Nursing Handoffs: Ensuring Safe Passage for Patients

A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced in contemporary clinical practice. It is intended to support, refute, or shed light on health care practices where little evidence exists. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature and encourage the submission of questions for future review.Handoffs serve many functions, from social bonding, to coaching and teaching, to team building, but the most important function of handoffs is information processing: making sure that essential data are transferred for patient safety. Substandard or variable handoffs have contributed to errors, care omissions, treatment delays, inefficiencies from repeated work, inappropriate treatment, adverse events with minor or major harm, increased length of stay, avoidable readmissions, and increased costs.1–3 The Institute of Medicine4 reported that communication failures account for most adverse outcomes in hospitals. Indeed, communication breakdowns were the primary root cause of more than 60% of 2000 sentinel events analyzed by the Joint Commission.2In 2006, the Joint Commission released a National Patient Safety Goal aimed at improving the effectiveness of communication among care-givers. Specifically, this goal required organizations to implement a standardized approach to communication during handoffs, incorporating an opportunity for staff to ask and respond to questions. A handoff is the “transfer and acceptance of responsibility for patient care that is achieved through effective communication. It is a real-time process of passing patient-specific information from one care-giver to another or from one team of caregivers to another to ensure the continuity and safety of that patient’s care.”1 Recognized as points of vulnerability, handoffs occur within and across clinical settings and disciplinary boundaries—on units at change-of-shift and to accommodate breaks, as well as when patients transfer between units or are transported to or from other departments for tests or procedures. Let’s take a hospital with an average daily census of 400, for example, where registered nurses work 12-hour shifts. In this practice environment alone, 2.9 million change-of-shift handoffs would occur each year (not to mention the numerous unit or interdepartmental handoffs!). As Haig et al5 stated, the intent of this National Patient Safety Goal was to create a shared mental model about the condition of the patient, because without this collective understanding, caregivers lose situational awareness. Thus, handoffs are designed to ensure the safe passage of information to increase the effectiveness of the actions of the receiving nurse, thereby enhancing continuity of care.6 The purpose of this review is to address the following PICO question: What effect do standardized nursing handoffs have on patients’, clinicians’, and financial outcomes?A search in CINAHL and MEDLINE, limited to the 5 years from 2007 to 2012, was conducted by using these terms: nursing handoff, interdepartmental handoff, change-of-shift, and shift report.Formal research and quality improvement studies were retrieved: 4 quality improvement, 1 prospective observational, 1 interventional study, and 1 systematic review. Reviewed evidence was limited to handoffs involving nurses in acute/critical care settings. Table 1 summarizes findings from evaluations of nursing handovers at shift change and interdepartmental transfers.Available evidence, albeit weak “level C” (Table 2), demonstrates that standardized change-of-shift and interdepartmental handoffs have a positive impact on many processes and outcomes:Overall, although these handoff practices are “promising,” they are in need of rigorous evaluation to examine handoff features that lead to the best performance by clinicians and the best outcomes for patients. Additional research is necessary to determine which type of protocols are most effective in varied settings and for different purposes.3,6 For instance, results of 1 study7 indicated that overall communication improved with structured change-of-shift handoff procedures, but openness and quality of information did not. Other authors reported that face-to-face structured handoffs produced less omission than taped handoffs but were more likely to lead to incongruent information.3 These unexpected findings warrant more systematic investigation.In order to achieve improved processes and outcomes, barriers that impede effective handoffs (Table 3) must be proactively addressed. These barriers include cultural aspects of our units/organizations, patient/staffing issues, human factors, time constraints, and educational issues. Deeply understanding that patients expect to be safe in our care, high-reliability organizations purposefully design human interactions that promote teamwork, structured communication, and situational awareness. Reliability refers to a failure-free operation over time from the viewpoint of the patient. In reference to handoffs, reliability means patient information flows consistently during transitions of care to enable safe, timely, and high-quality patient care.14Preventing communication failures begins with structured communication. Standard protocols identify necessary information for reliable handoffs and thus reduce clinicians’ use of their discretion, which often leads to variability and lower safety margins.14 Highly reliable handoffs incorporate 3 key elements: (1) face-to-face, 2-way communication, (2) structured written forms, templates, or checklists that allow clinicians to agree on minimum essential data that create a shared mental model, and (3) content that “captures intention,” meaning clinicians share problems and hypotheses with a predictive diagnosis of the patient’s clinical situation (foresight), rather than listing events and completed tasks (hindsight), which has been associated with handoff errors.13,15 Mnemonic devices such as SBAR (Situation, Background, Assessment, Recommendation) or “I PASS the BATON” (Introduction, Patient, Assessment, Situation, Safety concerns, Background, Actions, Timing, Ownership, Next) provide a format that can be tailored for different clinical areas and/or purposes. Such written tools introduce redundancy, helping nurses organize large amounts of information to convey complex issues related to patient care in a complete and meaningful way.3,6,16,17 Consistently discussing information in a standardized sequence or order also aids pattern recognition for clinicians.16 Other recommendations for standardization include interactive questioning, as well as closed-loop verification to confirm that information has been received and understood.1,3,18In addition to structured tools, bedside rounds at the end of change-of-shift handoffs serve many functions. Nurses can introduce the oncoming nurse and address patients’ concerns, giving them an opportunity to be involved in their care,16,17,19 and perform vital quality checks on equipment, alarms and settings, intravenous catheters and infusions, and so on. Receiving nurses can check for any missing information and ask final questions to create a shared baseline of the patient’s condition.3,16 Red flags on unexpected findings compared with the information relayed can be discussed and rectified in real time. Thus, handoff procedures create informed situational awareness.The role of education in standardizing handoffs in practice cannot be overemphasized. During initial and refresher education, nurses can practice standardized handoff procedures by role-playing real-life scenarios, while at the same time honing the whole family of human factor skills—teamwork, structured communication, situational awareness, assertiveness, and critical language. Posters and pocket cards may be useful to reinforce expectations for practice. More research is needed to determine the effectiveness of various educational and implementation strategies in reliably embedding standardized handoff procedures in practice.3