The Journal of Emergency Medicine, Vol. 47, No. 5, pp. 573–579, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2014.06.027

Education RESIDENT TO RESIDENT HANDOFFS IN THE EMERGENCY DEPARTMENT: AN OBSERVATIONAL STUDY Susan M. Peterson, MD,* Ayse P. Gurses, PHD,† and Linda Regan, MD* *Department of Emergency Medicine, The Johns Hopkins University, Baltimore, Maryland and †Armstrong Institute for Patient Safety and Quality, School of Medicine, The Johns Hopkins University, Baltimore, Maryland Reprint Address: Susan M. Peterson, MD, Department of Emergency Medicine, The Johns Hopkins University, 5801 Smith Avenue, Suite 3220, Baltimore, MD 21209

, Abstract—Background: Despite patient handoffs being well recognized as a potentially dangerous time in the care of patients in the emergency department (ED), there is no established standard and little supporting research on how to optimize the process. Minimizing handoff risks is particularly important at teaching hospitals, where residents often provide the majority of patient handoffs. Objective: Our aim was to identify hazards to patient safety and barriers to efficiency related to resident handoffs in the ED. Methods: An observational study was completed using the Systems Engineering Initiative for Patient Safety model to assess the safety and efficiency of resident handoffs. Thirty resident handoffs were observed with residents in emergency medicine over 16 weeks. Results: Residents were interrupted, on average, every 8.5 min. The most common deficit in relaying the plan of care strategy was failing to relay medications administered (32%). In addition, there were ambiguities related to medication administration, such as when the medication was next due or why a medication was chosen, in 56% of handoffs observed. Ninety percent of residents observed took handwritten notes. A small percentage (11%) also completed free texted computer progress notes. Ten percent of residents took no notes. Conclusions: The existing system allows for a clear summary of the patient’s visit. Two major deficits—frequent interruptions and inconsistent communication regarding medications administered—were noted.

There is inconsistency in how information is recorded at the time of handoff. Future studies should focus on handoff improvement and error reduction. Ó 2014 Elsevier Inc. , Keywords—hand offs; resident; patient safety; observational study; transitions of care

INTRODUCTION ‘‘Transitions of care’’ or ‘‘handoffs’’ are defined as the transition of responsibility for a patient and communication of patient-specific information, data, and care plans between health care providers (1). Communication errors during transitions of care were found to be a major source of adverse events, prompting the Joint Commission to prioritize this as a safety goal in 2006 (2). In the emergency department (ED), up to 24% of malpractice cases are directly attributed to communication errors at the time of patient handoff (3). Despite patient handoffs being well recognized as a critical time in the care of patients, there are no established standards and there is little supporting research on how to optimize handoffs in the ED (4–6). The 2010 Annals of Emergency Medicine article ‘‘Improving Handoffs in the Emergency Department’’ is a highly comprehensive review of handoffs in emergency medicine (EM). However, there remains a need for specific actionable recommendations on which to develop an ideal handoff system (6). The

Dr. Gurses was supported in part by the Agency for Healthcare Research and Quality K01 grant no. HS018762. Institutional Review Board approval was obtained.

RECEIVED: 21 October 2013; FINAL SUBMISSION RECEIVED: 31 January 2014; ACCEPTED: 30 June 2014 573

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literature offers only a few published studies examining some of the recommended strategies as well as numerous pneumonics that can be used. Unfortunately, there is little agreement on which is most effective (7). A 2007 crosssectional survey of EM training program directors found that 50% of physician staff handoffs were ‘‘verbal only’’ and 72% agreed that a standardized handoff system would improve communication and reduce medical error (8). Minimizing risks to patient safety at the time of handoffs is particularly important at teaching hospitals, where residents in training often provide a majority of the care to the patient. In 2007, a review of five insurance companies’ closed claims from a 22-year period of clinical practice found 889 claims to have both error and injury from that error. Two-hundred and forty of these medical adverse events involved trainees. Seventy percent of errors involving trainees were teamwork related and 20% were specifically due to handoffs (9). In addition, the newly released 2013 Accreditation Council for Graduate Medical Education requirements for EM require that residency programs ensure that residents are ‘‘competent in communicating with team members during handoffs,’’ while both programs and their sponsoring institutions ‘‘must ensure and monitor effective, structured handover processes to facilitate both continuity of care and patient safety’’ (10). While there is a growing body of literature from inpatient medicine and nursing suggesting that a combination of written and verbal communication is optimal, there remains a paucity of objective data regarding safety hazards, efficiency barriers, and best practices related to handoffs in the ED (11). This study uses observational methods to assess the safety and methods of resident to resident handoffs in our ED, to identify key barriers to handoffs of care, and to identify potential solutions to improve the safety of transitions of care. METHODS The study was conducted in the ED of a Level I trauma center and academic teaching hospital with an annual volume of approximately 62,000 patients per year. The ED uses an electronic patient record for documentation of the patient visit and no handoff tool existed at the time of the study. All trainees in the 4-year EM training program were eligible for inclusion and both day and night shifts were sampled. Off-service residents who rotate through the department and physician assistants were excluded from this study. In this study, we define a handoff as ‘‘a transfer of responsibility for assessment, treatment, and disposition from one EM resident to another.’’ No patient identification or health information was recorded in this study. The Institutional Review Board approved this study and all participants consented to involvement.

A convenience sample of observations were completed using the Systems Engineering Initiative for Patient Safety (SEIPS) model, a well-established human factors engineering framework to study health care systems, to assess the safety of resident handoffs (12). Seven areas were observed and recorded, including process steps, people involved, tools/technologies, organizational issues, physical environment, tasks, and ambiguities (13). Observations were completed by a single ED physician with basic training in human factors engineering. Training involved a workshop in human factors engineering and several one on one meetings with the developer of the SEIPS model. Data were transcribed at the time of the observation. Initial observations were reviewed by a human factors engineer to ensure consistency and relevance of observational data recorded. Analysis was progressively done as observations were completed. Observations were terminated when theoretical saturation point was met and clear patterns were established (14). In addition to the semi-structured observation tool from the SEIPS model, all observations were timed using a stopwatch. This was used to calculate the mean number of minutes per patient handed off and the frequency of interruptions. Additional information recorded for each observed handoff included the number of patients handed off. For each patient that was discussed, the observer recorded if the following was reviewed: history of present illness, laboratories, radiology findings, medications and intravenous fluids given, pending data, and disposition. RESULTS Thirty observations were completed during a 3-month period in the winter of 2012 to 2013. Twenty-five residents were consented and observed completing at least one handoff during this time period. Sixteen percent were first-year residents, 20% were second-year residents, 32% were third-year residents, and 32% were fourth-year residents. Fifty-six percent of observations were completed during the day (between 7 AM and 3 PM) and 44% were completed in the evening (between 3 PM and 11 PM). A mean of 3.3 min (standard deviation [SD] 2.19 min, median 3.0 min) was spent handing off each patient. The number of patients handed off ranged from 3 to 19, with a mean of 10 patients being handed off. The number of patients in the department at the time of handoff ranged between 39 and 110. Table 1 shows a summary of the observational data collected. Process The residents followed a relatively consistent process, with 93% of residents reviewing charts before the start

Process Steps

People Involved (Job Types)

Tools/Technologies

93% of incoming residents reviewed charts before arrival

100% of handoffs involved first- to fourth-year EM residents

100% of handoffs involved computers with Allscripts charting system

100% residents systematically reviewed HPI, laboratory results, radiology, medications, pending items, and disposition 100% of incoming residents reviewed laboratory results and radiology while listening to HPI 100% of residents went to the patient’s bedside after computer handoff for introductions There was opportunity to ask questions in 100% of handoffs

Mean of 3.3 min spent handing off each patient

100% of residents used portable phones

No. of patients signed out ranged from 3 to 19

90% of residents took handwritten notes

Mean no. of patients signed out was 10

10% of residents recorded notes in the chart in the form of a free texted progress note 10% of residents took no notes

Organizational Issues (Teamwork, Information Needed, Coordination, Supervision)

Physical Environment

Tasks (Non Value-Adding, Easiness, Workload, Time Pressure)

Ambiguities (Responsibility Ambiguity, Method Ambiguity)

The beginning or end of handoff occurred in critical care in 13% of observations One handoff began with a code and was conducted entirely in critical care Information about medications given was not discussed for a mean of 32% of patient’s handed off

ED 90%

Interrupted every 7.7 min in ED

Medication ambiguities (when to re-dose, why antibiotics were chosen) requiring clarification 56%

Observational area 7%

Interrupted every 10.1 min in observation unit

Ambiguities related to disposition were present in 70% of handoffs most often because of incomplete availability of information at time of handoff

One procedure was supervised by a senior resident in the middle of signout

Critical care 3%

Interrupted every 11 min in critical care

Workstation on wheels 7%

Interrupted every 9.8 min using workstation on wheels

No. of patients in department at time of signout ranged from 39 to 110

The completion of 7% of handoffs was rushed because a new patient was coming to critical care

Resident to Resident Handoffs

Table 1. Findings from Observations Guided by the Systems Engineering Initiative for Patient Safety*

ED = emergency department; EM = emergency medicine; HPI = history of present illness. * 100% refers to 30 total observations.

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of their shift. During observations completed, the offgoing resident reviewed the history of present illness, relevant medical history, laboratories, imaging, medications given, and disposition, while the oncoming resident listened and systematically reviewed the chart at an adjacent computer. This process was consistent except for those handoffs completed using workstations on wheels (7%). After review of the patient charts on the computer, residents went to the patient’s bedside. There was an opportunity to ask questions during every handoff observed. Tools/Technologies Organizational Issues Two computers adjacent to one another were used by the incoming and outgoing resident during each handoff, except for those handoffs conducted using the workstation on wheels (7%), as noted. Charts were reviewed in the Allscripts electronic charting system. Laboratory results and radiology results were available at the bottom of the chart in this system. Residents typically followed the electronic medical record format with the off-going resident verbally reviewing the history of present illness, laboratory studies, and radiology, making these items consistently reviewed. Residents had to go to a separate page of the chart to review medications and fluids, which was not frequently done. Information about medications given was omitted in 32% of patient handoffs observed. The majority of residents, 90%, took handwritten personal notes. Eleven percent of those taking handwritten notes also completed free texted computer progress notes. Ten percent of residents took no notes. All residents carried portable phones (which they also handed off) in order to be able to contact and to be contacted by remotely located staff. Physical Environment The physical environment at the time of handoff was noted to be highly variable and included details such as location of the handoff, number of patients in the department, and the level of attending coverage (single or double). The beginning or end of a handoff occurred in critical care for 13% of handoffs, which, in this institution, was located down the hall from the main ED. One handoff began with a code and was conducted entirely in critical care. Two of the four handoffs that occurred in critical care were truncated because a new patient was coming into critical care. Two of 30 handoffs occurred in the observation unit, as residents reported that they felt they were interrupted less frequently. Two of 30 handoffs were completed using workstations on wheels and patients were seen at the bedside immediately after reviewing the chart. Fifty-six percent of handoffs

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occurred during double attending coverage and 44% occurred with single attending coverage. Tasks Interruptions, such as a phone call to verify who was taking over a particular section of the ED, were recorded. Overall, residents were interrupted every 8.5 min (SD 4.4 min, median 6.66 min) during handoffs. Residents who signed out in the main ED were interrupted, on average, every 7.7 min during the handoff process. Interruptions when residents completed the handoff in the observation unit occurred every 10.1 min and every 11 min in critical care. Residents using the workstation on wheels were interrupted every 9.8 min. Ambiguities There were ambiguities related to medication administration or type of medication given in 56% of observed handoffs. Medication ambiguities were commonly related to why a medication was chosen or when the medication was next due to be administered. Ambiguities related to disposition were present in 70% of handoffs, most frequently secondary to incomplete availability of information at the time of the handoff, such as awaiting computed tomography scan completion and results in order to determine if the patient required admission. DISCUSSION Despite the lack of a template or prescribed signout system, our data support that the observed ED residents had a relatively consistent pattern for completion of a handoff. There were, however, notable inconsistencies with how information was recorded at the time of handoff, with few residents documenting in the chart at the time of handoff and 3 of 30 taking no notes. Only 10% of residents wrote a handoff note in the computer, leaving the majority of handoffs undocumented in the patient record. This illustrates two important communication parts of a handoff: actual provider to provider communication and written documentation that the handoff has occurred and what information was transmitted. Residents typically followed the electronic medical record (EMR) format, with the off-going resident verbally reviewing the history of present illness, laboratory studies, and radiology, making these items consistently reviewed. However, to view medications given, residents had to go to a separate page of the chart, which was frequently not done. Medications were often only reviewed if verbally communicated by the off-going resident. This was recognized during the observation

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process and it must be pointed out that this did not begin to be recorded until 11 observations had already been completed. Although is it difficult to make a direct correlation, one must consider if the medication ambiguities observed are a reflection of not consistently reviewing the medications given at the time of handoff. While the residents followed the EMR format and it provided some visual cues, the literature recommends that pertinent patient information be documented so that it can be easily referenced when needed (1,15). Templates for written documentation combined with verbal signouts have been found to be effective for inpatient adult medicine as well as in pediatrics (16,17). In addition, standardized checklist handoff tools have been found to be effective in high-stress, high-consequence environments similar to the ED, such as the pediatric intensive care unit, and may be useful in this environment (18–20). Interruptions were also noted to be a significant element of the handoffs. It should be noted that in this ED, the nursing and support staff change shifts at the same hour in the morning as the residents. Questions that come up as a result of this change in shift for all care providers may account for some of the interruptions during the morning handoffs, when the volume tended to be lower. The evening handoff is more variable for the residents and coincides less frequently with the support staff. The frequency of interruptions during the afternoon and evening signout is more likely related to the increased volume of patients during that time of day. This likely accounts for why interruptions in the morning and evening averaged about the same, 8.3 min/interruption in the morning (median 7.5 min) and a mean of 8.5 min/interruption in the evening (median 7.13 min). A study in the Academic Emergency Medicine Journal in 2000 showed that ED physicians are interrupted an average of every 6 min when observed for a 3-h period (21). Although the mean number of interruptions during handoffs was slightly better, it is concerning that during this recognized crucial time in patient care the interruptions are so frequent. The frequency of the interruptions noted during this observational study was concerning when considering the laboratory and clinical data regarding interruptions show that there can be as much as a 12% increase in errors (22,23). A recent study in the American Journal of Emergency Medicine in 2011 observing ED handoffs with primarily EM faculty (79%) and some senior residents had interruptions observed in 10% of handsoffs (24). This was markedly different than our observations. While this study was completed in another environment, it is possible that staff are more willing to interrupt physicians in training and this should be considered during future studies.

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Limitations There are limitations to be considered in this study. While this study was able to identify a number of potential hazards to patient safety, such as inconsistent documentation, omission of medications given, and frequent interruptions, measuring direct patient outcomes was beyond the scope of this study. Additionally, this study was completed at a single location and may not be generalizable. It should be noted that the Institutional Review Board required oral consent by participants, making them knowledgeable about the purpose of the observations, which may have introduced a bias. Audiorecordings were not collected because of resource limitations and it is possible that data were missed by the observer. There was only one observer so no inter-rater reliability was required, and initial observations were reviewed by a human factors engineer to try to limit biases introduced by single observer. Finally, data collection used a convenience sample, which may have introduced error. CONCLUSIONS Guided by the SEIPS model, we identified three major areas of concerns for EM resident to EM resident handoffs in an academic center. While the residents had a relatively uniform system for handoffs, they frequently neglect to discuss medications given, which might be causing the subsequent medication ambiguities that were observed. There is also inconsistency in documentation of handoffs, which has consistently been shown to be a suboptimal practice. Additionally, the residents are confronted with frequent interruptions during handoffs, which is associated with an increased error rate. These data will be used to inform a handoff-improvement program focused on standardization of process and documentation, highlighting medications administered, and minimizing interruptions at this institution. This method appears to be effective for identification of barriers to efficiency and potential hazards to patient safety, however, additional studies need to be completed using human factors and systems approaches to develop, evaluate, and implement interventions in the ED. REFERENCES 1. McSweeney ME, Lightdale JR, Vinci RJ, Moses J. Patient handoffs: pediatric resident experiences and lessons learned. Clin Pediatr (Phila) 2011;50:57–63. 2. Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf 2006;32:646–55. 3. Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2007;49:196–205. 4. Beach C, Croskerry P, Shapiro M. Profiles in patient safety: emergency care transitions. Acad Emerg Med 2003;10:364–7.

578 5. Solet DJ, Norvell JM, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med 2005;80:1094–9. 6. Cheung DS, Kelly JJ, Beach C, et al. Improving handoffs in the emergency department. Ann Emerg Med 2010;55:171–80. 7. Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Jt Comm J Qual Patient Saf 2010;36:52–61. 8. Sinha M, Shriki J, Salness R, Blackburn PA. Need for standardized sign-out in the emergency department: a survey of emergency medicine residency and pediatric emergency medicine fellowship program directors. Acad Emerg Med 2007;14: 192–6. 9. Singh H, Thomas EJ, Petersen LA, Studdert DM. Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med 2007;167:2030–6. 10. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Emergency Medicine. Available at: http://www.acgme.org/acgmeweb/ Portals/0/PFAssets/2013-PR-FAQ-PIF/110_emergency_medicine_ 07012013.pdf. Accessed July 7, 2013. 11. Perry SJ, Wears RL, Patterson ES. High-hanging fruit: improving transitions in health care. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in patient safety: new directions and alternative approaches, Vol. 3. Rockville, MD: Agency for Healthcare Research and Quality; 2008. Available at: http://www.ncbi. nlm.nih.gov/books/NBK43656/. 12. Carayon P, Schoofs Hundt A, Karsh BT, et al. Review work system design for patient safety: the SEIPS model. Qual Saf Health Care 2006;15:50–8. 13. Gurses AP, Seidl KL, Vaidya V, et al. Systems ambiguity and guideline compliance: a qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections. Qual Saf Health Care 2008;17:351–9.

S. M. Peterson et al. 14. Strauss A, Corbin J. Basics of qualitative research: techniques and procedures for developing grounded theory. Newbury Park, CA: Sage Publications; 1998. 15. Pillow M. Improving hand-off communications. Oak Brook, IL: Joint Commission Resources; 2007:29–34. 16. Chu ES, Reid M, Schulz T, et al. A structured handoff program for interns. Acad Med 2009;84:347–52. 17. Petersen LA, Orav EJ, Teich JM, O’Neil AC, Brennan TA. Using a computerized sign out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv 1998; 24:77–87. 18. Agarwal HS, Saville BR, Slayton JM, et al. Standardized postoperative handover process in the intensive care unit: a model for operational sustainability and improved team performance. Crit Care Med 2012;40:2109–15. 19. Zavalkoff SR, Razack SI, Lavoie J, et al. Handover after pediatric heart surgery: a simple tool improves information exchange. Pediatr Crit Care Med 2011;12:309–13. 20. Winters BD, Gurses AP, Lehmann H, Sexton JB, Rampersad CJ, Pronovost PJ. Clinical review: checklists—translating evidence into practice. Crit Care 2009;13:210. 21. Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians ‘‘interrupt-driven’’ and ‘‘multitasking’’? Acad Emerg Med 2000;7: 1239–43. 22. Clapp WC, Rubens MT, Sabharwal J, Gazzaley A. Deficit in switching between functional brain networks underlies the impact of multi-tasking on working memory in older adults. Proc Natl Acad Sci U S A 2011;108:7212–7. 23. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med 2010;170:683–90. 24. Maughan BC, Lei L, Cydulka RK. ED handoffs: observed practices and communication errors. Am J Emerg Med 2011;29:502–11.

Resident to Resident Handoffs

ARTICLE SUMMARY 1. Why is this topic important? How emergency physicians in training complete handoffs and train to complete hand offs will ultimately affect how they practice emergency medicine. 2. What does this study attempt to show? In this manuscript, we show a mechanism to evaluate resident to resident hand offs in the emergency department in order to identify potential hazards to patient safety and barriers to efficiency. 3. What are the key findings? Guided by the SEIPS model, we identified three major areas of concerns for EM resident to EM resident hand offs in an academic center. While the residents had a relatively uniform system for hand offs, they frequently neglect to discuss medications given which may be causing the subsequent medication ambiguities that were observed. There is also inconsistency in documentation of hand offs which has consistently been shown to be a suboptimal practice. Additionally the residents are confronted with frequent interruptions during hand offs which is associated with an increased error rate. 4. How is patient care impacted? This observational study demonstrates the ability to identify specific deficits and potential safety concerns related to hand offs, and the opportunity to create a tailored hand off system to improve the safety of patient hand offs and care based on these observations.

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Resident to resident handoffs in the emergency department: an observational study.

Despite patient handoffs being well recognized as a potentially dangerous time in the care of patients in the emergency department (ED), there is no e...
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