Efren Manjarrez, MD

In the 15 years since Wachter and Goldman coined the term hospitalists, the specialty of Hospital Medicine grew faster than any other in the history of American medicine.1 The early drivers for growth were largely economic: There were significant reductions in resource use, with a 13% decrease in hospital costs and a 16% decrease in hospital lengths of stay (LOS).2 Hospitalist clinician‐educators increased the satisfaction of residents and medical students in academic settings.2 Patient satisfaction and hospital mortality did not suffer.2

Recent growth of Hospital Medicine revolves around 3 drivers: 1) improving quality and safety of hospitalized patientsowing in large part to the Institute of Medicine's 2 compelling reports, To Err Is Human3 and Crossing the Quality Chasm4; 2) hospitalist and specialist (surgeon) comanagement; and 3) the effects of duty hours restrictions imposed by the Accreditation Council for Graduate Medical Education affecting United States (US) teaching hospitals.5

In this issue of the Journal of Hospital Medicine, Shu and colleagues6 report on the performance of a hospitalist program in Taiwan. To the best of our knowledge, this report from Asia is the first published report of a successful hospitalist model with measurable patient outcomes outside of North America. Specifically, over a year, the authors found that patients admitted by hospitalists had a shorter LOS and lower cost per case, with no difference in in‐hospital mortality and 30‐day readmission. These results were obtained despite the fact that the cohort of patients admitted to the hospitalist team was older, sicker, and had worse functional capacity. Additionally, the patients admitted to the hospitalist team, and who died during hospitalization, were more likely to have a do‐not‐resuscitate (DNR) order signed, when compared with those patients admitted to the general internal medicine teaching service. Comparing LOS with North America may be problematic. As Shu and colleagues6 point out, there are cultural and economic issues that affect the behavior of patients and physicians in Taiwan.

The healthcare system in Taiwan has similarities to the healthcare systems in the United Kingdom (UK) and the US. In 1995, Taiwan implemented a national health insurance system. The UK has had a National Health Service for many years that provides most services for free. The Taiwanese system requires modest copayments for services. The implementation of the national health insurance system in Taiwan increased healthcare access from 57% of the population to 98%.7 The increase in insurance across the population with modest copayments has made it possible for a larger percentage of the population to access the healthcare system.7 According to the authors, this has resulted in increased hospital admissions (35% in the decade since the introduction of national health insurance), resulting in a shortage of Hospital Medicine physicians and hospital beds.7 Compounding the stressors on this system is that the diagnosis related group (DRG) reimbursement model, similar to the American DRG reimbursement model, will soon take effect in Taiwan. As a result, our colleagues in Taiwan are experiencing issues commonly faced by mature hospitalist programs in the US: increased needs in efficiency to improve patient flow and decrease emergency room overcrowding and LOS; and concerns with safe discharges of high‐risk patients while ensuring outpatient follow‐up. This is a scenario with which US hospitalists are all too familiar.

The next step for Taiwan might be to implement a culturally specific patient education program regarding the discharge process. The first step would be a needs assessment survey of patients in Taiwan, inquiring about concerns regarding readiness for discharge. They might inquire about patient beliefs regarding understanding indications for inpatient hospitalization versus discharge to home, home with home services, or skilled nursing facilities. They might be able to drill down to the root cause of refusal to be discharged home. These data could help our colleagues in Taiwan create their own discharge program to drive down LOS closer to that of the US and other Western countries, in order to reap financial benefits and improve resource utilization.

What do we know about the growth of Hospital Medicine around the world? The Society of Hospital Medicine (SHM) reports international members from 26 countries around the world. In North America, SHM members are found in the US, Canada, and Bermuda. In Europe, SHM members are found in England, Ireland, Scotland, Spain, Belgium, Portugal, Italy, and Germany. In South America, SHM members are found in Brazil, Chile, Colombia, and Argentina. In Asia and the Middle East, SHM has members in Saudi Arabia, Israel, United Arab Emirates, Pakistan, Japan, China, the Philippines, and Singapore. In Oceania, SHM has members in Australia, and New Zealand. In Africa, 1 SHM member is from Nigeria (Society of Hospital Medicine Data, 2011). In fact, the International Hospitalists Section of SHM is 1 of only 2 sections that the Society recognizes.

Hospitalists are organizing themselves abroad as well. In Canada, the Canadian Society of Hospital Medicine was founded in 2001 and has had 8 national conferences to date.8 There are roughly 1,000 Canadian hospitalists (Wilton D, personal communication, 2011). Whereas most US hospitalists are internists or pediatricians, in Canada, most hospitalists are family physicians. In the US, hospitalists are more likely to perform the following services: consultation, intensive care unit patient care, rapid response team service, surgical comanagement, and evening on‐site coverage. Canadian hospitalists are more likely to provide pediatric care and psychiatry inpatient comanagement.9

In the UK, the professional organization of physicians most similar to US hospitalists, acute physicians, is called SAM (The Society for Acute Medicine). It was founded in 2000.10 In the UK, general practitioners (GPs) never care for inpatients; at the time, GPs referred all admissions to organ‐specific specialists (eg, cardiologists). Acute medicine was created due to the realization that medical inpatients were too complex to have specialists managing them. Training programs were set up circa 2003 to create this specialty and address this need. Acute physicians staff geographically localized acute medicine units near emergency departments. These patients stay 1 to 3 days in an effort to concentrate services and resources to these patients, to prevent longer stays once fully admitted (Smith R, personal communication, April 23, 2011). Acute medicine units in the UK, Ireland, and Australia have led to positive benefits on patient outcomes. A review article by Scott and colleagues revealed reductions in LOS, inpatient mortality, and emergency department LOS, without increased 30‐day readmission rates. They found increased staff and patient satisfaction, and more medical patients discharged directly to home from acute medical units.11 The development of acute medicine in Australia and New Zealand began around 2005 and derives from the geographic localization of the UK model. Whereas the UK model has a focus on the first 72 hours of hospitalization, the model in Australia and New Zealand is more similar to the US model of following patients through their entire admission.12 Unlike the UK, Australia does not have dedicated acute medicine training programs.

PASHA, the Pan‐American Society of Hospitalists, is a loose affiliation of hospitalists largely in South America, linking with their North American colleagues. PASHA grew out of SOBRAMH, Sociedade Brasileira de Medicina Hospitalarthe first Hospital Medicine Society in South America, tracing its roots to 2004. To date, PASHA has had 1 international conference, but there have been 2 national conferences each in Brazil and Chile, and 1 in Colombia. The concept and advantages of Hospital Medicine have been presented at a conference in Panama. Argentina has its first Hospital Medicine Congress scheduled for September 2011, in concert with PASHA.

Two Hospital Medicine programs abroad deserve special mention. Both started in 2005 and have instituted the full hospitalist package, including multiple evidence‐based order sets at both sites (eg, deep vein thrombosis [DVT] prophylaxis and hyperglycemia management). At the Pontificia Universidad Catlica in Santiago, Chile, they have been awarded national grants to study hyperglycemia in hospitalized patients, and they have sent their faculty to the US for additional training in patient safety, quality improvement, leadership, and medical informatics. They have succeeded in decreasing LOS and improved the exam grades of their learners. Their faculty has published in national journals and is now beginning to submit their work for publication in US‐based journals (Rojas L, personal communication, April 22, 2011). The Clnica Universidad de Navarra (CUN) in Pamplona, Spain is a Joint Commission certified facility with a full electronic medical record. Hospitalists there are looking at ways in which hospitalist‐staffed intermediate care units can benefit patient outcomes. Additionally, they have comanagement arrangements with nearly all surgical subspecialties. The Management of the Hospitalized Patient symposium was organized by CUN hospitalists in 2007the first Hospital Medicine Congress, to our knowledge, in continental Europe. At any one time, 30% of all residents in all specialties rotate with CUN hospitalists (Lucena F, personal communication, April 22, 2011).

The specialty of Hospital Medicine is truly global. Our colleagues around the world employing the hospitalist model of care are now producing outcomes similar to the published models in North America and to the acute medicine models in Europe and Australia. According to the Society of Hospital Medicine, there are over 30,000 hospitalists in the US. There could be well over 50,000 hospitalists around the world. In 5 years, the world may have 100,000 hospitalists. The same drivers are fueling the growth of Hospital Medicine around the world. The evidence is building that the hospitalist model of care has financial and quality benefits that transcend borders. We forecast that the hospitalist model of care will become an increasingly larger part of the solution around the world to fix these international healthcare systems.

In the 15 years since Wachter and Goldman coined the term hospitalists, the specialty of Hospital Medicine grew faster than any other in the history of American medicine.1 The early drivers for growth were largely economic: There were significant reductions in resource use, with a 13% decrease in hospital costs and a 16% decrease in hospital lengths of stay (LOS).2 Hospitalist clinician‐educators increased the satisfaction of residents and medical students in academic settings.2 Patient satisfaction and hospital mortality did not suffer.2

Recent growth of Hospital Medicine revolves around 3 drivers: 1) improving quality and safety of hospitalized patientsowing in large part to the Institute of Medicine's 2 compelling reports, To Err Is Human3 and Crossing the Quality Chasm4; 2) hospitalist and specialist (surgeon) comanagement; and 3) the effects of duty hours restrictions imposed by the Accreditation Council for Graduate Medical Education affecting United States (US) teaching hospitals.5

In this issue of the Journal of Hospital Medicine, Shu and colleagues6 report on the performance of a hospitalist program in Taiwan. To the best of our knowledge, this report from Asia is the first published report of a successful hospitalist model with measurable patient outcomes outside of North America. Specifically, over a year, the authors found that patients admitted by hospitalists had a shorter LOS and lower cost per case, with no difference in in‐hospital mortality and 30‐day readmission. These results were obtained despite the fact that the cohort of patients admitted to the hospitalist team was older, sicker, and had worse functional capacity. Additionally, the patients admitted to the hospitalist team, and who died during hospitalization, were more likely to have a do‐not‐resuscitate (DNR) order signed, when compared with those patients admitted to the general internal medicine teaching service. Comparing LOS with North America may be problematic. As Shu and colleagues6 point out, there are cultural and economic issues that affect the behavior of patients and physicians in Taiwan.

The healthcare system in Taiwan has similarities to the healthcare systems in the United Kingdom (UK) and the US. In 1995, Taiwan implemented a national health insurance system. The UK has had a National Health Service for many years that provides most services for free. The Taiwanese system requires modest copayments for services. The implementation of the national health insurance system in Taiwan increased healthcare access from 57% of the population to 98%.7 The increase in insurance across the population with modest copayments has made it possible for a larger percentage of the population to access the healthcare system.7 According to the authors, this has resulted in increased hospital admissions (35% in the decade since the introduction of national health insurance), resulting in a shortage of Hospital Medicine physicians and hospital beds.7 Compounding the stressors on this system is that the diagnosis related group (DRG) reimbursement model, similar to the American DRG reimbursement model, will soon take effect in Taiwan. As a result, our colleagues in Taiwan are experiencing issues commonly faced by mature hospitalist programs in the US: increased needs in efficiency to improve patient flow and decrease emergency room overcrowding and LOS; and concerns with safe discharges of high‐risk patients while ensuring outpatient follow‐up. This is a scenario with which US hospitalists are all too familiar.

The next step for Taiwan might be to implement a culturally specific patient education program regarding the discharge process. The first step would be a needs assessment survey of patients in Taiwan, inquiring about concerns regarding readiness for discharge. They might inquire about patient beliefs regarding understanding indications for inpatient hospitalization versus discharge to home, home with home services, or skilled nursing facilities. They might be able to drill down to the root cause of refusal to be discharged home. These data could help our colleagues in Taiwan create their own discharge program to drive down LOS closer to that of the US and other Western countries, in order to reap financial benefits and improve resource utilization.

What do we know about the growth of Hospital Medicine around the world? The Society of Hospital Medicine (SHM) reports international members from 26 countries around the world. In North America, SHM members are found in the US, Canada, and Bermuda. In Europe, SHM members are found in England, Ireland, Scotland, Spain, Belgium, Portugal, Italy, and Germany. In South America, SHM members are found in Brazil, Chile, Colombia, and Argentina. In Asia and the Middle East, SHM has members in Saudi Arabia, Israel, United Arab Emirates, Pakistan, Japan, China, the Philippines, and Singapore. In Oceania, SHM has members in Australia, and New Zealand. In Africa, 1 SHM member is from Nigeria (Society of Hospital Medicine Data, 2011). In fact, the International Hospitalists Section of SHM is 1 of only 2 sections that the Society recognizes.

Hospitalists are organizing themselves abroad as well. In Canada, the Canadian Society of Hospital Medicine was founded in 2001 and has had 8 national conferences to date.8 There are roughly 1,000 Canadian hospitalists (Wilton D, personal communication, 2011). Whereas most US hospitalists are internists or pediatricians, in Canada, most hospitalists are family physicians. In the US, hospitalists are more likely to perform the following services: consultation, intensive care unit patient care, rapid response team service, surgical comanagement, and evening on‐site coverage. Canadian hospitalists are more likely to provide pediatric care and psychiatry inpatient comanagement.9

In the UK, the professional organization of physicians most similar to US hospitalists, acute physicians, is called SAM (The Society for Acute Medicine). It was founded in 2000.10 In the UK, general practitioners (GPs) never care for inpatients; at the time, GPs referred all admissions to organ‐specific specialists (eg, cardiologists). Acute medicine was created due to the realization that medical inpatients were too complex to have specialists managing them. Training programs were set up circa 2003 to create this specialty and address this need. Acute physicians staff geographically localized acute medicine units near emergency departments. These patients stay 1 to 3 days in an effort to concentrate services and resources to these patients, to prevent longer stays once fully admitted (Smith R, personal communication, April 23, 2011). Acute medicine units in the UK, Ireland, and Australia have led to positive benefits on patient outcomes. A review article by Scott and colleagues revealed reductions in LOS, inpatient mortality, and emergency department LOS, without increased 30‐day readmission rates. They found increased staff and patient satisfaction, and more medical patients discharged directly to home from acute medical units.11 The development of acute medicine in Australia and New Zealand began around 2005 and derives from the geographic localization of the UK model. Whereas the UK model has a focus on the first 72 hours of hospitalization, the model in Australia and New Zealand is more similar to the US model of following patients through their entire admission.12 Unlike the UK, Australia does not have dedicated acute medicine training programs.

PASHA, the Pan‐American Society of Hospitalists, is a loose affiliation of hospitalists largely in South America, linking with their North American colleagues. PASHA grew out of SOBRAMH, Sociedade Brasileira de Medicina Hospitalarthe first Hospital Medicine Society in South America, tracing its roots to 2004. To date, PASHA has had 1 international conference, but there have been 2 national conferences each in Brazil and Chile, and 1 in Colombia. The concept and advantages of Hospital Medicine have been presented at a conference in Panama. Argentina has its first Hospital Medicine Congress scheduled for September 2011, in concert with PASHA.

Two Hospital Medicine programs abroad deserve special mention. Both started in 2005 and have instituted the full hospitalist package, including multiple evidence‐based order sets at both sites (eg, deep vein thrombosis [DVT] prophylaxis and hyperglycemia management). At the Pontificia Universidad Catlica in Santiago, Chile, they have been awarded national grants to study hyperglycemia in hospitalized patients, and they have sent their faculty to the US for additional training in patient safety, quality improvement, leadership, and medical informatics. They have succeeded in decreasing LOS and improved the exam grades of their learners. Their faculty has published in national journals and is now beginning to submit their work for publication in US‐based journals (Rojas L, personal communication, April 22, 2011). The Clnica Universidad de Navarra (CUN) in Pamplona, Spain is a Joint Commission certified facility with a full electronic medical record. Hospitalists there are looking at ways in which hospitalist‐staffed intermediate care units can benefit patient outcomes. Additionally, they have comanagement arrangements with nearly all surgical subspecialties. The Management of the Hospitalized Patient symposium was organized by CUN hospitalists in 2007the first Hospital Medicine Congress, to our knowledge, in continental Europe. At any one time, 30% of all residents in all specialties rotate with CUN hospitalists (Lucena F, personal communication, April 22, 2011).

The specialty of Hospital Medicine is truly global. Our colleagues around the world employing the hospitalist model of care are now producing outcomes similar to the published models in North America and to the acute medicine models in Europe and Australia. According to the Society of Hospital Medicine, there are over 30,000 hospitalists in the US. There could be well over 50,000 hospitalists around the world. In 5 years, the world may have 100,000 hospitalists. The same drivers are fueling the growth of Hospital Medicine around the world. The evidence is building that the hospitalist model of care has financial and quality benefits that transcend borders. We forecast that the hospitalist model of care will become an increasingly larger part of the solution around the world to fix these international healthcare systems.

In the 15 years since Wachter and Goldman coined the term hospitalists, the specialty of Hospital Medicine grew faster than any other in the history of American medicine.1 The early drivers for growth were largely economic: There were significant reductions in resource use, with a 13% decrease in hospital costs and a 16% decrease in hospital lengths of stay (LOS).2 Hospitalist clinician‐educators increased the satisfaction of residents and medical students in academic settings.2 Patient satisfaction and hospital mortality did not suffer.2

Recent growth of Hospital Medicine revolves around 3 drivers: 1) improving quality and safety of hospitalized patientsowing in large part to the Institute of Medicine's 2 compelling reports, To Err Is Human3 and Crossing the Quality Chasm4; 2) hospitalist and specialist (surgeon) comanagement; and 3) the effects of duty hours restrictions imposed by the Accreditation Council for Graduate Medical Education affecting United States (US) teaching hospitals.5

In this issue of the Journal of Hospital Medicine, Shu and colleagues6 report on the performance of a hospitalist program in Taiwan. To the best of our knowledge, this report from Asia is the first published report of a successful hospitalist model with measurable patient outcomes outside of North America. Specifically, over a year, the authors found that patients admitted by hospitalists had a shorter LOS and lower cost per case, with no difference in in‐hospital mortality and 30‐day readmission. These results were obtained despite the fact that the cohort of patients admitted to the hospitalist team was older, sicker, and had worse functional capacity. Additionally, the patients admitted to the hospitalist team, and who died during hospitalization, were more likely to have a do‐not‐resuscitate (DNR) order signed, when compared with those patients admitted to the general internal medicine teaching service. Comparing LOS with North America may be problematic. As Shu and colleagues6 point out, there are cultural and economic issues that affect the behavior of patients and physicians in Taiwan.

The healthcare system in Taiwan has similarities to the healthcare systems in the United Kingdom (UK) and the US. In 1995, Taiwan implemented a national health insurance system. The UK has had a National Health Service for many years that provides most services for free. The Taiwanese system requires modest copayments for services. The implementation of the national health insurance system in Taiwan increased healthcare access from 57% of the population to 98%.7 The increase in insurance across the population with modest copayments has made it possible for a larger percentage of the population to access the healthcare system.7 According to the authors, this has resulted in increased hospital admissions (35% in the decade since the introduction of national health insurance), resulting in a shortage of Hospital Medicine physicians and hospital beds.7 Compounding the stressors on this system is that the diagnosis related group (DRG) reimbursement model, similar to the American DRG reimbursement model, will soon take effect in Taiwan. As a result, our colleagues in Taiwan are experiencing issues commonly faced by mature hospitalist programs in the US: increased needs in efficiency to improve patient flow and decrease emergency room overcrowding and LOS; and concerns with safe discharges of high‐risk patients while ensuring outpatient follow‐up. This is a scenario with which US hospitalists are all too familiar.

The next step for Taiwan might be to implement a culturally specific patient education program regarding the discharge process. The first step would be a needs assessment survey of patients in Taiwan, inquiring about concerns regarding readiness for discharge. They might inquire about patient beliefs regarding understanding indications for inpatient hospitalization versus discharge to home, home with home services, or skilled nursing facilities. They might be able to drill down to the root cause of refusal to be discharged home. These data could help our colleagues in Taiwan create their own discharge program to drive down LOS closer to that of the US and other Western countries, in order to reap financial benefits and improve resource utilization.

What do we know about the growth of Hospital Medicine around the world? The Society of Hospital Medicine (SHM) reports international members from 26 countries around the world. In North America, SHM members are found in the US, Canada, and Bermuda. In Europe, SHM members are found in England, Ireland, Scotland, Spain, Belgium, Portugal, Italy, and Germany. In South America, SHM members are found in Brazil, Chile, Colombia, and Argentina. In Asia and the Middle East, SHM has members in Saudi Arabia, Israel, United Arab Emirates, Pakistan, Japan, China, the Philippines, and Singapore. In Oceania, SHM has members in Australia, and New Zealand. In Africa, 1 SHM member is from Nigeria (Society of Hospital Medicine Data, 2011). In fact, the International Hospitalists Section of SHM is 1 of only 2 sections that the Society recognizes.

Hospitalists are organizing themselves abroad as well. In Canada, the Canadian Society of Hospital Medicine was founded in 2001 and has had 8 national conferences to date.8 There are roughly 1,000 Canadian hospitalists (Wilton D, personal communication, 2011). Whereas most US hospitalists are internists or pediatricians, in Canada, most hospitalists are family physicians. In the US, hospitalists are more likely to perform the following services: consultation, intensive care unit patient care, rapid response team service, surgical comanagement, and evening on‐site coverage. Canadian hospitalists are more likely to provide pediatric care and psychiatry inpatient comanagement.9

In the UK, the professional organization of physicians most similar to US hospitalists, acute physicians, is called SAM (The Society for Acute Medicine). It was founded in 2000.10 In the UK, general practitioners (GPs) never care for inpatients; at the time, GPs referred all admissions to organ‐specific specialists (eg, cardiologists). Acute medicine was created due to the realization that medical inpatients were too complex to have specialists managing them. Training programs were set up circa 2003 to create this specialty and address this need. Acute physicians staff geographically localized acute medicine units near emergency departments. These patients stay 1 to 3 days in an effort to concentrate services and resources to these patients, to prevent longer stays once fully admitted (Smith R, personal communication, April 23, 2011). Acute medicine units in the UK, Ireland, and Australia have led to positive benefits on patient outcomes. A review article by Scott and colleagues revealed reductions in LOS, inpatient mortality, and emergency department LOS, without increased 30‐day readmission rates. They found increased staff and patient satisfaction, and more medical patients discharged directly to home from acute medical units.11 The development of acute medicine in Australia and New Zealand began around 2005 and derives from the geographic localization of the UK model. Whereas the UK model has a focus on the first 72 hours of hospitalization, the model in Australia and New Zealand is more similar to the US model of following patients through their entire admission.12 Unlike the UK, Australia does not have dedicated acute medicine training programs.

PASHA, the Pan‐American Society of Hospitalists, is a loose affiliation of hospitalists largely in South America, linking with their North American colleagues. PASHA grew out of SOBRAMH, Sociedade Brasileira de Medicina Hospitalarthe first Hospital Medicine Society in South America, tracing its roots to 2004. To date, PASHA has had 1 international conference, but there have been 2 national conferences each in Brazil and Chile, and 1 in Colombia. The concept and advantages of Hospital Medicine have been presented at a conference in Panama. Argentina has its first Hospital Medicine Congress scheduled for September 2011, in concert with PASHA.

Two Hospital Medicine programs abroad deserve special mention. Both started in 2005 and have instituted the full hospitalist package, including multiple evidence‐based order sets at both sites (eg, deep vein thrombosis [DVT] prophylaxis and hyperglycemia management). At the Pontificia Universidad Catlica in Santiago, Chile, they have been awarded national grants to study hyperglycemia in hospitalized patients, and they have sent their faculty to the US for additional training in patient safety, quality improvement, leadership, and medical informatics. They have succeeded in decreasing LOS and improved the exam grades of their learners. Their faculty has published in national journals and is now beginning to submit their work for publication in US‐based journals (Rojas L, personal communication, April 22, 2011). The Clnica Universidad de Navarra (CUN) in Pamplona, Spain is a Joint Commission certified facility with a full electronic medical record. Hospitalists there are looking at ways in which hospitalist‐staffed intermediate care units can benefit patient outcomes. Additionally, they have comanagement arrangements with nearly all surgical subspecialties. The Management of the Hospitalized Patient symposium was organized by CUN hospitalists in 2007the first Hospital Medicine Congress, to our knowledge, in continental Europe. At any one time, 30% of all residents in all specialties rotate with CUN hospitalists (Lucena F, personal communication, April 22, 2011).

The specialty of Hospital Medicine is truly global. Our colleagues around the world employing the hospitalist model of care are now producing outcomes similar to the published models in North America and to the acute medicine models in Europe and Australia. According to the Society of Hospital Medicine, there are over 30,000 hospitalists in the US. There could be well over 50,000 hospitalists around the world. In 5 years, the world may have 100,000 hospitalists. The same drivers are fueling the growth of Hospital Medicine around the world. The evidence is building that the hospitalist model of care has financial and quality benefits that transcend borders. We forecast that the hospitalist model of care will become an increasingly larger part of the solution around the world to fix these international healthcare systems.

Handoffs during hospitalization from one provider to another represent critical transition points in patient care.1 In‐hospital handoffs are a frequent occurrence, with 1 teaching hospital reporting 4000 handoffs daily for a total of 1.6 million per year.2

Incomplete or poor‐quality handoffs have been implicated as a source of adverse events and near misses in hospitalized patients.35 Standardizing the handoff process may improve patient safety during care transitions.6 In 2006, the Joint Commission issued a National Patient Safety Goal that requires care providers to adopt a standardized approach for handoff communications, including an opportunity to ask and respond to questions about a patient's care.7 The reductions in resident work hours by the Accreditation Council for Graduate Medical Education (ACGME) has also resulted in a greater number and greater scrutiny of handoffs in teaching hospitals.8, 9

In response to these issues, and because handoffs are a core competency for hospitalists, the Society of Hospital Medicine (SHM)convened a task force.10 Our goal was to develop a set of recommendations for handoffs that would be applicable in both community and academic settings; among physicians (hospitalists, internists, subspecialists, residents), nurse practitioners, and physicians assistants; and across roles including serving as the primary provider of hospital care, comanager, or consultant. This work focuses on handoffs that occur at shift change and service change.11 Shift changes are transitions of care between an outgoing provider and an incoming provider that occur at the end of the outgoing provider's continuous on‐duty period. Service changesa special type of shift changeare transitions of care between an outgoing provider and an incoming provider that occur when an outgoing provider is leaving a rotation or period of consecutive daily care for patients on the same service.

For this initiative, transfers of care in which the patient is moving from one patient area to another (eg, Emergency Department to inpatient floor, or floor to intensive care unit [ICU]) were excluded since they likely require unique consideration given their cross‐disciplinary and multispecialty nature. Likewise, transitions of care at hospital admission and discharge were also excluded because recommendations for discharge are already summarized in 2 complementary reports.12, 13

To develop recommendations for handoffs at routine shift change and service changes, the Handoff Task Force performed a systematic review of the literature to develop initial recommendations, obtained feedback from hospital‐based clinicians in addition to a panel of handoff experts, and finalized handoff recommendations, as well as a proposed research agenda, for the SHM.

Methods

The SHM Healthcare Quality and Patient Safety (HQPS) Committee convened the Handoff Task Force, which was comprised of 6 geographically diverse, predominantly academic hospitalists with backgrounds in education, patient safety, health communication, evidence‐based medicine, and handoffs. The Task Force then engaged a panel of 4 content experts selected for their work on handoffs in the fields of nursing, information technology, human factors engineering, and hospital medicine. Similar to clinical guideline development by professional societies, the Task Force used a combination of evidence‐based review and expert opinions to propose recommendations.

Results

Literature Review

Of the 374 articles identified by the electronic search of PubMed and the AHRQ Patient Safety Network, 109 were retrieved for detailed review, and 10 of these met the criteria for inclusion (Figure 1). Of these studies, 3 were derived from nursing literature and the remaining were tests of technology solutions or structured templates (Table 1).1618, 20, 22, 3842 No studies examined hospitalist handoffs. All eligible studies concerned shift change. There were no studies of service change. Only 1 study was a randomized controlled trial; the rest were pre‐post studies with historical controls or a controlled simulation. All reports were single‐site studies. Most outcomes were staff‐related or system‐related, with only 2 studies using patient outcomes.

Table 1.Characteristics of Studies Included in Review

Author (Year)	Study Design	Intervention	Setting and Study Population	Target	Outcomes
Abbreviations: IM, internal medicine; IS, ; UW, University of Washington.
Nursing
Kelly22 (2005)	Pre‐post	Change to walk‐round handover (at bedside) from baseline (control)	12‐bed rehab unit with 18 nurses and 10 patients	Staff, patient	11/18 nurses felt more or much more informed and involved; 8/10 patients felt more involved
Pothier et al.20 (2005)	Controlled simulation	Compared pure verbal to verbal with note‐taking to verbal plus typed content	Handover of 12 simulated patients over 5 cycles	System (data loss)	Minimal data loss with typed content, compared to 31% data retained with note‐taking, and no data retained with verbal only
Wallum38 (1995)	Pre‐post	Change from oral handover (baseline) to written template read with exchange	20 nurses in a geriatric dementia ward	Staff	83% of nurses felt care plans followed better; 88% knew care plans better
Technology or structured template
Cheah et al.39 (2005)	Pre‐post	Electronic template with free‐text entry compared to baseline	14 UK Surgery residents	Staff	100% (14) of residents rated electronic system as desirable, but 7 (50%) reported that information was not updated
Lee et al.40 (1996)	Pre‐post	Standardized signout card for interns to transmit information during handoffs compared to handwritten (baseline)	Inpatient cardiology service at IM residency program in Minnesota with 19 new interns over a 3‐month period	Staff	Intervention interns (n = 10) reported poor sign‐out less often than controls (n = 9) [intervention 8 nights (5.8%) vs. control 17 nights (14.9%); P = 0.016]
Kannry and Moore18 (1999)	Pre‐post	Compared web‐based signout program to usual system (baseline)	An academic teaching hospital in New York (34 patients admitted in 1997; 40 patients admitted in 1998)	System	Improved provider identification (86% web signout vs. 57% hospital census)
Petersen et al.17 (1998)	Pre‐post	4 months of computerized signouts compared to baseline period (control)	3747 patients admitted to the medical service at an academic teaching hospital	Patient	Preventable adverse events (ADE) decreased (1.7% to 1.2%, P < 0.10); risk of cross‐cover physician for ADE eliminated
Ram and Block41 (1993)	Pre‐post	Compared handwritten (baseline) to computer‐generated	Family medicine residents at 2 academic teaching hospitals [Buffalo (n = 16) and Pittsburgh (n = 16)]	Staff	Higher satisfaction after electronic signout, but complaints with burden of data entry and need to keep information updated
Van Eaton et al.42 (2004)	Pre‐post	Use of UW Cores links sign‐out to list for rounds and IS data	28 surgical and medical residents at 2 teaching hospitals	System	At 6 months, 66% of patients entered in system (adoption)
Van Eaton et al.16 (2005)	Prospective, randomized, crossover study.	Compared UW Cores* integrated system compared to usual system	14 inpatient resident teams (6 surgery, 8 IM) at 2 teaching hospitals for 5 months	Staff, system	50% reduction in the perceived time spent copying data [from 24% to 12% (P < 0.0001)] and number of patients missed on rounds (2.5 vs. 5 patients/team/month, P = 0.0001); improved signout quality (69.6% agree or strongly agree); and improved continuity of care (66.1% agree or strongly agree)

Figure 1

Overall, the literature presented supports the use of a verbal handoff supplemented with written documentation in a structured format or technology solution. The 2 most rigorous studies were led by Van Eaton et al.16 and Petersen et al.17 and focused on evaluating technology solutions. Van Eaton et al.16 performed a randomized controlled trial of a locally created rounding template with 161 surgical residents. This template downloads certain information (lab values and recent vital signs) from the hospital system into a sign‐out sheet and allows residents to enter notes about diagnoses, allergies, medications and to‐do items. When implemented, the investigators found the number of patients missed on rounds decreased by 50%. Residents reported an increase of 40% in the amount of time available to pre‐round, due largely to not having to copy data such as vital signs. They reported a decrease in rounding time by 3 hours per week, and this was perceived as helping them meet the ACGME 80 hours work rules. Lastly, the residents reported a higher quality of sign‐outs from their peers and perceived an overall improvement in continuity of care. Petersen and colleagues implemented a computerized sign‐out (auto‐imported medications, name, room number) in an internal medicine residency to improve continuity of care during cross‐coverage and decrease adverse events.17 Prior to the intervention, the frequency of preventable adverse events was 1.7% and it was significantly associated with cross‐coverage. Preventable adverse events were identified using a confidential self‐report system that was also validated by clinician review. After the intervention, the frequency of preventable adverse events dropped to 1.2% (P < 0.1), and cross‐coverage was no longer associated with preventable adverse events. In other studies, technological solutions also improved provider identification and staff communication.18, 19 Together, these technology‐based intervention studies suggest that a computerized sign‐out with auto‐imported fields has the ability to improve physician efficiency and also improve inpatient care (reduction in number of patients missed on rounds, decrease in preventable adverse events).

Studies from nursing demonstrated that supplementing a verbal exchange with written information improved transfer of information, compared to verbal exchange alone.20 One of these studies rated the transfer of information using videotaped simulated handoff cases.21 Last, 1 nursing study that more directly involved patients in the handoff process resulted in improved nursing knowledge and greater patient empowerment (Table 1).22

White papers or consensus statements originated from international and national consortia in patient safety including the Australian Council for Safety and Quality in Healthcare,23 the Junior Doctors Committee of the British Medical Association,24 University Health Consortium,25 the Department of Defense Patient Safety Program,26 and The Joint Commission.27 Several common themes were prevalent in all white papers. First, there exists a need to train new personnel on how to perform an effective handoff. Second, efforts should be undertaken to ensure adequate time for handoffs and reduce interruptions during handoffs. Third, several of the papers supported verbal exchange that facilitates interactive questioning, focuses on ill patients, and delineates actions to be taken. Lastly, content should be updated to ensure transfer of the latest clinical information.

Final Handoff Recommendations

The final handoff recommendations are shown in Figure 2. The recommendations were designed to be consistent with the overall finding of the literature review, which supports the use of a verbal handoff supplemented with written documentation or a technological solution in a structured format. With the exception of 1 recommendation that is specific to service changes, all recommendations are designed to refer to shift changes and service changes. One overarching recommendation refers to the need for a formally recognized handoff plan at a shift change or change of service. The remaining 12 recommendations are divided into 4 that refer to hospitalist groups or programs, 3 that refer to verbal exchange, and 5 that refer to content exchange. The distinction is an important one because program‐level recommendations require organizational support and buy‐in to promote clinician participation and adherence. The 4 program recommendations also form the necessary framework for the remaining recommendations. For example, the second program recommendation describes the need for a standardized template or technology solution for accessing and recording patient information during the handoff. After a program adopts such a mechanism for exchanging patient information, the specific details for use and maintenance are outlined in greater detail in content exchange recommendations.

Figure 2

Because of the limited trials of handoff strategies, none of the recommendations are supported with level of evidence A (multiple numerous randomized controlled trials). In fact, with the exception of using a template or technology solution which was supported with level of evidence B, all handoff recommendations were supported with C level of evidence. The recommendations, however, were rated as Class I (effective) because there were no conflicting expert opinions or studies (Figure 2).

Discussion

In summary, our review of the literature supports the use of face‐to‐face verbal handoffs that are aided by the use of structured template to guide exchange of information. Furthermore, the development of these recommendations is the first effort of its kind for hospitalist handoffs and a movement towards standardizing the handoff process. While these recommendations are meant to provide structure to the hospitalist handoff process, the use and implementation by individual hospitalist programs may require more specific detail than these recommendations provide. Local modifications can allow for improved acceptance and adoption by practicing hospitalists. These recommendations can also help guide teaching efforts for academic hospitalists who are responsible for supervising residents.

The limitations of these recommendations related to lack of evidence in this field. Studies suffered from small size, poor description of methods, and a paucity of controlled interventions. The described technology solutions are not standardized or commercially available. Only 1 study included patient outcomes.28 There are no multicenter studies, studies of hospitalist handoffs, or studies to guide inclusion of specific content. Randomized controlled trials, interrupted time series analyses, and other rigorous study designs are needed in both teaching and non‐teaching settings to evaluate these recommendations and other approaches to improving handoffs. Ideally, these studies would occur through multicenter collaboratives and with human factors researchers familiar with mixed methods approaches to evaluate how and why interventions work.29 Efforts should focus on developing surrogate measures that are sensitive to handoff quality and related to important patient outcomes. The results of future studies should be used to refine the present recommendations. Locating new literature could be facilitated through the introduction of Medical Subject Heading for the term handoff by the National Library of Medicine. After completing this systematic review and developing the handoff recommendations described here, a few other noteworthy articles have been published on this topic, to which we refer interested readers. Several of these studies demonstrate that standardizing content and process during medical or surgical intern sign‐out improves resident confidence with handoffs,30 resident perceptions of accuracy and completeness of signout,31 and perceptions of patient safety.32 Another prospective audiotape study of 12 days of resident signout of clinical information demonstrated that poor quality oral sign‐outs was associated with an increased risk of post‐call resident reported signout‐related problems.5 Lastly, 1 nursing study demonstrated improved staff reports of safety, efficiency, and teamwork after a change from verbal reporting in an isolated room to bedside handover.33 Overall, these additional studies continue to support the current recommendations presented in this paper and do not significantly impact the conclusions of our literature review.

While lacking specific content domain recommendations, this report can be used as a starting point to guide development of self and peer assessment of hospitalist handoff quality. Development and validation of such assessments is especially important and can be incorporated into efforts to certify hospitalists through the recently approved certificate of focused practice in hospital medicine by the American Board of Internal Medicine (ABIM). Initiatives by several related organizations may help guide these effortsThe Joint Commission, the ABIM's Stepping Up to the Plate (SUTTP) Alliance, the Institute for Healthcare Improvement, the Information Transfer and Communication Practices (ITCP) Project for surgical care transitions, and the Hospital at Night (H@N) Program sponsored by the United Kingdom's National Health Service.3437 Professional medical organizations can also serve as powerful mediators of change in this area, not only by raising the visibility of handoffs, but also by mobilizing research funding. Patients and their caregivers may also play an important role in increasing awareness and education in this area. Future efforts should target handoffs not addressed in this initiative, such as transfers from emergency departments to inpatient care units, or between ICUs and the medical floor.

Conclusion

With the growth of hospital medicine and the increased acuity of inpatients, improving handoffs becomes an important part of ensuring patient safety. The goal of the SHM Handoffs Task Force was to begin to standardize handoffs at change of shift and change of servicea fundamental activity of hospitalists. These recommendations build on the limited literature in surgery, nursing, and medical informatics and provide a starting point for promoting safe and seamless in‐hospital handoffs for practitioners of Hospital Medicine.

Handoffs during hospitalization from one provider to another represent critical transition points in patient care.1 In‐hospital handoffs are a frequent occurrence, with 1 teaching hospital reporting 4000 handoffs daily for a total of 1.6 million per year.2

Incomplete or poor‐quality handoffs have been implicated as a source of adverse events and near misses in hospitalized patients.35 Standardizing the handoff process may improve patient safety during care transitions.6 In 2006, the Joint Commission issued a National Patient Safety Goal that requires care providers to adopt a standardized approach for handoff communications, including an opportunity to ask and respond to questions about a patient's care.7 The reductions in resident work hours by the Accreditation Council for Graduate Medical Education (ACGME) has also resulted in a greater number and greater scrutiny of handoffs in teaching hospitals.8, 9

In response to these issues, and because handoffs are a core competency for hospitalists, the Society of Hospital Medicine (SHM)convened a task force.10 Our goal was to develop a set of recommendations for handoffs that would be applicable in both community and academic settings; among physicians (hospitalists, internists, subspecialists, residents), nurse practitioners, and physicians assistants; and across roles including serving as the primary provider of hospital care, comanager, or consultant. This work focuses on handoffs that occur at shift change and service change.11 Shift changes are transitions of care between an outgoing provider and an incoming provider that occur at the end of the outgoing provider's continuous on‐duty period. Service changesa special type of shift changeare transitions of care between an outgoing provider and an incoming provider that occur when an outgoing provider is leaving a rotation or period of consecutive daily care for patients on the same service.

For this initiative, transfers of care in which the patient is moving from one patient area to another (eg, Emergency Department to inpatient floor, or floor to intensive care unit [ICU]) were excluded since they likely require unique consideration given their cross‐disciplinary and multispecialty nature. Likewise, transitions of care at hospital admission and discharge were also excluded because recommendations for discharge are already summarized in 2 complementary reports.12, 13

To develop recommendations for handoffs at routine shift change and service changes, the Handoff Task Force performed a systematic review of the literature to develop initial recommendations, obtained feedback from hospital‐based clinicians in addition to a panel of handoff experts, and finalized handoff recommendations, as well as a proposed research agenda, for the SHM.

Methods

The SHM Healthcare Quality and Patient Safety (HQPS) Committee convened the Handoff Task Force, which was comprised of 6 geographically diverse, predominantly academic hospitalists with backgrounds in education, patient safety, health communication, evidence‐based medicine, and handoffs. The Task Force then engaged a panel of 4 content experts selected for their work on handoffs in the fields of nursing, information technology, human factors engineering, and hospital medicine. Similar to clinical guideline development by professional societies, the Task Force used a combination of evidence‐based review and expert opinions to propose recommendations.

Results

Literature Review

Of the 374 articles identified by the electronic search of PubMed and the AHRQ Patient Safety Network, 109 were retrieved for detailed review, and 10 of these met the criteria for inclusion (Figure 1). Of these studies, 3 were derived from nursing literature and the remaining were tests of technology solutions or structured templates (Table 1).1618, 20, 22, 3842 No studies examined hospitalist handoffs. All eligible studies concerned shift change. There were no studies of service change. Only 1 study was a randomized controlled trial; the rest were pre‐post studies with historical controls or a controlled simulation. All reports were single‐site studies. Most outcomes were staff‐related or system‐related, with only 2 studies using patient outcomes.

Table 1.Characteristics of Studies Included in Review

Author (Year)	Study Design	Intervention	Setting and Study Population	Target	Outcomes
Abbreviations: IM, internal medicine; IS, ; UW, University of Washington.
Nursing
Kelly22 (2005)	Pre‐post	Change to walk‐round handover (at bedside) from baseline (control)	12‐bed rehab unit with 18 nurses and 10 patients	Staff, patient	11/18 nurses felt more or much more informed and involved; 8/10 patients felt more involved
Pothier et al.20 (2005)	Controlled simulation	Compared pure verbal to verbal with note‐taking to verbal plus typed content	Handover of 12 simulated patients over 5 cycles	System (data loss)	Minimal data loss with typed content, compared to 31% data retained with note‐taking, and no data retained with verbal only
Wallum38 (1995)	Pre‐post	Change from oral handover (baseline) to written template read with exchange	20 nurses in a geriatric dementia ward	Staff	83% of nurses felt care plans followed better; 88% knew care plans better
Technology or structured template
Cheah et al.39 (2005)	Pre‐post	Electronic template with free‐text entry compared to baseline	14 UK Surgery residents	Staff	100% (14) of residents rated electronic system as desirable, but 7 (50%) reported that information was not updated
Lee et al.40 (1996)	Pre‐post	Standardized signout card for interns to transmit information during handoffs compared to handwritten (baseline)	Inpatient cardiology service at IM residency program in Minnesota with 19 new interns over a 3‐month period	Staff	Intervention interns (n = 10) reported poor sign‐out less often than controls (n = 9) [intervention 8 nights (5.8%) vs. control 17 nights (14.9%); P = 0.016]
Kannry and Moore18 (1999)	Pre‐post	Compared web‐based signout program to usual system (baseline)	An academic teaching hospital in New York (34 patients admitted in 1997; 40 patients admitted in 1998)	System	Improved provider identification (86% web signout vs. 57% hospital census)
Petersen et al.17 (1998)	Pre‐post	4 months of computerized signouts compared to baseline period (control)	3747 patients admitted to the medical service at an academic teaching hospital	Patient	Preventable adverse events (ADE) decreased (1.7% to 1.2%, P < 0.10); risk of cross‐cover physician for ADE eliminated
Ram and Block41 (1993)	Pre‐post	Compared handwritten (baseline) to computer‐generated	Family medicine residents at 2 academic teaching hospitals [Buffalo (n = 16) and Pittsburgh (n = 16)]	Staff	Higher satisfaction after electronic signout, but complaints with burden of data entry and need to keep information updated
Van Eaton et al.42 (2004)	Pre‐post	Use of UW Cores links sign‐out to list for rounds and IS data	28 surgical and medical residents at 2 teaching hospitals	System	At 6 months, 66% of patients entered in system (adoption)
Van Eaton et al.16 (2005)	Prospective, randomized, crossover study.	Compared UW Cores* integrated system compared to usual system	14 inpatient resident teams (6 surgery, 8 IM) at 2 teaching hospitals for 5 months	Staff, system	50% reduction in the perceived time spent copying data [from 24% to 12% (P < 0.0001)] and number of patients missed on rounds (2.5 vs. 5 patients/team/month, P = 0.0001); improved signout quality (69.6% agree or strongly agree); and improved continuity of care (66.1% agree or strongly agree)

Figure 1

Overall, the literature presented supports the use of a verbal handoff supplemented with written documentation in a structured format or technology solution. The 2 most rigorous studies were led by Van Eaton et al.16 and Petersen et al.17 and focused on evaluating technology solutions. Van Eaton et al.16 performed a randomized controlled trial of a locally created rounding template with 161 surgical residents. This template downloads certain information (lab values and recent vital signs) from the hospital system into a sign‐out sheet and allows residents to enter notes about diagnoses, allergies, medications and to‐do items. When implemented, the investigators found the number of patients missed on rounds decreased by 50%. Residents reported an increase of 40% in the amount of time available to pre‐round, due largely to not having to copy data such as vital signs. They reported a decrease in rounding time by 3 hours per week, and this was perceived as helping them meet the ACGME 80 hours work rules. Lastly, the residents reported a higher quality of sign‐outs from their peers and perceived an overall improvement in continuity of care. Petersen and colleagues implemented a computerized sign‐out (auto‐imported medications, name, room number) in an internal medicine residency to improve continuity of care during cross‐coverage and decrease adverse events.17 Prior to the intervention, the frequency of preventable adverse events was 1.7% and it was significantly associated with cross‐coverage. Preventable adverse events were identified using a confidential self‐report system that was also validated by clinician review. After the intervention, the frequency of preventable adverse events dropped to 1.2% (P < 0.1), and cross‐coverage was no longer associated with preventable adverse events. In other studies, technological solutions also improved provider identification and staff communication.18, 19 Together, these technology‐based intervention studies suggest that a computerized sign‐out with auto‐imported fields has the ability to improve physician efficiency and also improve inpatient care (reduction in number of patients missed on rounds, decrease in preventable adverse events).

Studies from nursing demonstrated that supplementing a verbal exchange with written information improved transfer of information, compared to verbal exchange alone.20 One of these studies rated the transfer of information using videotaped simulated handoff cases.21 Last, 1 nursing study that more directly involved patients in the handoff process resulted in improved nursing knowledge and greater patient empowerment (Table 1).22

White papers or consensus statements originated from international and national consortia in patient safety including the Australian Council for Safety and Quality in Healthcare,23 the Junior Doctors Committee of the British Medical Association,24 University Health Consortium,25 the Department of Defense Patient Safety Program,26 and The Joint Commission.27 Several common themes were prevalent in all white papers. First, there exists a need to train new personnel on how to perform an effective handoff. Second, efforts should be undertaken to ensure adequate time for handoffs and reduce interruptions during handoffs. Third, several of the papers supported verbal exchange that facilitates interactive questioning, focuses on ill patients, and delineates actions to be taken. Lastly, content should be updated to ensure transfer of the latest clinical information.

Final Handoff Recommendations

The final handoff recommendations are shown in Figure 2. The recommendations were designed to be consistent with the overall finding of the literature review, which supports the use of a verbal handoff supplemented with written documentation or a technological solution in a structured format. With the exception of 1 recommendation that is specific to service changes, all recommendations are designed to refer to shift changes and service changes. One overarching recommendation refers to the need for a formally recognized handoff plan at a shift change or change of service. The remaining 12 recommendations are divided into 4 that refer to hospitalist groups or programs, 3 that refer to verbal exchange, and 5 that refer to content exchange. The distinction is an important one because program‐level recommendations require organizational support and buy‐in to promote clinician participation and adherence. The 4 program recommendations also form the necessary framework for the remaining recommendations. For example, the second program recommendation describes the need for a standardized template or technology solution for accessing and recording patient information during the handoff. After a program adopts such a mechanism for exchanging patient information, the specific details for use and maintenance are outlined in greater detail in content exchange recommendations.

Figure 2

Because of the limited trials of handoff strategies, none of the recommendations are supported with level of evidence A (multiple numerous randomized controlled trials). In fact, with the exception of using a template or technology solution which was supported with level of evidence B, all handoff recommendations were supported with C level of evidence. The recommendations, however, were rated as Class I (effective) because there were no conflicting expert opinions or studies (Figure 2).

Discussion

In summary, our review of the literature supports the use of face‐to‐face verbal handoffs that are aided by the use of structured template to guide exchange of information. Furthermore, the development of these recommendations is the first effort of its kind for hospitalist handoffs and a movement towards standardizing the handoff process. While these recommendations are meant to provide structure to the hospitalist handoff process, the use and implementation by individual hospitalist programs may require more specific detail than these recommendations provide. Local modifications can allow for improved acceptance and adoption by practicing hospitalists. These recommendations can also help guide teaching efforts for academic hospitalists who are responsible for supervising residents.

The limitations of these recommendations related to lack of evidence in this field. Studies suffered from small size, poor description of methods, and a paucity of controlled interventions. The described technology solutions are not standardized or commercially available. Only 1 study included patient outcomes.28 There are no multicenter studies, studies of hospitalist handoffs, or studies to guide inclusion of specific content. Randomized controlled trials, interrupted time series analyses, and other rigorous study designs are needed in both teaching and non‐teaching settings to evaluate these recommendations and other approaches to improving handoffs. Ideally, these studies would occur through multicenter collaboratives and with human factors researchers familiar with mixed methods approaches to evaluate how and why interventions work.29 Efforts should focus on developing surrogate measures that are sensitive to handoff quality and related to important patient outcomes. The results of future studies should be used to refine the present recommendations. Locating new literature could be facilitated through the introduction of Medical Subject Heading for the term handoff by the National Library of Medicine. After completing this systematic review and developing the handoff recommendations described here, a few other noteworthy articles have been published on this topic, to which we refer interested readers. Several of these studies demonstrate that standardizing content and process during medical or surgical intern sign‐out improves resident confidence with handoffs,30 resident perceptions of accuracy and completeness of signout,31 and perceptions of patient safety.32 Another prospective audiotape study of 12 days of resident signout of clinical information demonstrated that poor quality oral sign‐outs was associated with an increased risk of post‐call resident reported signout‐related problems.5 Lastly, 1 nursing study demonstrated improved staff reports of safety, efficiency, and teamwork after a change from verbal reporting in an isolated room to bedside handover.33 Overall, these additional studies continue to support the current recommendations presented in this paper and do not significantly impact the conclusions of our literature review.

While lacking specific content domain recommendations, this report can be used as a starting point to guide development of self and peer assessment of hospitalist handoff quality. Development and validation of such assessments is especially important and can be incorporated into efforts to certify hospitalists through the recently approved certificate of focused practice in hospital medicine by the American Board of Internal Medicine (ABIM). Initiatives by several related organizations may help guide these effortsThe Joint Commission, the ABIM's Stepping Up to the Plate (SUTTP) Alliance, the Institute for Healthcare Improvement, the Information Transfer and Communication Practices (ITCP) Project for surgical care transitions, and the Hospital at Night (H@N) Program sponsored by the United Kingdom's National Health Service.3437 Professional medical organizations can also serve as powerful mediators of change in this area, not only by raising the visibility of handoffs, but also by mobilizing research funding. Patients and their caregivers may also play an important role in increasing awareness and education in this area. Future efforts should target handoffs not addressed in this initiative, such as transfers from emergency departments to inpatient care units, or between ICUs and the medical floor.

Conclusion

With the growth of hospital medicine and the increased acuity of inpatients, improving handoffs becomes an important part of ensuring patient safety. The goal of the SHM Handoffs Task Force was to begin to standardize handoffs at change of shift and change of servicea fundamental activity of hospitalists. These recommendations build on the limited literature in surgery, nursing, and medical informatics and provide a starting point for promoting safe and seamless in‐hospital handoffs for practitioners of Hospital Medicine.

Handoffs during hospitalization from one provider to another represent critical transition points in patient care.1 In‐hospital handoffs are a frequent occurrence, with 1 teaching hospital reporting 4000 handoffs daily for a total of 1.6 million per year.2

Incomplete or poor‐quality handoffs have been implicated as a source of adverse events and near misses in hospitalized patients.35 Standardizing the handoff process may improve patient safety during care transitions.6 In 2006, the Joint Commission issued a National Patient Safety Goal that requires care providers to adopt a standardized approach for handoff communications, including an opportunity to ask and respond to questions about a patient's care.7 The reductions in resident work hours by the Accreditation Council for Graduate Medical Education (ACGME) has also resulted in a greater number and greater scrutiny of handoffs in teaching hospitals.8, 9

In response to these issues, and because handoffs are a core competency for hospitalists, the Society of Hospital Medicine (SHM)convened a task force.10 Our goal was to develop a set of recommendations for handoffs that would be applicable in both community and academic settings; among physicians (hospitalists, internists, subspecialists, residents), nurse practitioners, and physicians assistants; and across roles including serving as the primary provider of hospital care, comanager, or consultant. This work focuses on handoffs that occur at shift change and service change.11 Shift changes are transitions of care between an outgoing provider and an incoming provider that occur at the end of the outgoing provider's continuous on‐duty period. Service changesa special type of shift changeare transitions of care between an outgoing provider and an incoming provider that occur when an outgoing provider is leaving a rotation or period of consecutive daily care for patients on the same service.

For this initiative, transfers of care in which the patient is moving from one patient area to another (eg, Emergency Department to inpatient floor, or floor to intensive care unit [ICU]) were excluded since they likely require unique consideration given their cross‐disciplinary and multispecialty nature. Likewise, transitions of care at hospital admission and discharge were also excluded because recommendations for discharge are already summarized in 2 complementary reports.12, 13

To develop recommendations for handoffs at routine shift change and service changes, the Handoff Task Force performed a systematic review of the literature to develop initial recommendations, obtained feedback from hospital‐based clinicians in addition to a panel of handoff experts, and finalized handoff recommendations, as well as a proposed research agenda, for the SHM.

Methods

The SHM Healthcare Quality and Patient Safety (HQPS) Committee convened the Handoff Task Force, which was comprised of 6 geographically diverse, predominantly academic hospitalists with backgrounds in education, patient safety, health communication, evidence‐based medicine, and handoffs. The Task Force then engaged a panel of 4 content experts selected for their work on handoffs in the fields of nursing, information technology, human factors engineering, and hospital medicine. Similar to clinical guideline development by professional societies, the Task Force used a combination of evidence‐based review and expert opinions to propose recommendations.

Results

Literature Review

Of the 374 articles identified by the electronic search of PubMed and the AHRQ Patient Safety Network, 109 were retrieved for detailed review, and 10 of these met the criteria for inclusion (Figure 1). Of these studies, 3 were derived from nursing literature and the remaining were tests of technology solutions or structured templates (Table 1).1618, 20, 22, 3842 No studies examined hospitalist handoffs. All eligible studies concerned shift change. There were no studies of service change. Only 1 study was a randomized controlled trial; the rest were pre‐post studies with historical controls or a controlled simulation. All reports were single‐site studies. Most outcomes were staff‐related or system‐related, with only 2 studies using patient outcomes.

Table 1.Characteristics of Studies Included in Review

Author (Year)	Study Design	Intervention	Setting and Study Population	Target	Outcomes
Abbreviations: IM, internal medicine; IS, ; UW, University of Washington.
Nursing
Kelly22 (2005)	Pre‐post	Change to walk‐round handover (at bedside) from baseline (control)	12‐bed rehab unit with 18 nurses and 10 patients	Staff, patient	11/18 nurses felt more or much more informed and involved; 8/10 patients felt more involved
Pothier et al.20 (2005)	Controlled simulation	Compared pure verbal to verbal with note‐taking to verbal plus typed content	Handover of 12 simulated patients over 5 cycles	System (data loss)	Minimal data loss with typed content, compared to 31% data retained with note‐taking, and no data retained with verbal only
Wallum38 (1995)	Pre‐post	Change from oral handover (baseline) to written template read with exchange	20 nurses in a geriatric dementia ward	Staff	83% of nurses felt care plans followed better; 88% knew care plans better
Technology or structured template
Cheah et al.39 (2005)	Pre‐post	Electronic template with free‐text entry compared to baseline	14 UK Surgery residents	Staff	100% (14) of residents rated electronic system as desirable, but 7 (50%) reported that information was not updated
Lee et al.40 (1996)	Pre‐post	Standardized signout card for interns to transmit information during handoffs compared to handwritten (baseline)	Inpatient cardiology service at IM residency program in Minnesota with 19 new interns over a 3‐month period	Staff	Intervention interns (n = 10) reported poor sign‐out less often than controls (n = 9) [intervention 8 nights (5.8%) vs. control 17 nights (14.9%); P = 0.016]
Kannry and Moore18 (1999)	Pre‐post	Compared web‐based signout program to usual system (baseline)	An academic teaching hospital in New York (34 patients admitted in 1997; 40 patients admitted in 1998)	System	Improved provider identification (86% web signout vs. 57% hospital census)
Petersen et al.17 (1998)	Pre‐post	4 months of computerized signouts compared to baseline period (control)	3747 patients admitted to the medical service at an academic teaching hospital	Patient	Preventable adverse events (ADE) decreased (1.7% to 1.2%, P < 0.10); risk of cross‐cover physician for ADE eliminated
Ram and Block41 (1993)	Pre‐post	Compared handwritten (baseline) to computer‐generated	Family medicine residents at 2 academic teaching hospitals [Buffalo (n = 16) and Pittsburgh (n = 16)]	Staff	Higher satisfaction after electronic signout, but complaints with burden of data entry and need to keep information updated
Van Eaton et al.42 (2004)	Pre‐post	Use of UW Cores links sign‐out to list for rounds and IS data	28 surgical and medical residents at 2 teaching hospitals	System	At 6 months, 66% of patients entered in system (adoption)
Van Eaton et al.16 (2005)	Prospective, randomized, crossover study.	Compared UW Cores* integrated system compared to usual system	14 inpatient resident teams (6 surgery, 8 IM) at 2 teaching hospitals for 5 months	Staff, system	50% reduction in the perceived time spent copying data [from 24% to 12% (P < 0.0001)] and number of patients missed on rounds (2.5 vs. 5 patients/team/month, P = 0.0001); improved signout quality (69.6% agree or strongly agree); and improved continuity of care (66.1% agree or strongly agree)

Figure 1

Overall, the literature presented supports the use of a verbal handoff supplemented with written documentation in a structured format or technology solution. The 2 most rigorous studies were led by Van Eaton et al.16 and Petersen et al.17 and focused on evaluating technology solutions. Van Eaton et al.16 performed a randomized controlled trial of a locally created rounding template with 161 surgical residents. This template downloads certain information (lab values and recent vital signs) from the hospital system into a sign‐out sheet and allows residents to enter notes about diagnoses, allergies, medications and to‐do items. When implemented, the investigators found the number of patients missed on rounds decreased by 50%. Residents reported an increase of 40% in the amount of time available to pre‐round, due largely to not having to copy data such as vital signs. They reported a decrease in rounding time by 3 hours per week, and this was perceived as helping them meet the ACGME 80 hours work rules. Lastly, the residents reported a higher quality of sign‐outs from their peers and perceived an overall improvement in continuity of care. Petersen and colleagues implemented a computerized sign‐out (auto‐imported medications, name, room number) in an internal medicine residency to improve continuity of care during cross‐coverage and decrease adverse events.17 Prior to the intervention, the frequency of preventable adverse events was 1.7% and it was significantly associated with cross‐coverage. Preventable adverse events were identified using a confidential self‐report system that was also validated by clinician review. After the intervention, the frequency of preventable adverse events dropped to 1.2% (P < 0.1), and cross‐coverage was no longer associated with preventable adverse events. In other studies, technological solutions also improved provider identification and staff communication.18, 19 Together, these technology‐based intervention studies suggest that a computerized sign‐out with auto‐imported fields has the ability to improve physician efficiency and also improve inpatient care (reduction in number of patients missed on rounds, decrease in preventable adverse events).

Studies from nursing demonstrated that supplementing a verbal exchange with written information improved transfer of information, compared to verbal exchange alone.20 One of these studies rated the transfer of information using videotaped simulated handoff cases.21 Last, 1 nursing study that more directly involved patients in the handoff process resulted in improved nursing knowledge and greater patient empowerment (Table 1).22

White papers or consensus statements originated from international and national consortia in patient safety including the Australian Council for Safety and Quality in Healthcare,23 the Junior Doctors Committee of the British Medical Association,24 University Health Consortium,25 the Department of Defense Patient Safety Program,26 and The Joint Commission.27 Several common themes were prevalent in all white papers. First, there exists a need to train new personnel on how to perform an effective handoff. Second, efforts should be undertaken to ensure adequate time for handoffs and reduce interruptions during handoffs. Third, several of the papers supported verbal exchange that facilitates interactive questioning, focuses on ill patients, and delineates actions to be taken. Lastly, content should be updated to ensure transfer of the latest clinical information.

Final Handoff Recommendations

The final handoff recommendations are shown in Figure 2. The recommendations were designed to be consistent with the overall finding of the literature review, which supports the use of a verbal handoff supplemented with written documentation or a technological solution in a structured format. With the exception of 1 recommendation that is specific to service changes, all recommendations are designed to refer to shift changes and service changes. One overarching recommendation refers to the need for a formally recognized handoff plan at a shift change or change of service. The remaining 12 recommendations are divided into 4 that refer to hospitalist groups or programs, 3 that refer to verbal exchange, and 5 that refer to content exchange. The distinction is an important one because program‐level recommendations require organizational support and buy‐in to promote clinician participation and adherence. The 4 program recommendations also form the necessary framework for the remaining recommendations. For example, the second program recommendation describes the need for a standardized template or technology solution for accessing and recording patient information during the handoff. After a program adopts such a mechanism for exchanging patient information, the specific details for use and maintenance are outlined in greater detail in content exchange recommendations.

Figure 2

Because of the limited trials of handoff strategies, none of the recommendations are supported with level of evidence A (multiple numerous randomized controlled trials). In fact, with the exception of using a template or technology solution which was supported with level of evidence B, all handoff recommendations were supported with C level of evidence. The recommendations, however, were rated as Class I (effective) because there were no conflicting expert opinions or studies (Figure 2).

Discussion

In summary, our review of the literature supports the use of face‐to‐face verbal handoffs that are aided by the use of structured template to guide exchange of information. Furthermore, the development of these recommendations is the first effort of its kind for hospitalist handoffs and a movement towards standardizing the handoff process. While these recommendations are meant to provide structure to the hospitalist handoff process, the use and implementation by individual hospitalist programs may require more specific detail than these recommendations provide. Local modifications can allow for improved acceptance and adoption by practicing hospitalists. These recommendations can also help guide teaching efforts for academic hospitalists who are responsible for supervising residents.

The limitations of these recommendations related to lack of evidence in this field. Studies suffered from small size, poor description of methods, and a paucity of controlled interventions. The described technology solutions are not standardized or commercially available. Only 1 study included patient outcomes.28 There are no multicenter studies, studies of hospitalist handoffs, or studies to guide inclusion of specific content. Randomized controlled trials, interrupted time series analyses, and other rigorous study designs are needed in both teaching and non‐teaching settings to evaluate these recommendations and other approaches to improving handoffs. Ideally, these studies would occur through multicenter collaboratives and with human factors researchers familiar with mixed methods approaches to evaluate how and why interventions work.29 Efforts should focus on developing surrogate measures that are sensitive to handoff quality and related to important patient outcomes. The results of future studies should be used to refine the present recommendations. Locating new literature could be facilitated through the introduction of Medical Subject Heading for the term handoff by the National Library of Medicine. After completing this systematic review and developing the handoff recommendations described here, a few other noteworthy articles have been published on this topic, to which we refer interested readers. Several of these studies demonstrate that standardizing content and process during medical or surgical intern sign‐out improves resident confidence with handoffs,30 resident perceptions of accuracy and completeness of signout,31 and perceptions of patient safety.32 Another prospective audiotape study of 12 days of resident signout of clinical information demonstrated that poor quality oral sign‐outs was associated with an increased risk of post‐call resident reported signout‐related problems.5 Lastly, 1 nursing study demonstrated improved staff reports of safety, efficiency, and teamwork after a change from verbal reporting in an isolated room to bedside handover.33 Overall, these additional studies continue to support the current recommendations presented in this paper and do not significantly impact the conclusions of our literature review.

While lacking specific content domain recommendations, this report can be used as a starting point to guide development of self and peer assessment of hospitalist handoff quality. Development and validation of such assessments is especially important and can be incorporated into efforts to certify hospitalists through the recently approved certificate of focused practice in hospital medicine by the American Board of Internal Medicine (ABIM). Initiatives by several related organizations may help guide these effortsThe Joint Commission, the ABIM's Stepping Up to the Plate (SUTTP) Alliance, the Institute for Healthcare Improvement, the Information Transfer and Communication Practices (ITCP) Project for surgical care transitions, and the Hospital at Night (H@N) Program sponsored by the United Kingdom's National Health Service.3437 Professional medical organizations can also serve as powerful mediators of change in this area, not only by raising the visibility of handoffs, but also by mobilizing research funding. Patients and their caregivers may also play an important role in increasing awareness and education in this area. Future efforts should target handoffs not addressed in this initiative, such as transfers from emergency departments to inpatient care units, or between ICUs and the medical floor.

Conclusion

With the growth of hospital medicine and the increased acuity of inpatients, improving handoffs becomes an important part of ensuring patient safety. The goal of the SHM Handoffs Task Force was to begin to standardize handoffs at change of shift and change of servicea fundamental activity of hospitalists. These recommendations build on the limited literature in surgery, nursing, and medical informatics and provide a starting point for promoting safe and seamless in‐hospital handoffs for practitioners of Hospital Medicine.