Avoiding Common Hand-off Mistakes

SAN DIEGO – Hospitalists may be tempted to rely on their electronic health record systems to do all the work on patient hand-offs, but that probably won’t turn out very well, according to Dr. Vineet Arora.

Dr. Arora, an associate professor of medicine at the University of Chicago and a patient safety researcher who has investigated the barriers to proper hand-offs, said technology can be a great tool, but over-relying on it can lead to just as many errors as a traditional paper sign-out. And just because the information is in the EHR, doesn’t mean physicians can skip the verbal hand-off, he said at the annual meeting of the Society of Hospital Medicine.

"The truth is that the electronic health record doesn’t substitute for the communication, the verbal dialogue, that actually needs to happen at the time of the handoff," Dr. Arora said in an interview.

The verbal hand-off is the place where the departing physician shares their clinical judgment and reviews the "to-do" items and "if-then" items for the sickest patients.

The trick is to make sure the hand-off is focused. "Hospitalists may actually be receiving well over 50 patients, and in some cases, over a hundred." Dr. Arora said. "An electronic patient list of that size is not going to actually communicate the information that somebody might need, which is that bed two or bed three is really sick."

Information overload is a common mistake in patient hand-offs. Some physicians include so much information in the written sign-out that it becomes a "shadow chart," she said.

Beware of offering too much information in the verbal hand-off too. Dr. Arora said most people can only remember about four things from a particular conversation.

"So as opposed to having a verbal hand-over that’s an entire recitation of a patient’s history, or going through every single case in nauseating detail, what you really want to do is focus on the top things that you want somebody to remember," Dr. Arora said.

Dr. Arora offered some tips on the best ways to deliver a better verbal hand-off:

• Focus on the sickest patients first.

• Provide an update on the daily progress with the day’s baseline and updated events.

• Give directions on what needs to be done.

• Provide a rationale for any instructions and further directions on what to do with the results. Avoid ambiguous instructions such as "check CBC." Personalize the instructions for the care of the patient by giving the hemoglobin value at which blood transfusion and number of units would be needed, for example.

• Make sure the physician receiving the hand-off really understands. Encourage questions.

Hospitalists who are receiving patients in the hand-off process can also do these things to be better, and more active, listeners:

• Limit interruptions.

• Take notes.

• Ask questions.

• Use a system to keep track of to-do items.

• Read back instructions.

Dr. Arora said there are also some systems issues that can help set the stage for better hand-offs. For instance, hospitals can provide physician education on the need to curb side conversations and other interruptions during the verbal hand-off. And they can schedule shifts so that there is sufficient overlap of outgoing and incoming physicians.

Hospitalists who are looking to improve not just their own hand-offs but the overall process at their hospital, should start by describing the current situation, Dr. Arora said. From there, they can identify the areas for improvement, find physicians to champion the project, and figure out what resources will be needed to make changes.

She advised that a standard hand-off protocol should be discipline specific, so what works for neurology won’t work for hospital medicine. Both the process and the content should be standardized. And once the hospitalists have agreed on a protocol, make sure to identify problems as they arise.

Dr. Arora said she has received grants and contracts from the Agency for Healthcare Research and Quality, the Accreditation Council for Graduate Medical Education, and the National Institute on Aging.

SAN DIEGO – Hospitalists may be tempted to rely on their electronic health record systems to do all the work on patient hand-offs, but that probably won’t turn out very well, according to Dr. Vineet Arora.

Dr. Arora, an associate professor of medicine at the University of Chicago and a patient safety researcher who has investigated the barriers to proper hand-offs, said technology can be a great tool, but over-relying on it can lead to just as many errors as a traditional paper sign-out. And just because the information is in the EHR, doesn’t mean physicians can skip the verbal hand-off, he said at the annual meeting of the Society of Hospital Medicine.

"The truth is that the electronic health record doesn’t substitute for the communication, the verbal dialogue, that actually needs to happen at the time of the handoff," Dr. Arora said in an interview.

The verbal hand-off is the place where the departing physician shares their clinical judgment and reviews the "to-do" items and "if-then" items for the sickest patients.

The trick is to make sure the hand-off is focused. "Hospitalists may actually be receiving well over 50 patients, and in some cases, over a hundred." Dr. Arora said. "An electronic patient list of that size is not going to actually communicate the information that somebody might need, which is that bed two or bed three is really sick."

Information overload is a common mistake in patient hand-offs. Some physicians include so much information in the written sign-out that it becomes a "shadow chart," she said.

Beware of offering too much information in the verbal hand-off too. Dr. Arora said most people can only remember about four things from a particular conversation.

"So as opposed to having a verbal hand-over that’s an entire recitation of a patient’s history, or going through every single case in nauseating detail, what you really want to do is focus on the top things that you want somebody to remember," Dr. Arora said.

Dr. Arora offered some tips on the best ways to deliver a better verbal hand-off:

• Focus on the sickest patients first.

• Provide an update on the daily progress with the day’s baseline and updated events.

• Give directions on what needs to be done.

• Provide a rationale for any instructions and further directions on what to do with the results. Avoid ambiguous instructions such as "check CBC." Personalize the instructions for the care of the patient by giving the hemoglobin value at which blood transfusion and number of units would be needed, for example.

• Make sure the physician receiving the hand-off really understands. Encourage questions.

Hospitalists who are receiving patients in the hand-off process can also do these things to be better, and more active, listeners:

• Limit interruptions.

• Take notes.

• Ask questions.

• Use a system to keep track of to-do items.

• Read back instructions.

Dr. Arora said there are also some systems issues that can help set the stage for better hand-offs. For instance, hospitals can provide physician education on the need to curb side conversations and other interruptions during the verbal hand-off. And they can schedule shifts so that there is sufficient overlap of outgoing and incoming physicians.

Hospitalists who are looking to improve not just their own hand-offs but the overall process at their hospital, should start by describing the current situation, Dr. Arora said. From there, they can identify the areas for improvement, find physicians to champion the project, and figure out what resources will be needed to make changes.

She advised that a standard hand-off protocol should be discipline specific, so what works for neurology won’t work for hospital medicine. Both the process and the content should be standardized. And once the hospitalists have agreed on a protocol, make sure to identify problems as they arise.

Dr. Arora said she has received grants and contracts from the Agency for Healthcare Research and Quality, the Accreditation Council for Graduate Medical Education, and the National Institute on Aging.

SAN DIEGO – Hospitalists may be tempted to rely on their electronic health record systems to do all the work on patient hand-offs, but that probably won’t turn out very well, according to Dr. Vineet Arora.

Dr. Arora, an associate professor of medicine at the University of Chicago and a patient safety researcher who has investigated the barriers to proper hand-offs, said technology can be a great tool, but over-relying on it can lead to just as many errors as a traditional paper sign-out. And just because the information is in the EHR, doesn’t mean physicians can skip the verbal hand-off, he said at the annual meeting of the Society of Hospital Medicine.

"The truth is that the electronic health record doesn’t substitute for the communication, the verbal dialogue, that actually needs to happen at the time of the handoff," Dr. Arora said in an interview.

The verbal hand-off is the place where the departing physician shares their clinical judgment and reviews the "to-do" items and "if-then" items for the sickest patients.

The trick is to make sure the hand-off is focused. "Hospitalists may actually be receiving well over 50 patients, and in some cases, over a hundred." Dr. Arora said. "An electronic patient list of that size is not going to actually communicate the information that somebody might need, which is that bed two or bed three is really sick."

Information overload is a common mistake in patient hand-offs. Some physicians include so much information in the written sign-out that it becomes a "shadow chart," she said.

Beware of offering too much information in the verbal hand-off too. Dr. Arora said most people can only remember about four things from a particular conversation.

"So as opposed to having a verbal hand-over that’s an entire recitation of a patient’s history, or going through every single case in nauseating detail, what you really want to do is focus on the top things that you want somebody to remember," Dr. Arora said.

Dr. Arora offered some tips on the best ways to deliver a better verbal hand-off:

• Focus on the sickest patients first.

• Provide an update on the daily progress with the day’s baseline and updated events.

• Give directions on what needs to be done.

• Provide a rationale for any instructions and further directions on what to do with the results. Avoid ambiguous instructions such as "check CBC." Personalize the instructions for the care of the patient by giving the hemoglobin value at which blood transfusion and number of units would be needed, for example.

• Make sure the physician receiving the hand-off really understands. Encourage questions.

Hospitalists who are receiving patients in the hand-off process can also do these things to be better, and more active, listeners:

• Limit interruptions.

• Take notes.

• Ask questions.

• Use a system to keep track of to-do items.

• Read back instructions.

Dr. Arora said there are also some systems issues that can help set the stage for better hand-offs. For instance, hospitals can provide physician education on the need to curb side conversations and other interruptions during the verbal hand-off. And they can schedule shifts so that there is sufficient overlap of outgoing and incoming physicians.

Hospitalists who are looking to improve not just their own hand-offs but the overall process at their hospital, should start by describing the current situation, Dr. Arora said. From there, they can identify the areas for improvement, find physicians to champion the project, and figure out what resources will be needed to make changes.

She advised that a standard hand-off protocol should be discipline specific, so what works for neurology won’t work for hospital medicine. Both the process and the content should be standardized. And once the hospitalists have agreed on a protocol, make sure to identify problems as they arise.

Dr. Arora said she has received grants and contracts from the Agency for Healthcare Research and Quality, the Accreditation Council for Graduate Medical Education, and the National Institute on Aging.