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IJHCQA 26,8
What constitutes a good hand offs in the emergency department: a patient’s perspective
760 Received 5 March 2012 Revised 30 April 2012 Accepted 11 June 2012
La Vonne Downey Health Services/Public Administration Department, Roosevelt University, Chicago, Illinois, USA, and
Leslie Zun and Trena Burke Department of Emergency Medicine, Chicago, Mount Sinai Hospital, Illinois, USA Abstract Purpose – The aim is to determine, from the patient’s perspective, what constitutes a good hand-off procedure in the emergency department (ED). The secondary purpose is to evaluate what impact a formalized hand-off had on patient knowledge, throughput and customer service Design/methodology/approach – This study used a randomized controlled clinical trial involving two unique hand-off approaches and a convenience sample. The study alternated between the current hand-off process that documented the process but not specific elements (referred to as the informal process) to one using the IPASS the BATON process (considered the formal process). Consenting patients completed a 12-question validated questionnaire on how the process was perceived by patients and about their understanding why they waited in the ED. Statistical analysis using SPSS calculated descriptive frequencies and t-tests. Findings – In total 107 patients were enrolled: 50 in the informal and 57 in the formal group. Most patients had positive answers to the customer survey. There were significant differences between formal and informal groups: recalling the oncoming and outgoing physician coming to the patient’s bed ð p ¼ 0:000Þ; with more formal group recalling that than informal group patients; the oncoming physician introducing him/herself ð p ¼ 0:01Þ; with more from the formal group answering yes and the physician discussing tests and implications with formal group patients ð p ¼ 0:02Þ: Research limitations/implications – This study was done at an urban inner city ED, a fact that may have skewed its results. A comparison of suburban and rural EDs would make the results stronger. It also reflected a very high level of customer satisfaction within the ED. This lack of variance may have meant that the correlation between customer service and handoffs was missed or underrepresented. There was no codified observation of either those using the IPASS the BATON script or those using informal procedures, so no comparison of level and types of information given between the two groups was done. There could have been a bias of those attending who had internalized the IPASS the BATON procedures and used them even when they were assigned to the informal group. Practical implications – A hand off from one physician to the next in the emergency department is best done using a formalized process. IPASS the BATON is a useful tool for hand off in the ED in part because it involved the patient in the process. The formal hand off increased communication between patient and doctor as its use increased the patient’s opportunity to ask and respond to questions. Originality/value – The researchers evaluated an ED physician specific hand-off process and illustrate the value and impact of involving patients in the hand-off process.
International Journal of Health Care Quality Assurance Vol. 26 No. 8, 2013 pp. 760-767 q Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-03-2012-0028
Keywords Quality improvement, Patient satisfaction, Clinical guidelines, Customer, Patient centredness Paper type Case study
The authors appreciate the summer research fellows and emergency physicians’ contributions: Kristopher Wnek, Erin Alexander, Gabrielle Binstock, Tejesh Reddy, Jenny Luo and Anna Helms.
Introduction The Harvard Medical Practice study (Croskerry et al., 2004) and subsequent researchers found that emergency departments (ED) have the highest preventable error levels. According to the Joint Commission on Accreditation of Healthcare Organizations ( JCAHO, 2005), poor communication causes most sentinel events, medical mistakes and so-called near misses. The Joint Commission (2007) noted that communication failures between care providers or between providers and patients and their families caused up to 65 percent of the sentinel events. Effective communication among all these individuals in the ED is central to good patient care. One place where communication breaks down is in the patient hand-off process – the information exchange from one ED physician to another, which is mandated any time when attending physicians change. According to (Apker et al., 2007), communication breakdowns during patient hand-offs threatens most patient safety. There are several factors that exacerbate ED hand-off difficulties. First, the ED patient hand-off can be a complex process owing to the range and type of patients and presenting illnesses seen every day. Second, ED staff experience overcrowding that result in long waiting times treatment delays, which is why several reports, such as Aurora and Johnson (2006) and JCAHO (2007), recommended using a standardized approach to hand-off communications as one national patient safety goal. These guidelines recommend that patients and families are given opportunities to ask and respond to questions. It did not, however, include any specific hand-off process. Formalized hand-off involves using a precise codified approach. Chu et al. (2009); Solet (2005); Cohen and Hilligoss (2010) and Catchpole et al. (2010) showed that there are various tools that can be used for formal hand-offs; however, none has been used or tested in the ED. One formal method is IPASS the BATON, which is based on a protocol from Tricare Management in Falls Church Virginia, Department of Defense (2008). This method uses a bedside documentation hand-over technique. Unlike other hand-off methods, it specifically involves the patient in the process. The JCAHO (2007) National Patient Safety Goals states that a standardized hand-off communications approach includes an opportunity for the patient to ask and respond to questions. As patients are becoming more active in their care, including their ideas and understanding, the process is imperative. Involving patients in this process is shown to increase patient satisfaction and an important tool that can be used to monitor and improve service quality. This hand-off process is codified using specific steps, with information being explained by the attending physician and patient: I ¼ Introduction: introduce yourself. P ¼ Patient: name, identifiers, age, sex, location. A ¼ Assessment: the problem, procedure, etc., so far in the process. S ¼ Situation: current status/circumstances, uncertainty, recent changes. B ¼ Background: co-morbidities, previous episodes, current medications, family. A ¼ Actions: what are the actions to be taken and brief rational? T ¼ Timing: urgency, explicit timing, prioritizing actions.
What constitutes a good hand offs
761
IJHCQA 26,8
762
O ¼ Ownership: who is responsible (person/team) including patient/family. N ¼ Next: what happens next? Research question and method The study aimed to determine from the patient’s perspective what constitutes a good hand-off procedure. The current hand-off was compared to the IPASS the BATON process using patient satisfaction data. Including customer service indicators in the study provides a supplementary view to the hand-off process that could avoid communication breakdown. Worthington et al. (2004), Bordreaux et al. (2004) and Muntlin et al. (2006) showed that patients who feel they receive more information are more satisfied and more likely to comply with medical instructions. More satisfied patients are less likely to sue caregivers (Worthington, 2004). They also bring their ED experience to bear on how they view the hospital and it has been shown that there is a correlation between patient satisfaction and hospital profitability (Sun et al., 2004). Our study was a randomized controlled clinical trial involving two unique hand-off approaches and a convenience sample. Random numbers were generated each day during the study, which allowed patients to be randomly selected from day and night shifts. The study alternated between the current informal verbal hand-off processes to using a more formal process following the IPASS the BATON technique. Measures Depending upon randomization, doctors were told to perform their usual informal or the IPASS the BATON (Appendix 1) hand-off procedure. The informal method did not dictate the process but required the interaction to be documented. After the hand-off procedure, patients completed a 12-item questionnaire; they were asked how they perceived the process and how well they understood their medical conditions (Appendix 2). These 12 questions were taken from the Waisman et al. (2003) and Sun et al. (2004) validated patient-understanding and satisfaction questionnaire, administered by a research fellow after the patient gave consent. Demographic information was obtained on all consenting adults. Study setting and population The setting was an inner-city, Level I (highest and widest surgical-specialist level with 24-hour availability) pediatric and adult trauma center with 60,000 visits per year. All consenting, stable adult patients, presenting to ED staff, undergoing hand-off to another medical department within the hospital were eligible. Hand-off from one ED attending physician to another was mandated anytime the physician changed. To achieve an 80 percent power, using the t-test with an alpha of 0.05, the questionnaire was administered to 107 English-speaking patients, 57 patients in the formal and 50 in the informal group. The study was internal review board approved. Data analysis We used SPSS 17 software to analyze our data. To detect any differences between the two groups, we used a paired Wilcoxon t-test. Confidence intervals were also examined to test the strength of those differences among numerous indicators.
Results Most patients were African American (86 percent), female (59.8 percent) and with a high school education (43.9 percent). Hand-offs occurred during different shifts, with 47 percent in the first shift, 50 percent in the second and 3 percent in the third. Most patients answered positively to the customer survey, stating that emergency physicians introduced themselves (81.3 percent), discussed diagnosis, tests and treatment (69.2 percent) and explained what the patient was waiting for (79.4 percent). Almost all patients felt that staff were responsive to their comfort and care needs (94 percent) and that they had good to very good interpersonal skills regarding their illness and its management (90 percent). Overall, patients stated that they felt that quality was good or very good (85.1 percent) and were satisfied or very satisfied (59.3 percent) with their ED care. Patients were divided in their attitudes towards the time spent in the ED being long, too long or about right. There was a significant difference between patient responses depending on whether or not they had formal or informal hand-off procedures. These differences were reflected in their recall of oncoming and outgoing physician coming to their beds ð p ¼ 0:000Þ; with more from the formal group recalling whether the oncoming physician introduced him/herself ð p ¼ 0:01Þ; more formal cohort answering yes, physician discussed tests and implications with patient ð p ¼ 0:02Þ: No other significant differences were found between informal and formal hand-off procedures (Table I).
What constitutes a good hand offs
763
Limitations, conclusion and recommendations Overall, patients felt that formal and informal hand-off processes were informative, were satisfied with the process and overall care quality. The formalized hand-off process had additional benefits – it increased the patient’s recall of oncoming and
Mean Patient age Patient race Patient gender Diagnosis Admitted or released Throughput time (hrs) Do you recall the physician leaving and the on 2 coming physician coming to your bedside? Did the on 2 coming physician introduce him/herself? Did the on 2 coming physician discuss your diagnosis, tests, treatment, etc. with you? Do you recall the nurse leaving and the on 2 coming physician coming to your bedside? The medical staff’s interpersonal skills and attitudes toward your illness and your opinions about the management? Did your physicians and nurses discuss what you were waiting for? Did they offer you any comfort measures?
SD
41.89 16.37 0.14 10.03 2 0.12 0.65 3.55 5.52 2 0.11 1.21 7.09 5.15
95% CIs Lower Upper 45.12 20.055 20.25 4.67 20.35 8.12
t
38.65 2 25.71 0.35 1.44 0.01 2 1.96 2.44 2 6.33 0.13 2 0.91 6.05 2 13.62
0.23 0.26
0.58 0.58
0.12 0.15
0.35 0.38
4.07 * 4.62 *
0.14
0.65
0.01
0.27
2.28 *
2 1.01
0.995
21.20
20.81 2 10.20
2 2.83
1.04
23.03
22.62 2 27.11 *
0.24 0.40
0.63 0.53
0.12 0.30
Note: *Significant at the 0.05 level or less; * *significant at the 0.06 level or less
0.37 0.51
3.89 7.66 * *
Table I. Differences between formal and informal hand-off
IJHCQA 26,8
764
outgoing ED physicians and gave them an opportunity to more fully understand the laboratory tests they were undergoing. Communication breakdown was one area in previous studies that could compromise patient safety. The formalized hand-off process appears to have provided an opportunity to increase the patient’s opportunity to ask and respond to questions specifically about-tests. This was an area that JACHO (2007) staff felt a formal hand-off process would help ED patient safety and communication. Our study shows that IPASS the BATON is a useful ED hand-off procedure, as it increases communication between patient and physician – it gave patients and doctors an additional opportunity to exchange information. Worthington et al. (2004), Bordreaux et al. (2004) and Muntlin et al. (2006) show how these affect patient care. Their studies also found that patients who feel they receive more information had higher satisfaction levels and more likely to comply with medical instructions. Results also illustrated that physicians were receptive to involving patients and families in the hand-off process. Our study needs to be expanded as it was conducted at one urban inner-city ED, which may have skewed our results. Comparing suburban and rural EDs would make the results stronger. Results also reflected a high ED-customer satisfaction, but the lack of variance in customer service ratings may have meant that the correlation between customer service and hand-offs was missed or underrepresented. There was no codified observation of either those using the IPASS the BATON script or those using informal procedures, so information type and amount were not compared. There could have been bias among those attending who had internalized the IPASS the BATON procedures and used them even when they were assigned to the informal group. The ED hand-off process is complex, multilayered and involves numerous individuals. This study only reflects the first part of the hand-off process. The next steps would be to expand the formal hand-off process to include nurses and other care providers who interact with patients. Mutlin et al. (2006) shows that using nursing and support staff to improve communication has even a larger impact on patient understanding and customer service compared to physicians. Implementing a formal process between emergency department and other medicine floors and documenting the process could examine if the hand-off process would be improved throughout the patient’s entire stay. Data could then illustrate whether or not an ED formalized hand-off procedure reduces preventable errors and costs, and improves patient outcomes.
References Apker, J., Mallak, L. and Gibson, S. (2007), “Communicating in the gray zone perceptions about emergency physician-hospitalist hand-offs and patient safety”, Academic Emergency Medicine, Vol. 14 No. 10, pp. 884-893. Aurora, V. and Johnson, J. (2006), “A model for building a standardized hand-off protocol”, Journal of Quality Patent Safety, Vol. 22, pp. 646-655. Boudreaux, E. (2004), “Predictors of emergency department patient satisfaction: stability over 17 months”, Academic Emergency Medicine, Vol. 11, pp. 51-58. Catchpole, K., Sellers, R. and Goldman, A. (2010), “Patient handovers within the hospital – translating knowledge from motor racing to healthcare”, Quality and Safety, Vol. 19, pp. 318-322.
Chu, E.S., Reid, M., Schulz, T., Burden, M., Mancini, D., Ambardekar, A., Keniston, A. and Albert, R. (2009), “A structured hand-off program for interns”, Academic Medicine, Vol. 84, pp. 347-352. Cohen, M. and Hilligoss, B. (2010), “The published literature on handoffs in hospitals: deficiencies identified in an extensive review”, Quality and Safety, Vol. 19, pp. 493-497. Croskerry, M., Shapiro, S., Cambell, C., LaBlanc, C., Sinclair, D., Wren, P. and Marcoux, M. (2004), “Profiles in patient safety: medical errors in the emergency department”, Academic Emergency Medicine, Vol. 11 No. 3, pp. 289-299. Department of Defense Patient Safety Program (2008), Healthcare Communications Toolkit to Improve Transitions in Care, available at: http://dodpatientsafety.usuhs.mil (accessed July 2011). Joint Commission (2007), Improving Hand-off Communication, Joint Commission Publications, Oakbrook Terrace, IL. Joint Commission on Accreditation of Healthcare Organizations ( JCAHO) (2005), “Sentinel event root causes”, Joint Commission Perspective Patient Safety, Vol. 5 No. 7, pp. 5-6. Joint Commission on Accreditation of Healthcare Organizations ( JCAHO) (2007), “Improving America’s hospitals: the Joint Commission annual report on quality and safety”, available at: www.jointcommissionreport.org/pdf/JC2006 annual report.pdf (accessed July 2011). Muntlin, A., Gunningberg, L. and Carlsson, M. (2006), “Patients’ perceptions of quality of care at an emergency department and identification of areas for quality improvement”, Journal of Clinical Nursing, Vol. 15 No. 8, pp. 1045-1056. Solet, D.J., Norvell, J.M. and Rutan, G.H. (2005), “Lost in translation: challenges and opportunities in physician to physician communication during patient hand-offs”, Academic Medicine, Vol. 80, pp. 1094-1099. Sun, B., Brinkley, M. and Morrissey, J. (2004), “A patient education intervention does not improve satisfaction with emergency care”, Annals of Emergency Medicine, Vol. 44, pp. 378-383. Toma, G., Triner, W. and McNutt, L-A. (2009), “An analysis of emergency department revisit rates based on patient satisfaction scores”, Annals of Emergency Medicine, Vol. 54 No. 3, pp. 360-367. Waisman, Y., Siegal, N. and Chemo, M. (2003), “Do patients understand emergency department discharge instructions - a survey analysis”, International Journal of Emergency Medicine, Vol. 5, pp. 567-570. Worthington, K. (2004), “Customer satisfaction in the emergency department”, Emergency Medicine Clinics of North America, Vol. 22, pp. 87-102. Corresponding author La Vonne Downey can be contacted at: [email protected]
What constitutes a good hand offs
765
IJHCQA 26,8
766
Figure A1.
Appendix 1. IPASS the BATON
Appendix 2. Formal vs informal hand-off and its effect on patient satisfaction – survey questionnaire (Toma et al., 2009)
What constitutes a good hand offs
767
Figure A2.
IJHCQA 26,8
What constitutes a good hand offs in the emergency department: a patient’s perspective
760 Received 5 March 2012 Revised 30 April 2012 Accepted 11 June 2012
La Vonne Downey Health Services/Public Administration Department, Roosevelt University, Chicago, Illinois, USA, and
Leslie Zun and Trena Burke Department of Emergency Medicine, Chicago, Mount Sinai Hospital, Illinois, USA Abstract Purpose – The aim is to determine, from the patient’s perspective, what constitutes a good hand-off procedure in the emergency department (ED). The secondary purpose is to evaluate what impact a formalized hand-off had on patient knowledge, throughput and customer service Design/methodology/approach – This study used a randomized controlled clinical trial involving two unique hand-off approaches and a convenience sample. The study alternated between the current hand-off process that documented the process but not specific elements (referred to as the informal process) to one using the IPASS the BATON process (considered the formal process). Consenting patients completed a 12-question validated questionnaire on how the process was perceived by patients and about their understanding why they waited in the ED. Statistical analysis using SPSS calculated descriptive frequencies and t-tests. Findings – In total 107 patients were enrolled: 50 in the informal and 57 in the formal group. Most patients had positive answers to the customer survey. There were significant differences between formal and informal groups: recalling the oncoming and outgoing physician coming to the patient’s bed ð p ¼ 0:000Þ; with more formal group recalling that than informal group patients; the oncoming physician introducing him/herself ð p ¼ 0:01Þ; with more from the formal group answering yes and the physician discussing tests and implications with formal group patients ð p ¼ 0:02Þ: Research limitations/implications – This study was done at an urban inner city ED, a fact that may have skewed its results. A comparison of suburban and rural EDs would make the results stronger. It also reflected a very high level of customer satisfaction within the ED. This lack of variance may have meant that the correlation between customer service and handoffs was missed or underrepresented. There was no codified observation of either those using the IPASS the BATON script or those using informal procedures, so no comparison of level and types of information given between the two groups was done. There could have been a bias of those attending who had internalized the IPASS the BATON procedures and used them even when they were assigned to the informal group. Practical implications – A hand off from one physician to the next in the emergency department is best done using a formalized process. IPASS the BATON is a useful tool for hand off in the ED in part because it involved the patient in the process. The formal hand off increased communication between patient and doctor as its use increased the patient’s opportunity to ask and respond to questions. Originality/value – The researchers evaluated an ED physician specific hand-off process and illustrate the value and impact of involving patients in the hand-off process.
International Journal of Health Care Quality Assurance Vol. 26 No. 8, 2013 pp. 760-767 q Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-03-2012-0028
Keywords Quality improvement, Patient satisfaction, Clinical guidelines, Customer, Patient centredness Paper type Case study
The authors appreciate the summer research fellows and emergency physicians’ contributions: Kristopher Wnek, Erin Alexander, Gabrielle Binstock, Tejesh Reddy, Jenny Luo and Anna Helms.
Introduction The Harvard Medical Practice study (Croskerry et al., 2004) and subsequent researchers found that emergency departments (ED) have the highest preventable error levels. According to the Joint Commission on Accreditation of Healthcare Organizations ( JCAHO, 2005), poor communication causes most sentinel events, medical mistakes and so-called near misses. The Joint Commission (2007) noted that communication failures between care providers or between providers and patients and their families caused up to 65 percent of the sentinel events. Effective communication among all these individuals in the ED is central to good patient care. One place where communication breaks down is in the patient hand-off process – the information exchange from one ED physician to another, which is mandated any time when attending physicians change. According to (Apker et al., 2007), communication breakdowns during patient hand-offs threatens most patient safety. There are several factors that exacerbate ED hand-off difficulties. First, the ED patient hand-off can be a complex process owing to the range and type of patients and presenting illnesses seen every day. Second, ED staff experience overcrowding that result in long waiting times treatment delays, which is why several reports, such as Aurora and Johnson (2006) and JCAHO (2007), recommended using a standardized approach to hand-off communications as one national patient safety goal. These guidelines recommend that patients and families are given opportunities to ask and respond to questions. It did not, however, include any specific hand-off process. Formalized hand-off involves using a precise codified approach. Chu et al. (2009); Solet (2005); Cohen and Hilligoss (2010) and Catchpole et al. (2010) showed that there are various tools that can be used for formal hand-offs; however, none has been used or tested in the ED. One formal method is IPASS the BATON, which is based on a protocol from Tricare Management in Falls Church Virginia, Department of Defense (2008). This method uses a bedside documentation hand-over technique. Unlike other hand-off methods, it specifically involves the patient in the process. The JCAHO (2007) National Patient Safety Goals states that a standardized hand-off communications approach includes an opportunity for the patient to ask and respond to questions. As patients are becoming more active in their care, including their ideas and understanding, the process is imperative. Involving patients in this process is shown to increase patient satisfaction and an important tool that can be used to monitor and improve service quality. This hand-off process is codified using specific steps, with information being explained by the attending physician and patient: I ¼ Introduction: introduce yourself. P ¼ Patient: name, identifiers, age, sex, location. A ¼ Assessment: the problem, procedure, etc., so far in the process. S ¼ Situation: current status/circumstances, uncertainty, recent changes. B ¼ Background: co-morbidities, previous episodes, current medications, family. A ¼ Actions: what are the actions to be taken and brief rational? T ¼ Timing: urgency, explicit timing, prioritizing actions.
What constitutes a good hand offs
761
IJHCQA 26,8
762
O ¼ Ownership: who is responsible (person/team) including patient/family. N ¼ Next: what happens next? Research question and method The study aimed to determine from the patient’s perspective what constitutes a good hand-off procedure. The current hand-off was compared to the IPASS the BATON process using patient satisfaction data. Including customer service indicators in the study provides a supplementary view to the hand-off process that could avoid communication breakdown. Worthington et al. (2004), Bordreaux et al. (2004) and Muntlin et al. (2006) showed that patients who feel they receive more information are more satisfied and more likely to comply with medical instructions. More satisfied patients are less likely to sue caregivers (Worthington, 2004). They also bring their ED experience to bear on how they view the hospital and it has been shown that there is a correlation between patient satisfaction and hospital profitability (Sun et al., 2004). Our study was a randomized controlled clinical trial involving two unique hand-off approaches and a convenience sample. Random numbers were generated each day during the study, which allowed patients to be randomly selected from day and night shifts. The study alternated between the current informal verbal hand-off processes to using a more formal process following the IPASS the BATON technique. Measures Depending upon randomization, doctors were told to perform their usual informal or the IPASS the BATON (Appendix 1) hand-off procedure. The informal method did not dictate the process but required the interaction to be documented. After the hand-off procedure, patients completed a 12-item questionnaire; they were asked how they perceived the process and how well they understood their medical conditions (Appendix 2). These 12 questions were taken from the Waisman et al. (2003) and Sun et al. (2004) validated patient-understanding and satisfaction questionnaire, administered by a research fellow after the patient gave consent. Demographic information was obtained on all consenting adults. Study setting and population The setting was an inner-city, Level I (highest and widest surgical-specialist level with 24-hour availability) pediatric and adult trauma center with 60,000 visits per year. All consenting, stable adult patients, presenting to ED staff, undergoing hand-off to another medical department within the hospital were eligible. Hand-off from one ED attending physician to another was mandated anytime the physician changed. To achieve an 80 percent power, using the t-test with an alpha of 0.05, the questionnaire was administered to 107 English-speaking patients, 57 patients in the formal and 50 in the informal group. The study was internal review board approved. Data analysis We used SPSS 17 software to analyze our data. To detect any differences between the two groups, we used a paired Wilcoxon t-test. Confidence intervals were also examined to test the strength of those differences among numerous indicators.
Results Most patients were African American (86 percent), female (59.8 percent) and with a high school education (43.9 percent). Hand-offs occurred during different shifts, with 47 percent in the first shift, 50 percent in the second and 3 percent in the third. Most patients answered positively to the customer survey, stating that emergency physicians introduced themselves (81.3 percent), discussed diagnosis, tests and treatment (69.2 percent) and explained what the patient was waiting for (79.4 percent). Almost all patients felt that staff were responsive to their comfort and care needs (94 percent) and that they had good to very good interpersonal skills regarding their illness and its management (90 percent). Overall, patients stated that they felt that quality was good or very good (85.1 percent) and were satisfied or very satisfied (59.3 percent) with their ED care. Patients were divided in their attitudes towards the time spent in the ED being long, too long or about right. There was a significant difference between patient responses depending on whether or not they had formal or informal hand-off procedures. These differences were reflected in their recall of oncoming and outgoing physician coming to their beds ð p ¼ 0:000Þ; with more from the formal group recalling whether the oncoming physician introduced him/herself ð p ¼ 0:01Þ; more formal cohort answering yes, physician discussed tests and implications with patient ð p ¼ 0:02Þ: No other significant differences were found between informal and formal hand-off procedures (Table I).
What constitutes a good hand offs
763
Limitations, conclusion and recommendations Overall, patients felt that formal and informal hand-off processes were informative, were satisfied with the process and overall care quality. The formalized hand-off process had additional benefits – it increased the patient’s recall of oncoming and
Mean Patient age Patient race Patient gender Diagnosis Admitted or released Throughput time (hrs) Do you recall the physician leaving and the on 2 coming physician coming to your bedside? Did the on 2 coming physician introduce him/herself? Did the on 2 coming physician discuss your diagnosis, tests, treatment, etc. with you? Do you recall the nurse leaving and the on 2 coming physician coming to your bedside? The medical staff’s interpersonal skills and attitudes toward your illness and your opinions about the management? Did your physicians and nurses discuss what you were waiting for? Did they offer you any comfort measures?
SD
41.89 16.37 0.14 10.03 2 0.12 0.65 3.55 5.52 2 0.11 1.21 7.09 5.15
95% CIs Lower Upper 45.12 20.055 20.25 4.67 20.35 8.12
t
38.65 2 25.71 0.35 1.44 0.01 2 1.96 2.44 2 6.33 0.13 2 0.91 6.05 2 13.62
0.23 0.26
0.58 0.58
0.12 0.15
0.35 0.38
4.07 * 4.62 *
0.14
0.65
0.01
0.27
2.28 *
2 1.01
0.995
21.20
20.81 2 10.20
2 2.83
1.04
23.03
22.62 2 27.11 *
0.24 0.40
0.63 0.53
0.12 0.30
Note: *Significant at the 0.05 level or less; * *significant at the 0.06 level or less
0.37 0.51
3.89 7.66 * *
Table I. Differences between formal and informal hand-off
IJHCQA 26,8
764
outgoing ED physicians and gave them an opportunity to more fully understand the laboratory tests they were undergoing. Communication breakdown was one area in previous studies that could compromise patient safety. The formalized hand-off process appears to have provided an opportunity to increase the patient’s opportunity to ask and respond to questions specifically about-tests. This was an area that JACHO (2007) staff felt a formal hand-off process would help ED patient safety and communication. Our study shows that IPASS the BATON is a useful ED hand-off procedure, as it increases communication between patient and physician – it gave patients and doctors an additional opportunity to exchange information. Worthington et al. (2004), Bordreaux et al. (2004) and Muntlin et al. (2006) show how these affect patient care. Their studies also found that patients who feel they receive more information had higher satisfaction levels and more likely to comply with medical instructions. Results also illustrated that physicians were receptive to involving patients and families in the hand-off process. Our study needs to be expanded as it was conducted at one urban inner-city ED, which may have skewed our results. Comparing suburban and rural EDs would make the results stronger. Results also reflected a high ED-customer satisfaction, but the lack of variance in customer service ratings may have meant that the correlation between customer service and hand-offs was missed or underrepresented. There was no codified observation of either those using the IPASS the BATON script or those using informal procedures, so information type and amount were not compared. There could have been bias among those attending who had internalized the IPASS the BATON procedures and used them even when they were assigned to the informal group. The ED hand-off process is complex, multilayered and involves numerous individuals. This study only reflects the first part of the hand-off process. The next steps would be to expand the formal hand-off process to include nurses and other care providers who interact with patients. Mutlin et al. (2006) shows that using nursing and support staff to improve communication has even a larger impact on patient understanding and customer service compared to physicians. Implementing a formal process between emergency department and other medicine floors and documenting the process could examine if the hand-off process would be improved throughout the patient’s entire stay. Data could then illustrate whether or not an ED formalized hand-off procedure reduces preventable errors and costs, and improves patient outcomes.
References Apker, J., Mallak, L. and Gibson, S. (2007), “Communicating in the gray zone perceptions about emergency physician-hospitalist hand-offs and patient safety”, Academic Emergency Medicine, Vol. 14 No. 10, pp. 884-893. Aurora, V. and Johnson, J. (2006), “A model for building a standardized hand-off protocol”, Journal of Quality Patent Safety, Vol. 22, pp. 646-655. Boudreaux, E. (2004), “Predictors of emergency department patient satisfaction: stability over 17 months”, Academic Emergency Medicine, Vol. 11, pp. 51-58. Catchpole, K., Sellers, R. and Goldman, A. (2010), “Patient handovers within the hospital – translating knowledge from motor racing to healthcare”, Quality and Safety, Vol. 19, pp. 318-322.
Chu, E.S., Reid, M., Schulz, T., Burden, M., Mancini, D., Ambardekar, A., Keniston, A. and Albert, R. (2009), “A structured hand-off program for interns”, Academic Medicine, Vol. 84, pp. 347-352. Cohen, M. and Hilligoss, B. (2010), “The published literature on handoffs in hospitals: deficiencies identified in an extensive review”, Quality and Safety, Vol. 19, pp. 493-497. Croskerry, M., Shapiro, S., Cambell, C., LaBlanc, C., Sinclair, D., Wren, P. and Marcoux, M. (2004), “Profiles in patient safety: medical errors in the emergency department”, Academic Emergency Medicine, Vol. 11 No. 3, pp. 289-299. Department of Defense Patient Safety Program (2008), Healthcare Communications Toolkit to Improve Transitions in Care, available at: http://dodpatientsafety.usuhs.mil (accessed July 2011). Joint Commission (2007), Improving Hand-off Communication, Joint Commission Publications, Oakbrook Terrace, IL. Joint Commission on Accreditation of Healthcare Organizations ( JCAHO) (2005), “Sentinel event root causes”, Joint Commission Perspective Patient Safety, Vol. 5 No. 7, pp. 5-6. Joint Commission on Accreditation of Healthcare Organizations ( JCAHO) (2007), “Improving America’s hospitals: the Joint Commission annual report on quality and safety”, available at: www.jointcommissionreport.org/pdf/JC2006 annual report.pdf (accessed July 2011). Muntlin, A., Gunningberg, L. and Carlsson, M. (2006), “Patients’ perceptions of quality of care at an emergency department and identification of areas for quality improvement”, Journal of Clinical Nursing, Vol. 15 No. 8, pp. 1045-1056. Solet, D.J., Norvell, J.M. and Rutan, G.H. (2005), “Lost in translation: challenges and opportunities in physician to physician communication during patient hand-offs”, Academic Medicine, Vol. 80, pp. 1094-1099. Sun, B., Brinkley, M. and Morrissey, J. (2004), “A patient education intervention does not improve satisfaction with emergency care”, Annals of Emergency Medicine, Vol. 44, pp. 378-383. Toma, G., Triner, W. and McNutt, L-A. (2009), “An analysis of emergency department revisit rates based on patient satisfaction scores”, Annals of Emergency Medicine, Vol. 54 No. 3, pp. 360-367. Waisman, Y., Siegal, N. and Chemo, M. (2003), “Do patients understand emergency department discharge instructions - a survey analysis”, International Journal of Emergency Medicine, Vol. 5, pp. 567-570. Worthington, K. (2004), “Customer satisfaction in the emergency department”, Emergency Medicine Clinics of North America, Vol. 22, pp. 87-102. Corresponding author La Vonne Downey can be contacted at: [email protected]
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Figure A1.
Appendix 1. IPASS the BATON
Appendix 2. Formal vs informal hand-off and its effect on patient satisfaction – survey questionnaire (Toma et al., 2009)
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Figure A2.
