As stated earlier, we identified 46 articles describing residents’ and attending physicians’ handoffs in the United States. Eighteen were research studies (39.1%), only two of which were randomized controlled trials. The majority (71.7%) of articles were published in recent years, which is not surprising, given the Joint Commission's National Patient Safety Goal on handoffs issued in 2006. However, as demonstrated by our quality assessment scores (see the Appendix), there is a remarkable lack of high-quality outcomes studies. It is notable that one third of the reviewed research studies obtained quality scores at or below 8 (out of a possible 16), and only one study achieved a score of 13.
One purpose of the current study was to identify features of physicians’ handoffs that have been shown to be effective. Unfortunately, only 6 of the 18 (33.3%) research studies included measures of effectiveness. Of the three studies using computerized handoff systems, one was a stand-alone system,78 and the other two had some linkage with the hospital computer system.67,77 While these all provided a structured template, they also relied to varying degrees on residents to enter information, which introduces an opportunity for errors to occur.69,71 Most of the studies assessing effectiveness used self-reported data, with a few exceptions. Van Eaton and colleagues67 looked at the number of patients missed on resident rounds and showed a decrease from 5 to 2.5 patients/team/month (P = .0001) when using a computerized handoff system. Two other studies assessed errors on resident-maintained handoff forms when compared with the medical record69,71 (a surrogate for actual medical errors) and, not surprisingly, found errors on the resident lists.
Of note, two survey studies documented a lack of formal handoffs instruction during residency, with 60% to 74.4% (internal medicine72 and emergency medicine,73 respectively) reporting that they have no lectures or workshops on the topic. Although 72.3% of the 185 emergency medicine residency/fellowship program directors studied agreed that standardized handoffs would reduce medical errors,73 the majority did not have a uniform policy or procedure regarding handoffs. Only one of the studies reviewed here included the development, implementation, and assessment of a formal, structured handoffs curriculum.75 Horwitz and colleagues75 provide a comprehensive curricular template for others to use; however, they relied on postsession evaluations of perceived comfort and importance of handoffs. We commend their plan to conduct observation of handoff skills and look forward to their future publications.
Almost all of the research articles (17 of 18; 94%) were conducted within a residency program. Graduate medical education has taken the lead in conducting handoffs research, which is one demonstration of the value added to health care by medical education.
We identified 91 barriers to effective handoffs that could be organized into eight major categories. Of barrier categories, communication issues were reported most frequently (30.8%), with general communication barriers ranging from not listening to inadequate communication. Because effective communication is an essential component of handoffs, this was an expected finding. However, hierarchy and social barriers constituted a less intuitive group. Here, we found things such as relational communication barriers and residents not being likely to hand off work to more senior residents, because of a rigid reliance on hierarchical norms that prohibit such behavior. Thus, adequately addressing handoff issues will require more than protocols, structure, and training. Understanding the complex social structures and hierarchies in which residents and attending physicians work, as well as the unwritten rules that govern the handoff of patient responsibilities, will be required.
We identified 140 strategies that could be organized into seven major categories. Strategies for standardization were noted most frequently (44.3%), with technological solutions (16.4%), such as computerized handoff systems, next. Interestingly, whereas communication issues constituted approximately one third of barriers, improving communication skills was noted much less frequently (11.4%) as a strategy. Standardization would address some communication issues, but not all, such as language differences. Providing training or education (10%), evaluating the process (7.1%), and addressing environmental issues (5.7%), such as lighting and limiting interruptions and noise, make intuitive sense. However, a less obvious strategy was insuring the recognition that a transfer of responsibility/accountability (5.0%) had occurred.
Handoffs in a variety of environments were studied, which makes it difficult to use our findings to formulate barriers and strategies for use in every handoff situation. For example, some techniques may be better applied to inpatient medicine as opposed to the emergency department. In addition, we abstracted barriers and strategies from all sections of the articles studied, including the introduction. This may have resulted in overemphasis of some barriers or strategies, depending on the author's views and on repetition. However, we only counted the same barrier or strategy multiple times if the wording was significantly different in subsequent use and if the two instances could stand alone as different aspects of the same category.
The current study is limited by the Ovid search strategy used. Specifically, the selected search terms may not have included all relevant terms. We strengthened the possibility of identifying all articles that met inclusion criteria by reviewing the reference sections of all obtained articles. Although this strategy minimizes the risk of missing germane studies, it does not eliminate the possibility.
Although our quality scoring system was based on a validated methodology developed to assess experimental and observational studies together, our system has not been validated across multiple settings and investigators. The relative weightings may require refinement, and there may prove to be additional relevant categories. The system did have a high internal reliability, and reviewers of various educational backgrounds and experience found it straightforward and easy to use. Further, the quality scoring system provides a reproducible template for the assessment of handoffs articles.
Evidence-based practice is informed by high-quality research. Recent publication guidelines for patient safety and quality initiatives have established a framework for standardized reporting.88,89 We recommend that future handoffs studies use the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines.89 Many of the studies reviewed here would have been improved by doing so.
Others have noted that it may be unreasonable to expect patient safety and quality studies to follow the design rigors of randomized controlled trials.87 However, the RAND/UCLA Appropriateness Method provides a structured, rigorous method to synthesize data from other clinical study types with expert opinion to provide the best available guidelines.90 Unfortunately, the literature on handoffs identified here is not of sufficient quality and quantity to synthesize into evidence-based recommendations.
Although the Joint Commission is calling for structured handoffs, we identified very little evidence to support the use of any specific structure, protocol, or method. However, direct observation of handoffs in other settings (i.e., NASA mission control, nuclear power, railroad, and ambulance dispatch) with high consequences for error, yielded 21 common strategies,91 which could offer a starting point in the development of health care handoffs research. Our review of the U.S. physicians’ handoffs literature has led us to develop a list of research questions, organized by the content domains of knowledge, attitudes, skills, process outcomes, and clinical outcomes (see List 1).
Across the United States, hospitals are implementing structured handoff protocols in an effort to comply with Joint Commission requirements. High-quality outcomes studies that focus on systems factors, human performance, and the effectiveness of protocols and interventions are urgently needed. These studies should address the barriers and strategies identified here. In addition, handoffs in different disciplines are likely to have different requirements and issues. For instance, an emergency department handoff will need to have different content than one for inpatient medicine or pediatrics. Therefore, researchers should conduct discipline-specific handoff studies.
We call for rigorous outcomes studies designed to (1) assess the effectiveness of handoffs, (2) determine the elements of handoffs that lead to improved patient outcomes, and (3) identify the best implementation strategies. Finally, these studies should be reported using the SQUIRE guidelines. Without these studies, hospitals across the United States are destined to waste time, resources, and effort on flawed handoff practices.
Special thanks to Ellen M. Justice, MLIS, AHIP, medical librarian of the Lewis B. Flinn Medical Library, Christiana Care Health System, for conducting literature searches; Dolores Ann Moran, medical library assistant II, and Janice Evans, medical library assistant II, for their assistance in locating articles; and Donald Riesenberg, MD, for feedback on the manuscript.
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