating the checklist into the EHR allows data to be auto-populated and eliminates reliance on the provider’s memory for specific details of, for instance, medication dosages or administration times.

Measures

As with any successful quality improvement project, it is important to measure the impact of a handover project over time. Process measures include the rate of adherence to a set handover outline or a tracking of handover score.⁵⁹ In their cardiac OR to cardiac SICU handover process implementation, the Mount Sinai Hospital in Toronto rated handover content, teamwork (eg, absence of interruptions, inclusion of readback), and patient care planning.⁵³ These metrics demonstrate the effectiveness of the roll-out and training sessions for a handover initiative. Outcome metrics should also be tracked; indeed, implementation of a handover program has been shown to reduce medical errors and preventable adverse events on the wards.⁵⁷ In the perioperative context, standardized handovers can reduce antibiotic delays and the number of hemodynamic and respiratory interventions required postoperatively.⁶⁰ Finally, with any new initiative, balance measures should also be used to ensure that any unintended consequences are recognized and negative effects are mitigated. Balancing measures may include length of handover and provider satisfaction.^18,53

Summary

Perioperative handovers are a complex process that has the potential to lead to patient harm. The lack of standardization among team members present and information provided can lead to failure of communication of vital information. Standardization of the handover process can help mitigate potential errors, but must occur at the local, institutional level. In addition, the process of implementation of the standardized handover process must include measures to ensure sustainability of the initiative. Effective communication is critical to transferring patient care in a way that mitigates harm.