Hand-offs and Transitions in Care

[Richard Corcoran]

Communication, team culture, shift reports, sign outs, hand-offs, and lack of information have been identified as key recurring organizational system problems that increase the likelihood of hospital errors. A root cause analysis of 2,966 hospital “sentinel events” (JCAHO defined) between 1995-2004 identified “communication” problems as a primary root cause in nearly 2/3 of them. Lack of communication on patient status at 'hand-off' has been cited as the single most common reason for adverse events.

A hand-off, simply defined, is the transfer of care from one provider (team of providers, unit, shift, facility, etc.) to another provider (team of providers, unit, shift, facility, etc.). The handoff is a mechanism for transferring information, primary responsibility, and authority from one or a set of caregivers to another. Hospital hand-offs occur upon admission, at shift changes, before and after procedures (both diagnostic and therapeutic), upon unit changes, and at discharge.

Two decades of focused study have clearly identified hand-offs as a major patient safety issue. Evidence clearly demonstrates that hospital hand-offs are high-risk, high frequency events in which critical information must be transferred completely and accurately with a narrow margin for error in an environment that, in many ways, either allows or promotes failure. Communication failures occur in 80% of malpractice cases and significantly increase the costs of providing care. Communication failures become very visible to everybody involved, patients and families included, thereby creating confusion, anxiety, and eroding trust. Patient outcomes, satisfaction, and compliance with the plan of care fall sharply.

Hand-offs are the price we pay for the increasing complexity of hospital care and the benefits of advances in medical and nursing practice, medical technology, and specialized life saving and life-enhancing care. We now recognize that our human cognitive and communication skills have simply not kept pace with our medical, nursing, and rehabilitative skills and technologies.

Improving communication at hand-offs and transitions in care has been the subject of intense study, research, and discussion by many individuals and organizations for the past decade. Out of this effort has emerged clear evidence about what works and what doesn’t, best practices that provide the context for improvement, and tools to help you improve in your hospital. This thread is intended to share and discuss what you need to know about how to create totally effective hand-offs and transitions in your hospital.

The following commonly accepted principles of error-free hand-offs may help you get started thinking about what steps you can take to improve:

Communicate interactively, allowing and promoting questions between the giver and receiver of information.
Communicate up-to-date information regarding care, treatment, services, condition, and recent or anticipated changes.
Limit interruptions to avoid losing or skewing the information shared.
Allow sufficient time to complete the hand-off.
Require a verification process – repeat-backs or read-backs as appropriate.
Insure that the receiver of information has the opportunity to review relevant historical data, including previous care treatment services.Future posts to this thread will include specific information on resources and practical, evidence-based tools (e.g. S-BAR, Checklists, Briefs-Huddles-Debriefs, etc.) that have become available. As we proceed, feel free to post your own thoughts, questions, or experiences in this area.

[Richard Corcoran]

Lack of communication on patient status at 'hand-off' has been cited as the single most common reason for adverse events. A root cause analysis of 2,966 hospital “sentinel events” between 1995-2004 identified “communication” problems as a primary root cause in nearly 2/3 of them (cf. attached Root Cause chart).

Because of this compelling evidence, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) established a new National Patient Safety Goal for hospitals and critical access hospitals in 2006. Goal 2E (http://www.jcaho.org/accredited+organizations/patient+safety/06_npsg/06_npsg_cah_hap.htm) requires that hospitals “Implement a standardized approach to ‘handoff’ communications, including an opportunity to ask and respond to questions.”

Patient “handoffs” occur several times during a typical hospital stay, including -

Nursing shift or unit change
Physician-Physician Report: Consults, Case Transfers or on-call responsibility
Within or between specialty areas: Anesthesia to PACU nurse, Pre-admission Testing to Ambulatory Surgery, Radiology/Endoscopy/Labs to units
Nurse-MD handoff to inpatient unit
Critical lab-imaging reports
Hospital transfers, Nursing home/Home health
Emergency or Crisis Interventions: Rapid Response Teams, Code Blue, Mental Health Codes, or Emergency Services
Medical School Staff: residents, interns, medical students to any provider
Other transitions in care (e.g. admission, discharge)We all know that there are many factors that can make communication difficult between individuals and within a team. Some people, due to culture, experience or personality become intimidated easily, find it hard to speak directly with a professional superior, or maintain the appropriate assertiveness and tenacity needed in making key points. This causes a breakdown of communication to take place. Part of the reason this breakdown occurs is also because different members of the team have different communication styles, or have been trained to communicate in different ways. SBAR is a powerful tool borrowed from the military that enables individuals on a team to communicate with greater clarity and focus.

SBAR stands for Situation, Background, Assessment and Recommendation. It is a proven structure for sharing information when nurses, doctors or any member of the clinical team need to communicate about a patient’s condition. It provides a standardized framework for communication between members of the health care team. SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician's attention and action. It allows for a straightforward way to set expectations for what will be communicated and how between members of the team. This is essential for developing teamwork and fostering a culture of patient safety.

At the heart of SBAR is a process that is shared (and sometimes a form that is filled out and shared) with the other health care professionals treating the patient. It is divided into four sections:

Situation: the punch line 5-10 seconds (this includes patient identification information, code status, vitals, and provider concerns)
Background: the context, objective data, how did we get here (information is noted on patient's mental status, skin condition, whether he or she is on oxygen and other relevant facts)
Assessment: what is the problem? (here the provider indicates what he or she believes to be the problem)
Recommendation: what do we need to do? (follow-up actions are suggested, including possible tests)Originally used to improve nurse to physician communication regarding significant changes in a patient’s condition, the SBAR process has been successfully used to improve communication between and among provider teams. Though not a “magic bullet”, SBAR is a standardized, focused, direct, thoughtful, and relevant two-way communication regarding a patient’s condition and care needs. The technique is adaptable enough to incorporate various levels of detail or triggers to fit into your hospital systems.

Put into practice, hospitals and clinicians have found that SBAR not only supports patient quality and safety but offers many secondary benefits. It is efficient, streamlining the communication in a sequential logical form that is easier to respond to. It limits duplicate calls, convoluted planning, reactive and less effective action plans, etc. It builds consistency and dependability - thus trust and teamwork. There have also been a few studies that show increased professional satisfaction among teams that use SBAR.

The IHI 100K Lives Campaign Rapid Response Team initiative points to the need for highly reliable and standardized formats for emergency communications and promotes the SBAR technique (http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingM odel.htm) as one proven briefing method (cf. attached SBAR report). You may also want to check out how Vanderbilt University Medical Center has recently adopted the SBAR technique as a template for system-wide information exchange via their 2005 Hand-Off Communication Policy (http://vumcpolicies.mc.vanderbilt.edu/E-Manual/Hpolicy.nsf/AllDocs/7B944642C6E02F09862570DE0071A4AD).

Feel free to ask questions about or share your own experience with SBAR.

[Richard Corcoran]

I’m attaching an update below from the Institute for Healthcare Improvement (IHI) regarding an upcoming program offering that may interest those of you who are considering using the SBAR technique to improve communication between caregivers in your facility. This is a three-session program (90 minutes each on June 29th, July 20th, and August 9th) and there is a fee.

[Richard Corcoran]

The following question was recently posed on the Patient Safety Talk (PST) listserve –

Does anyone have any tips for successful implementation of SBAR?


One of the PST participants responded with what I consider a really good answer. She advises (I’m paraphrasing here) to start small, pilot the process in a limited area, learn some lessons, make appropriate changes, and then spread elsewhere. Seems like sound advice to me.

She lists five steps in the process (again, I’m paraphrasing) -

§Draft a tool and policy
§Pilot for 1 week
§Discuss outcomes and address staff issues
§Make changes to the policy and the tool
§Implement house wide


I’m attaching the Handoff Policy and SBAR tool shared on PST. The policy applies to all hospital departments. The SBAR tool is used to prepare and support the handoff, but does not become part of the medical record. Specific clinical information recorded on the tool can be modified as appropriate by each department.

Take a look and let me know if this is useful to you!

[Richard Corcoran]

For those of you who are thinking about implementing SBAR or who have already begun the process, this audioconference may interest you. Both speakers have experience with SBAR and Rapid Response Teams (RRT). The attached email from HCPro has the details. There is a fee.

[Richard Corcoran]

In a perfect world, accurate and meaningful medical information moves with the patient, so caregivers can stay informed at every turn. Although the goal is for a seamless transition, the hand-off from one caregiver to another, one unit to another, one shift to another, patient care can often be disrupted due to:

interruptions
lack of clarity with the process
non-standardized technique
incomplete information.We all recognize that hospital handoffs occur in a complex, demanding, and risky environment. Much of our current understanding of how to improve handoff communication is based on study and analysis of how communication occurs in other high-risk environments. A 2004 report published in the International Journal for Quality in Health Care, “Handoff strategies in settings with high consequences for failure: lessons for health care operations”, describes strategies employed during handoffs in four complex, high-risk settings (NASA, nuclear power, railroad dispatch, and ambulance dispatch) in terms of 21 handoff strategies recommended for health care. These settings were chosen because of their similarities to health care settings:

complex, interconnected systems
event-driven
time-pressured
resource-constrained
work distributed across multiple people in dedicated roles with specialized knowledge
potential for high consequences for system failureSound familiar?

The report identifies that 19 of the 21 hospital handoff strategies occur in other high-risk settings and discusses how these strategies can by applied in hospitals more successfully. This discussion may be useful to you in understanding how to modify handoff procedures to improve patient safety.

Click here (http://csel.eng.ohio-state.edu/woods/medicine/final%20handoffs.pdf) to access the full report.

[Richard Corcoran]

For far too many reasons, what I say to you may not be what you hear. One way to increase the likelihood that what I’ve said has been accurately heard is for you to repeat back what I said. If what I hear you say is what I said, this closes the communication loop. But if what I hear you say is not what I said, we can repeat the process until the loop is closed. This activity has been enshrined as one of the Joint Commission’s National Patient Safety Goals for 2007 – 2A (http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_hap_cah_npsgs.htm), applied to verbal or telephone orders and for the reporting of critical test results by telephone.

The process described above is called “readback/hearback.” Developed largely in the transportation industry, it’s a technique for improving the reliability of information exchanged among two or more people. Readback/hearback can also be applied during patient handoffs. Depending on the circumstances, the technique can be applied on it’s own or incorporated into SBAR.

Click here (http://www.jcipatientsafety.org/fpdf/psp/JournalArticles/JQS-08-04-JeffBrown.pdf) to read more.

[Richard Corcoran]

Communication failure is the leading cause of medication errors in the perioperative setting, according to a new MEDMARX report released by United States Pharmacopeia (USP) in partnership with the Uniformed Services University of the Health Sciences, the Association of perioperative Registered Nurses, and the American Society of Perianesthesia Nurses.

The report tracked more than 11,000 medication errors, 5% of which led to harm and four deaths. The report makes 47 recommendations to reduce medication errors, including dedicating a pharmacist to the perioperative unit and improving hand-off coordination.

According to this week’s press release (http://vocuspr.vocus.com/vocuspr30/Newsroom/Query.aspx?SiteName=uspharm&Entity=PRAsset&SF_PRAsset_PRAssetID_EQ=103331&XSL=PressRelease&Cache=)-

“What many people generically call “surgery” is actually a system of several different departments that patients must be transported through to receive perioperative care and each department is likely to have different teams of healthcare providers.

“Even if located along a single hallway, these departments can be remarkably disconnected from one another,” says Diane Cousins, R. Ph., vice president of USP’s Healthcare Quality Information department and one of the authors of the report. “The fragmented system creates a high risk for harmful medication errors.”

To improve patient safety and reduce the risk of medication errors, USP recommends that hospitals and health systems dedicate pharmacists to the perioperative units so they can oversee the distribution of medications and that surgical staff better coordinate hand-offs to eliminate the loss of patient information.”The complete report, MEDMARX® Data Report A Chartbook of Medication Error Findings from Perioperative Settings From 1998–2005, can be ordered from USP by clicking here (http://www.usp.org/products/medMarx/).

[Allison]

Lack of communication on patient status at 'hand-off' has been cited as the single most common reason for adverse events. A root cause analysis of 2,966 hospital “sentinel events” between 1995-2004 identified “communication” problems as a primary root cause in nearly 2/3 of them (cf. attached Root Cause chart).

Because of this compelling evidence, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) established a new National Patient Safety Goal for hospitals and critical access hospitals in 2006. Goal 2E (http://www.jcaho.org/accredited+organizations/patient+safety/06_npsg/06_npsg_cah_hap.htm) requires that hospitals “Implement a standardized approach to ‘handoff’ communications, including an opportunity to ask and respond to questions.”

Patient “handoffs” occur several times during a typical hospital stay, including -

Nursing shift or unit change
Physician-Physician Report: Consults, Case Transfers or on-call responsibility
Within or between specialty areas: Anesthesia to PACU nurse, Pre-admission Testing to Ambulatory Surgery, Radiology/Endoscopy/Labs to units
Nurse-MD handoff to inpatient unit
Critical lab-imaging reports
Hospital transfers, Nursing home/Home health
Emergency or Crisis Interventions: Rapid Response Teams, Code Blue, Mental Health Codes, or Emergency Services
Medical School Staff: residents, interns, medical students to any provider
Other transitions in care (e.g. admission, discharge)We all know that there are many factors that can make communication difficult between individuals and within a team. Some people, due to culture, experience or personality become intimidated easily, find it hard to speak directly with a professional superior, or maintain the appropriate assertiveness and tenacity needed in making key points. This causes a breakdown of communication to take place. Part of the reason this breakdown occurs is also because different members of the team have different communication styles, or have been trained to communicate in different ways. SBAR is a powerful tool borrowed from the military that enables individuals on a team to communicate with greater clarity and focus.

SBAR stands for Situation, Background, Assessment and Recommendation. It is a proven structure for sharing information when nurses, doctors or any member of the clinical team need to communicate about a patient’s condition. It provides a standardized framework for communication between members of the health care team. SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician's attention and action. It allows for a straightforward way to set expectations for what will be communicated and how between members of the team. This is essential for developing teamwork and fostering a culture of patient safety.

At the heart of SBAR is a process that is shared (and sometimes a form that is filled out and shared) with the other health care professionals treating the patient. It is divided into four sections:

Situation: the punch line 5-10 seconds (this includes patient identification information, code status, vitals, and provider concerns)
Background: the context, objective data, how did we get here (information is noted on patient's mental status, skin condition, whether he or she is on oxygen and other relevant facts)
Assessment: what is the problem? (here the provider indicates what he or she believes to be the problem)
Recommendation: what do we need to do? (follow-up actions are suggested, including possible tests)Originally used to improve nurse to physician communication regarding significant changes in a patient’s condition, the SBAR process has been successfully used to improve communication between and among provider teams. Though not a “magic bullet”, SBAR is a standardized, focused, direct, thoughtful, and relevant two-way communication regarding a patient’s condition and care needs. The technique is adaptable enough to incorporate various levels of detail or triggers to fit into your hospital systems.

Put into practice, hospitals and clinicians have found that SBAR not only supports patient quality and safety but offers many secondary benefits. It is efficient, streamlining the communication in a sequential logical form that is easier to respond to. It limits duplicate calls, convoluted planning, reactive and less effective action plans, etc. It builds consistency and dependability - thus trust and teamwork. There have also been a few studies that show increased professional satisfaction among teams that use SBAR.

The IHI 100K Lives Campaign Rapid Response Team initiative points to the need for highly reliable and standardized formats for emergency communications and promotes the SBAR technique (http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingM odel.htm) as one proven briefing method (cf. attached SBAR report). You may also want to check out how Vanderbilt University Medical Center has recently adopted the SBAR technique as a template for system-wide information exchange via their 2005 Hand-Off Communication Policy (http://vumcpolicies.mc.vanderbilt.edu/E-Manual/Hpolicy.nsf/AllDocs/7B944642C6E02F09862570DE0071A4AD).

Feel free to ask questions about or share your own experience with SBAR.
has any recently used this tool and how is it going??

[Allison]

:confused: any input on ahnd off communication tools

[Richard Corcoran]

Hi Allison,

Just want you to know that both your questions are noted. I would invite any reader of this forum to feel free to address Allison's questions. :)

Here's my quick response:

As to the use of SBAR, many, many hospitals have been using SBAR successfully for some time now. Policies, procedures, and tools abound. I'm in the process of collecting materials that I will post on JENY in the near future to describe how SBAR has been used, to what effect, and to share some of the tools hospitals are using. Keep an eye out for that. One of the primary lessons learned from field experience has been, no matter what tools and documents are used, training and practice in the SBAR communication skills are key to improving the flow of important clinical information during handoffs. Confidence and results come through practice and doing.

Your second question regarding what specific handoff tools to use seems tightly bound to the context and culture of the hospital. Again, many hospitals have tried many tools. SBAR, and its variants, being one of the most frequently implemented. I have been observing that those hospitals that have taken on the rather daunting task of improving their "patient safety culture" and spend some time trying to create a "non-punitive" environment (read "just culture") seem to benefit greatly from this effort. I'd be interested if any reader is seeing the same thing?

Allison, thanks for the questions.

[Richard Corcoran]

The GreaterNew York Hospital Association (GNYHA) and United Hospital Fund (UHF) presented a conference over two days entitled -SBAR and Beyond: A Framework for Patient Safety. Materials from these sessions – held on April 12 and 13, 2007are posted in this JENY thread.

Click here (http://jeny.ipro.org/showthread.php?p=2967) to find a treasure trove of useful, downloadable information and tools.

[Richard Corcoran]

The Association of periOperative Registered Nurses (AORN) and the U.S. Department of Defense Patient Safety Program collaboratively developed a new Web-based tool kit that provides the resources to guide perioperative professionals in standardizing hand-off communications among caregivers.

The AORN Patient Hand-Off Tool Kit includes supporting research for evidence-based recommendations on perioperative patient hand offs, sample checklists and forms, PowerPoint presentations on standardizing communication and information exchanges in perioperative practice, and an annotated guide to additional resources.

Click here (http://www.aorn.org/toolkit/patienthandoff/) to download the tool kit components free of charge.

[mariefel35]

hi Allison,

our establishement is in the process of utilizing this method...

right now, we just do verbal hand-off, nothing on paper...:o

[Richard Corcoran]

For those of you who are in the process of drafting, editing, reviewing, comparing or who are otherwise interested in hand off communication policies, I’m attaching a few that I’ve been collecting from various sources. All of these are currently being used or considered for use by hospitals that want to insure that the right information is available at the right time to the provider next in line.

Feel free to take what you need to assess, develop, or improve your own policies.

[Richard Corcoran]

For those of you who are in the process of drafting, editing, reviewing, comparing or who are otherwise interested in hand off communication forms, I’m attaching a few that I’ve been collecting from various sources. All of these are currently being used or considered for use by hospitals that want to insure that the right information is available at the right time to the provider next in line.

Feel free to take what you need to assess, develop, or improve your own forms and guidelines.

[William Gardiner]

Recently, a question was asked about SBAR methodology and if there were any resources available. The following attachments were shared by the Performance Improvement QIOSC.

An SBAR worksheet
A physician worksheet
Two PowerPoint presentations outlining SBAR methodology and it's applications
A guidelines sheet.If you have any questions, please contact William Gardiner at 518.426.3300, extension 105 or by e-mail at: wgardiner@nyqio.sdps.org

[pgammon]

Well-designed recording and playback systems for Hand-off Reports that also document the process while permitting and encouraging questioning, feedback, and clarity, improves overall hand-off communication and provides quality and accurate hand-off reports. Standardized reports using SBAR (or other standard's based templates) can be implemented more easily with a system that actually prompts the nurse for each piece of information needed. A telephone based solution for hand-off reports can be used much like a tape recorder (on steroids) without having to deal with multiple tapes or broken recorders. Just use any telephone (wired or wireless). 100's of hospitals and 1,000s of users worldwide have standardized their hand-off communication and reports with a system like this. The value of automated hand-off systems and the significant benefit they provide to nurses and PATIENTS is enormous.

Although the Joint Commission stresses having face to face time before a shift departs, for report and Q&A, an automated hand-off reporting system can provide a unique ability to allow the nurse (or other care providers such as therapist, case worker, etc) to record or add to the hand-off report at any time during the shift and provide more accurate information. Recording the patient information during a shift rather than waiting to the end of the shift also prevents critical information from being forgotten or misplaced. The report can be added to during the shift as items come up with regard to a patient. Care providers other than the nurse (therapist, etc) can record their report as well. The benefit is that hand-off reports are finished well before the end of the shift so that the current shift nurses are making their final patient rounds, while the incoming shift can relax with a coke or coffee and (using any telephone in the hospital) listen to the hand-off reports for all of their patients while making notes of any questions they may have. THEN, before the current nurse leaves for the day, the nurses have their face-face meeting but now, instead of 30-45 min., its 10-15 for confirmation of the report that has already been heard and opportunity to ask and answer any questions. A recording system like this can also be used to supplement bedside reports.

Transfer of patients from one unit to another (or transfer to an outside agency - nursing home, etc) can be automated by allowing the patient's nurse to record a transfer hand-off report. The system then calls the receiving unit and announces that a report needs to be heard. When the new unit's nurse listens to the transfer report, the system then calls the sending unit back and let's them know the patient's report has been heard and the patient can be transferred. The transfer is made without the nurses playing telephone tag due to what could be called....nurse unavailability.

Hospitalists are also required to provide hand-off report to the next physician. And an automated system, developed originally for and by nurses, can be used here as well.

A system like this could also provide the ability to record patient status reports for family members, and discharge instructions for the patient (so they don't call the nurse when they get home and forget what they've been told). This significantly reduces the number of interruptions a nurse receives during the shift to answer the phone.

Automated system reports can be provided to allow nurse managers to document system use, as well as its value and efficiency. Nurse Managers could use this system to "audit" their nurse's hand-off reports for quality and compliance with established standard's based reporting templates (SBAR, ISBAR, etc). Time is saved, the quality of hand-off reports goes up (and is standardized), and patient care is improved......a win-win situation for everyone.

Pete Gammon
VoiceCare
pgammon@voicecare.com
www.voicecare.com
(Attend one of our weekly webinars)

[sahod]

:confused: any input on ahnd off communication tools


A client of mine has had some success with an "enabling technology" called Voicecare. You can see more about it here (http://www.voicecare.com/index.asp?mid=77). Feel free to visit my website for more information on our hospital quality improvement (http://mavhc.com)services.