Elizabeth Lyden, MS

Handoffs are the exchange of information between health professionals that accompany the transfer of patient‐care responsibility.[1] Poor handoff practices are associated with unsafe and inefficient care.[2, 3, 4] Teaching hospitals are especially at risk, as resident work‐hour restrictions have increased the number of handoffs.[5] Accreditation agencies now require that hospitals and residency programs have structured handoff processes[6, 7] and that medical students[8] and residents[9, 10, 11, 12] demonstrate competency in handoffs.

Physician handoff research has primarily focused on handoffs within a service or discipline. These within‐unit handoffs should be differentiated from interunit handoffs.[13, 14] Interunit handoffs, such as the transition from the emergency department (ED) to inpatient setting, are subject to unique challenges. The ED admission process involves changes in personnel, provider specialty, and location.[15] The transition occurs when the patient's clinical trajectory is uncertain, treatments are being initiated, and test results are pending. Other barriers include interdisciplinary cultural differences, interphysician conflict, unstructured communication, environmental factors, and complex care coordination.[13, 14, 15, 16, 17, 18] Despite these challenges, there is relatively little research specifically examining ED to inpatient handoffs, and most of what is available has focused on individual services within an institution.[13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25]

As part of an institutional effort to improve our ED admission handoff practices, we conducted a cross‐sectional, survey‐based needs‐assessment involving emergency medicine (EM) and 5 inpatient medical services. The objective of this study was to determine physicians' perceptions of the ED admission handoff process and to identify potential barriers to safe patient care.

METHODS

RESULTS

After applying exclusion criteria, the survey response rate was 63% for admitting physicians (94/150) and 86% for EM physicians (32/37). Participants' service affiliation and level of training are shown in the Table 1. Table 2 provides the distribution of survey responses for EM and admitting physicians.

The processes for assigning responsibilities following the initial handoff differed between admitting services, and within a service the process was often dynamic. For example, within the university‐based IM and community‐based FM services, the assignment process varied depending on timing (day vs night, weekday vs weekend). For the critical care medicine and cardiology services, fellows accepted admission handoff calls, and depending on competing clinical responsibilities and the patient's stability, either evaluated the patient independently or sent a resident to perform a preliminary evaluation. We reviewed and classified these varied admission assignment strategies into 4 general schemes (Figure 1). All 5 admitting services relied partly or entirely on housestaff for receiving admission handoffs, as did the EM service.

Figure 1

DISCUSSION

Based upon physician self‐reporting, we identified perceived barriers to safe ED admission handoff across several domains. This study adds to the literature, as it provides a cross‐section of multiple inpatient services with varying admission schemes to underscore the complexities facing hospitals in safely transitioning patients between units. As noted in previous studies, one‐third of physicians reported a handoff‐related adverse event,[15] and there was significant disagreement between handoff participants about communication of critical information.[21, 26] These differences in perceptions suggest a failure of physicians to accurately transfer information to create a shared understanding of patient care,[21] which is the central function of handoffs.

EM physicians frequently felt that admitting physicians did not trust their clinical decisions, a perception supported by the fact that over 25% of admitting respondents' usually disagreed with decisions in the ED. Interdisciplinary trust is central in negotiating a shared plan of care[13] and mitigating conflict to ensure a safe transition of patient care.[16] Handoffs are complex social interactions, and feelings of defensiveness and mistrust are likely exacerbated by in‐group/out‐group biases,[15] conflicting information expectations,[19] and discordant ways of interpreting and framing handoff interactions.[13] Interestingly, EM residents were less likely than interns or faculty to report feeling defensive. This may be in part because residents from EM and admitting services develop relationships during interdisciplinary rotations, which may help facilitate future handoff interactions.[27] The fact that EM respondents felt defensive, despite reporting less‐frequent questioning than admitting physicians, suggests that tone and content of questions played an important role. These findings support the importance of interdisciplinary education and standardization of handoff communication between ED and admitting physicians.[23] Beach and colleagues have recommended a conceptual framework for interunit handoffs between EM and hospital physicians, but further research is needed to measure its impact in real‐world settings.[14]

We also found great variability in admitting services' processes for assigning patient‐care responsibility following the initial handoff. Even within an individual service, these processes were often dynamic and relied on physicians at different levels of training. This has several potential consequences. First, it may be difficult for physicians engaged in a handoff to know the level of experience and expertise of one another. These contextual variables play an important role in how handoff information is conveyed, as less experienced clinicians may require explicit information that a more experienced provider may infer.[1, 21] Second, the variability in admission assignment processes may further exacerbate uncertainty regarding responsibility for patients boarding in the ED, making it increasingly difficult for nurses and ancillary staff to know which physician is ultimately responsible for patient care. Finally, the diversity of admission schemes may complicate the development of standardized interunit handoff protocols, policy, and education.

A related finding was that sequential handoffs were common within both EM and admitting services. EM shift handoffs have their own set of barriers,[28] which can lead to ineffective communication.[29] Likewise, about two‐thirds of admitting respondents reported using an admission triage system. The goal of such systems is to simplify complex call schedules and diverse patient assignment schemes within admitting services, thus streamlining the admission process. These systems may also allow for more consistency in the quality of handoff communication through the creation of triage specialists. These potential advantages need to be weighed against the increased risk of communication breakdown. The introduction of sequential handoffs creates a game of telephone, in which there is no direct communication between the first and final caregivers (Figure 1), allowing misinformation to be propagated forward.[30] Sequential handoffs contributed to several reported adverse events, and the majority of surveyed physicians felt they negatively impacted patient care. Further research is necessary to determine the impact of centralized triage systems and to explore strategies to mitigate information decay that results from sequential handoffs, as quality‐improvement interventions may be of limited benefit if downstream communication remains ineffective. Potential strategies may include standardizing sequential handoff communication, leveraging centralized handoff notes within electronic health records, or developing handoff systems that ensure direct communication between the EM physician and the ultimate admitting provider.

FUTURE DIRECTIONS

Further research is needed to examine interventions that may improve clinically relevant outcomes. Development of structured admission handoff protocols should be collaborative[31] and focus on clinical judgment, rather than rote recitation of data.[14] Based on our study findings, we are pilot testing a standardized approach for ED‐to‐hospital handoffs, and portions of this survey will be repeated in the postintervention assessment.

At our institution, housestaff at all levels of training regularly participated in the handoff process. The Accreditation Council for Graduate Medical Education requires that residents demonstrate competence in performing handoffs,[7] yet handoff training and assessment are inconsistent,[23, 32, 33] and published interventions have focused primarily on within‐unit handoffs.[34, 35, 36] Additional training should focus on the unique aspects of interunit handoffs. Approaches could include interprofessional communication training, simulation training, and enhanced assessment methods. Additionally, increasing face‐to‐face communication, perhaps as part of bedside handoffs, could improve relationships and the development of a shared mental model of patient care. More direct involvement by attending physicians will also be important, as there is evidence that such oversight may improve training[36] and safety,[37] as more experienced physicians better integrate handoff information.[21]

CONCLUSION

We identified several perceived barriers to safe interunit handoff from the ED to the inpatient setting. Handoff‐related adverse events, a pattern of conflicting physician perceptions, and frequent sequential handoffs were of particular concern. Our findings support the need for collaborative efforts to improve interdisciplinary communication.

Handoffs are the exchange of information between health professionals that accompany the transfer of patient‐care responsibility.[1] Poor handoff practices are associated with unsafe and inefficient care.[2, 3, 4] Teaching hospitals are especially at risk, as resident work‐hour restrictions have increased the number of handoffs.[5] Accreditation agencies now require that hospitals and residency programs have structured handoff processes[6, 7] and that medical students[8] and residents[9, 10, 11, 12] demonstrate competency in handoffs.

Physician handoff research has primarily focused on handoffs within a service or discipline. These within‐unit handoffs should be differentiated from interunit handoffs.[13, 14] Interunit handoffs, such as the transition from the emergency department (ED) to inpatient setting, are subject to unique challenges. The ED admission process involves changes in personnel, provider specialty, and location.[15] The transition occurs when the patient's clinical trajectory is uncertain, treatments are being initiated, and test results are pending. Other barriers include interdisciplinary cultural differences, interphysician conflict, unstructured communication, environmental factors, and complex care coordination.[13, 14, 15, 16, 17, 18] Despite these challenges, there is relatively little research specifically examining ED to inpatient handoffs, and most of what is available has focused on individual services within an institution.[13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25]

As part of an institutional effort to improve our ED admission handoff practices, we conducted a cross‐sectional, survey‐based needs‐assessment involving emergency medicine (EM) and 5 inpatient medical services. The objective of this study was to determine physicians' perceptions of the ED admission handoff process and to identify potential barriers to safe patient care.

METHODS

RESULTS

After applying exclusion criteria, the survey response rate was 63% for admitting physicians (94/150) and 86% for EM physicians (32/37). Participants' service affiliation and level of training are shown in the Table 1. Table 2 provides the distribution of survey responses for EM and admitting physicians.

The processes for assigning responsibilities following the initial handoff differed between admitting services, and within a service the process was often dynamic. For example, within the university‐based IM and community‐based FM services, the assignment process varied depending on timing (day vs night, weekday vs weekend). For the critical care medicine and cardiology services, fellows accepted admission handoff calls, and depending on competing clinical responsibilities and the patient's stability, either evaluated the patient independently or sent a resident to perform a preliminary evaluation. We reviewed and classified these varied admission assignment strategies into 4 general schemes (Figure 1). All 5 admitting services relied partly or entirely on housestaff for receiving admission handoffs, as did the EM service.

Figure 1

DISCUSSION

Based upon physician self‐reporting, we identified perceived barriers to safe ED admission handoff across several domains. This study adds to the literature, as it provides a cross‐section of multiple inpatient services with varying admission schemes to underscore the complexities facing hospitals in safely transitioning patients between units. As noted in previous studies, one‐third of physicians reported a handoff‐related adverse event,[15] and there was significant disagreement between handoff participants about communication of critical information.[21, 26] These differences in perceptions suggest a failure of physicians to accurately transfer information to create a shared understanding of patient care,[21] which is the central function of handoffs.

EM physicians frequently felt that admitting physicians did not trust their clinical decisions, a perception supported by the fact that over 25% of admitting respondents' usually disagreed with decisions in the ED. Interdisciplinary trust is central in negotiating a shared plan of care[13] and mitigating conflict to ensure a safe transition of patient care.[16] Handoffs are complex social interactions, and feelings of defensiveness and mistrust are likely exacerbated by in‐group/out‐group biases,[15] conflicting information expectations,[19] and discordant ways of interpreting and framing handoff interactions.[13] Interestingly, EM residents were less likely than interns or faculty to report feeling defensive. This may be in part because residents from EM and admitting services develop relationships during interdisciplinary rotations, which may help facilitate future handoff interactions.[27] The fact that EM respondents felt defensive, despite reporting less‐frequent questioning than admitting physicians, suggests that tone and content of questions played an important role. These findings support the importance of interdisciplinary education and standardization of handoff communication between ED and admitting physicians.[23] Beach and colleagues have recommended a conceptual framework for interunit handoffs between EM and hospital physicians, but further research is needed to measure its impact in real‐world settings.[14]

We also found great variability in admitting services' processes for assigning patient‐care responsibility following the initial handoff. Even within an individual service, these processes were often dynamic and relied on physicians at different levels of training. This has several potential consequences. First, it may be difficult for physicians engaged in a handoff to know the level of experience and expertise of one another. These contextual variables play an important role in how handoff information is conveyed, as less experienced clinicians may require explicit information that a more experienced provider may infer.[1, 21] Second, the variability in admission assignment processes may further exacerbate uncertainty regarding responsibility for patients boarding in the ED, making it increasingly difficult for nurses and ancillary staff to know which physician is ultimately responsible for patient care. Finally, the diversity of admission schemes may complicate the development of standardized interunit handoff protocols, policy, and education.

A related finding was that sequential handoffs were common within both EM and admitting services. EM shift handoffs have their own set of barriers,[28] which can lead to ineffective communication.[29] Likewise, about two‐thirds of admitting respondents reported using an admission triage system. The goal of such systems is to simplify complex call schedules and diverse patient assignment schemes within admitting services, thus streamlining the admission process. These systems may also allow for more consistency in the quality of handoff communication through the creation of triage specialists. These potential advantages need to be weighed against the increased risk of communication breakdown. The introduction of sequential handoffs creates a game of telephone, in which there is no direct communication between the first and final caregivers (Figure 1), allowing misinformation to be propagated forward.[30] Sequential handoffs contributed to several reported adverse events, and the majority of surveyed physicians felt they negatively impacted patient care. Further research is necessary to determine the impact of centralized triage systems and to explore strategies to mitigate information decay that results from sequential handoffs, as quality‐improvement interventions may be of limited benefit if downstream communication remains ineffective. Potential strategies may include standardizing sequential handoff communication, leveraging centralized handoff notes within electronic health records, or developing handoff systems that ensure direct communication between the EM physician and the ultimate admitting provider.

FUTURE DIRECTIONS

Further research is needed to examine interventions that may improve clinically relevant outcomes. Development of structured admission handoff protocols should be collaborative[31] and focus on clinical judgment, rather than rote recitation of data.[14] Based on our study findings, we are pilot testing a standardized approach for ED‐to‐hospital handoffs, and portions of this survey will be repeated in the postintervention assessment.

At our institution, housestaff at all levels of training regularly participated in the handoff process. The Accreditation Council for Graduate Medical Education requires that residents demonstrate competence in performing handoffs,[7] yet handoff training and assessment are inconsistent,[23, 32, 33] and published interventions have focused primarily on within‐unit handoffs.[34, 35, 36] Additional training should focus on the unique aspects of interunit handoffs. Approaches could include interprofessional communication training, simulation training, and enhanced assessment methods. Additionally, increasing face‐to‐face communication, perhaps as part of bedside handoffs, could improve relationships and the development of a shared mental model of patient care. More direct involvement by attending physicians will also be important, as there is evidence that such oversight may improve training[36] and safety,[37] as more experienced physicians better integrate handoff information.[21]

CONCLUSION

We identified several perceived barriers to safe interunit handoff from the ED to the inpatient setting. Handoff‐related adverse events, a pattern of conflicting physician perceptions, and frequent sequential handoffs were of particular concern. Our findings support the need for collaborative efforts to improve interdisciplinary communication.

Handoffs are the exchange of information between health professionals that accompany the transfer of patient‐care responsibility.[1] Poor handoff practices are associated with unsafe and inefficient care.[2, 3, 4] Teaching hospitals are especially at risk, as resident work‐hour restrictions have increased the number of handoffs.[5] Accreditation agencies now require that hospitals and residency programs have structured handoff processes[6, 7] and that medical students[8] and residents[9, 10, 11, 12] demonstrate competency in handoffs.

Physician handoff research has primarily focused on handoffs within a service or discipline. These within‐unit handoffs should be differentiated from interunit handoffs.[13, 14] Interunit handoffs, such as the transition from the emergency department (ED) to inpatient setting, are subject to unique challenges. The ED admission process involves changes in personnel, provider specialty, and location.[15] The transition occurs when the patient's clinical trajectory is uncertain, treatments are being initiated, and test results are pending. Other barriers include interdisciplinary cultural differences, interphysician conflict, unstructured communication, environmental factors, and complex care coordination.[13, 14, 15, 16, 17, 18] Despite these challenges, there is relatively little research specifically examining ED to inpatient handoffs, and most of what is available has focused on individual services within an institution.[13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25]

As part of an institutional effort to improve our ED admission handoff practices, we conducted a cross‐sectional, survey‐based needs‐assessment involving emergency medicine (EM) and 5 inpatient medical services. The objective of this study was to determine physicians' perceptions of the ED admission handoff process and to identify potential barriers to safe patient care.

METHODS

RESULTS

After applying exclusion criteria, the survey response rate was 63% for admitting physicians (94/150) and 86% for EM physicians (32/37). Participants' service affiliation and level of training are shown in the Table 1. Table 2 provides the distribution of survey responses for EM and admitting physicians.

The processes for assigning responsibilities following the initial handoff differed between admitting services, and within a service the process was often dynamic. For example, within the university‐based IM and community‐based FM services, the assignment process varied depending on timing (day vs night, weekday vs weekend). For the critical care medicine and cardiology services, fellows accepted admission handoff calls, and depending on competing clinical responsibilities and the patient's stability, either evaluated the patient independently or sent a resident to perform a preliminary evaluation. We reviewed and classified these varied admission assignment strategies into 4 general schemes (Figure 1). All 5 admitting services relied partly or entirely on housestaff for receiving admission handoffs, as did the EM service.

Figure 1

DISCUSSION

Based upon physician self‐reporting, we identified perceived barriers to safe ED admission handoff across several domains. This study adds to the literature, as it provides a cross‐section of multiple inpatient services with varying admission schemes to underscore the complexities facing hospitals in safely transitioning patients between units. As noted in previous studies, one‐third of physicians reported a handoff‐related adverse event,[15] and there was significant disagreement between handoff participants about communication of critical information.[21, 26] These differences in perceptions suggest a failure of physicians to accurately transfer information to create a shared understanding of patient care,[21] which is the central function of handoffs.

EM physicians frequently felt that admitting physicians did not trust their clinical decisions, a perception supported by the fact that over 25% of admitting respondents' usually disagreed with decisions in the ED. Interdisciplinary trust is central in negotiating a shared plan of care[13] and mitigating conflict to ensure a safe transition of patient care.[16] Handoffs are complex social interactions, and feelings of defensiveness and mistrust are likely exacerbated by in‐group/out‐group biases,[15] conflicting information expectations,[19] and discordant ways of interpreting and framing handoff interactions.[13] Interestingly, EM residents were less likely than interns or faculty to report feeling defensive. This may be in part because residents from EM and admitting services develop relationships during interdisciplinary rotations, which may help facilitate future handoff interactions.[27] The fact that EM respondents felt defensive, despite reporting less‐frequent questioning than admitting physicians, suggests that tone and content of questions played an important role. These findings support the importance of interdisciplinary education and standardization of handoff communication between ED and admitting physicians.[23] Beach and colleagues have recommended a conceptual framework for interunit handoffs between EM and hospital physicians, but further research is needed to measure its impact in real‐world settings.[14]

We also found great variability in admitting services' processes for assigning patient‐care responsibility following the initial handoff. Even within an individual service, these processes were often dynamic and relied on physicians at different levels of training. This has several potential consequences. First, it may be difficult for physicians engaged in a handoff to know the level of experience and expertise of one another. These contextual variables play an important role in how handoff information is conveyed, as less experienced clinicians may require explicit information that a more experienced provider may infer.[1, 21] Second, the variability in admission assignment processes may further exacerbate uncertainty regarding responsibility for patients boarding in the ED, making it increasingly difficult for nurses and ancillary staff to know which physician is ultimately responsible for patient care. Finally, the diversity of admission schemes may complicate the development of standardized interunit handoff protocols, policy, and education.

A related finding was that sequential handoffs were common within both EM and admitting services. EM shift handoffs have their own set of barriers,[28] which can lead to ineffective communication.[29] Likewise, about two‐thirds of admitting respondents reported using an admission triage system. The goal of such systems is to simplify complex call schedules and diverse patient assignment schemes within admitting services, thus streamlining the admission process. These systems may also allow for more consistency in the quality of handoff communication through the creation of triage specialists. These potential advantages need to be weighed against the increased risk of communication breakdown. The introduction of sequential handoffs creates a game of telephone, in which there is no direct communication between the first and final caregivers (Figure 1), allowing misinformation to be propagated forward.[30] Sequential handoffs contributed to several reported adverse events, and the majority of surveyed physicians felt they negatively impacted patient care. Further research is necessary to determine the impact of centralized triage systems and to explore strategies to mitigate information decay that results from sequential handoffs, as quality‐improvement interventions may be of limited benefit if downstream communication remains ineffective. Potential strategies may include standardizing sequential handoff communication, leveraging centralized handoff notes within electronic health records, or developing handoff systems that ensure direct communication between the EM physician and the ultimate admitting provider.

FUTURE DIRECTIONS

Further research is needed to examine interventions that may improve clinically relevant outcomes. Development of structured admission handoff protocols should be collaborative[31] and focus on clinical judgment, rather than rote recitation of data.[14] Based on our study findings, we are pilot testing a standardized approach for ED‐to‐hospital handoffs, and portions of this survey will be repeated in the postintervention assessment.

At our institution, housestaff at all levels of training regularly participated in the handoff process. The Accreditation Council for Graduate Medical Education requires that residents demonstrate competence in performing handoffs,[7] yet handoff training and assessment are inconsistent,[23, 32, 33] and published interventions have focused primarily on within‐unit handoffs.[34, 35, 36] Additional training should focus on the unique aspects of interunit handoffs. Approaches could include interprofessional communication training, simulation training, and enhanced assessment methods. Additionally, increasing face‐to‐face communication, perhaps as part of bedside handoffs, could improve relationships and the development of a shared mental model of patient care. More direct involvement by attending physicians will also be important, as there is evidence that such oversight may improve training[36] and safety,[37] as more experienced physicians better integrate handoff information.[21]

CONCLUSION

We identified several perceived barriers to safe interunit handoff from the ED to the inpatient setting. Handoff‐related adverse events, a pattern of conflicting physician perceptions, and frequent sequential handoffs were of particular concern. Our findings support the need for collaborative efforts to improve interdisciplinary communication.