Standardized process reduces handoff-related care failures in children's hospitals

By Will Boggs MD

NEW YORK (Reuters Health) - Use of a standardized evidence-based handoff process can significantly reduce handoff-related care failures in children's hospitals, according to results from a 23-hospital study.

"We asked hospitals to identify their area of greatest opportunity for handoff improvement - and then we provided them with key features of effective handoffs," Dr. Michael T. Bigham from Akron Children's Hospital in Ohio told Reuters Health by email.

The Joint Commission, the World Health Organization (WHO), and the Institute of Medicine (IOM) have all highlighted the role of handoff processes to improve patient safety, but studies linking standardized handoff processes to decreased patient harm are rare.

Dr. Bigham and colleagues evaluated the effect of the "Improving Patient Handoffs" quality improvement collaborative on handoff-related care failures over the course of the 12-month initiative.

The required elements of the quality improvement program included (1) defined handoff intent; (2) defined handoff content; (3) defined handoff process; and (4) maximized team effectiveness. Each hospital developed its own standardized handoff process.

"Interestingly, the collaborative didn't mandate highly specific interventions - or frankly we didn't even drive which handoff type to target amongst the collaborative," Dr. Bigham explained. "We used an 'all teach, all learn' strategy through webinars where programs were asked to share their local interventions and 'lessons learned' with the collaborative, permitting programs to hear how others have applied improvements."

Prior to implementation of the standardized handoff process, 25.8% of handoffs were linked to a handoff-related care failure, according to the July 7 Pediatrics online report.

By the final quarter of the initiative, only 7.9% of handoffs were linked to a handoff-related care failure, a reduction of 69% from baseline.

"Importantly, four of the hospitals eliminated their handoff-related failures by the final quarter of the study," Dr. Bigham said.

Handoff measures that improved significantly during the intervention included achieving a common understanding about the patient, achieving a clear transition of responsibility, and operating with minimal interruptions and distractions. The overall process effectiveness for these three measures increased from 87% compliance at baseline to 94% compliance in the final quarter of the intervention.

Staff satisfaction improved in parallel with reduced handoff-related failures, from 55% at baseline to 70% at the final intervention quarter.

"The 3 main challenges with implementing this improvement work were similar to other improvement work," Dr. Bigham explained. "1 - Creating the awareness across leadership and front-line staff that current performance around handoffs puts our patients at risk and that change is necessary. 2 - Committing the frontline and quality improvement resources to implement improvement strategies, measure their effect, and then oftentimes implement more or different improvement efforts . . . (and) 3 - One particularly challenging aspect of this work is that handoff improvement required a change in communication patterns. Successfully changing behavior and sustaining these changes in behavior is one of the most challenging areas in quality improvement."

"Overall, I'd like to highlight the ability to introduce and accomplish improvement across a wide array of clinical settings," Dr. Bigham said. "The success, in my opinion, is on the shoulders of hospital leadership who has chosen to invest in and support this and other important patient safety efforts."

"Future research related to handoffs in health care should focus on the effect of reliable handoffs on patient harm and clinical outcomes," the researchers conclude.

Dr. Lyra Burch from Boston Children's Hospital and Boston Medical Center in Massachusetts has written about patient handoff at the end of pediatric residency. She told Reuters Health via email, "As the culture of medicine trends more toward shift work, both among residents as well as hospitalists, the use of evidence based handoff structures is becoming increasingly important for patient safety and quality of care."

Dr. Burch added, "Although most of the focus on handoffs is on hospitalized patients, as I noted in my commentary piece, formal handoffs in primary care are also needed, whether among graduating residents or departing attendings. While the acuity is not often present in the primary care scenario, the fund of knowledge for each patient has the potential to be much greater and deserves to be communicated."

Dr. Mark Shen is president of Dell Children's Medical Center of Central Texas in Austin. He told Reuters Health by email, "There is little reason to not standardize handoffs given that the Joint Commission estimates that 2/3 of errors in hospitals are related to communication issues."

Dr. Shen said his institution has handoff standards like these.

"Almost all physicians recognize that the handoff or 'sign-out' process is fraught with difficulty and frustration," Dr. Shen said. "At both ends of the spectrum, from the overly brief 10 second statement to the long-winded interesting narrative, the traditional emphasis has been on the storyteller and not the relevant pieces of data and ensuring that the information has been understood. Given the critical role of communication in patient safety, like hand washing, standardized handoffs should be a part of every physician's daily routine."

SOURCE: http://bit.ly/1kzxJbs

Pediatrics 2014;134:e1-e8.

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