For hospitalized patients, restrictions on resident duty hours and the hospitalist movement have led to fragmentation in care.[1] After 2003 duty‐hour regulations were implemented, one study estimated an increase of 11% in care transfers for a given patient, whereas another study reported that an individual intern participated in 40% more handoffs.[2, 3] Although these changes have represented an improvement in safety with reduced provider fatigue and increased expertise in inpatient care, tradeoffs in safety may occur. Communication breakdown during care transfers has been implicated in many medical errors,[4, 5, 6] and the ability to safely transfer a patient's care has been identified as a necessary clinical skill.[7] The Accreditation Council on Graduate Medical Education has mandated that training programs include education to ensure effective handoff processes.[8] The Joint Commission has developed a toolset for improving handoffs.[9] Taking cues from the military and other industries that operate continuously, approaches designed to standardize handoffs have been developed.[3, 10, 11, 12]

The use of handoff tools has been reported to reduce the time required to transfer care from one provider to another,[13] but evidence that these handoff tools improve quality of care is limited.[14, 15] Concern that patients have poorer outcomes in care transitions remains, particularly at night when many patients are cared for by covering or night float providers.[6] Studies regarding the outcomes of patients at night have had mixed results.[16, 17, 18] Uncertainty is inherent in the trajectories of individual patients and in the systems in which they receive care.[19] The recognition of uncertainty reframes care transitions from a problem of improving information transfer to a problem of navigating uncertainty, or making sense. Sensemaking is an activity through which providers come to understand what is happening with a patient, in a way that allows them to take action.[20]

We sought to better understand how to support providers' ability to make sense and act in uncertain situations, focusing on night float resident physicians. We hoped to better understand overnight encounters and the information needed to navigate them. We approached the issue in two ways: first, through assessing resident attitudes and perceptions of handoffs using survey methodology, and second, through assessing actual calls night float residents receive and strategies they use to navigate these scenarios. We focused on handoffs between the primary team and covering nighttime providers. Our goal was to use this information to understand what approaches could better support care transitions and handoff practices.

METHODS

RESULTS

DISCUSSION

Our goal was to understand how to better support care transitions and handoff processes. Our residents report that current approaches to care transitions are safe and useful. Although this perception is reassuring, it is difficult to know whether this reflects the actual delivery of safe care. A minority of residents report giving and receiving do not do lists, which are important aspects of care when giving guidance to a covering physician. Also, we find discrepancies between our survey results and nighttime call collection data in important areas. Although residents report that the written sign‐out is useful, it was deemed useful for resolving a clinical issue only 27% of the time. Previous reports have found variable and conflicting rates of written sign‐out utilization, as well as variable quality of a written sign‐out,[21, 22, 23] and our data support infrequent usage. Residents were much more likely to access the electronic medical record than they were to use the handoff tool. Additionally, although residents report documentation, very little actual documentation occurred. The high rates of calls for routine and pain‐related notifications are notable and should be examined further for areas of potential improvement. Preemptive orders for routine, common, and benign conditions are often not employed as strategy and their omission can lead to higher workloads for nighttime physicians. Additionally, education and training may be necessary to help housestaff understand how such a strategy is safely implemented, such as a specific regimen for mild pain, and why it is helpful beyond reducing nighttime workload, such as a proactive approach to clinical care.

Several important insights emerge from our results. First, the electronic health record is accessible, and providers use it frequently. This raises the question of the need for a handoff tool for information transfer. When data can be easily accessed, their presence in a physical tool may be less important. Because electronic health records can easily be leveraged to populate handoff tools, having a brief tool that minimizes information transfer but better supports clinical reasoning may be more effective.

Second, our data highlight the need to focus on the handback, or providing information back to the returning day team. Our experience and previous studies support that this process is not adequately developed.[24, 25] There is little opportunity for communication between the covering and primary providers, and there is little documentation. In our observations, 3.8% of calls resulted in documentation, whereas the majority of respondents to the survey state it is performed frequently or always. The reason for this discrepancy is unclear, but fostering more of a mentality that considers all of the providers involved in patient care to be part of the same team may help address this issue.

Third, clinical services assume providers have what they need to provide care in the form of the handoff instrument. In fact, providers have handoff instruments, but whether they need them is unclear. Based on these observations, overnight physicians are able to provide care in the vast majority of cases without the use of the handoff tool.

Fourth, our data demonstrate the social or relational nature of providing clinical coverage. The single most frequent action taken by covering residents was speaking to the nurse. This may not be surprising; however, when we reframe transitions of care and handoffs as a relational issue, we are forced to reframe potential strategies to improve these transitions. The problem we need to address is not only of information transfer; it is also of making sense of what is happening.

How do we make handoff tools more effective sensemaking tools? More focus on contingency statements might be an approach. These have the dual benefit of helping the covering provider to make sense using the primary team's reasoning, as well as improving the primary team's reasoning by making the potential complications more explicit. Another approach could be to reinforce relational actions, through providing guidance on who to call if there is a change in the status of the patient. We found that the night intern rarely discussed care with supervising physicians, indicating weak integration of the night team. The handoff tool could thus strengthen the network of providers caring for the patient. A tool that emphasizes sensemaking may be a tool that captures the nonroutine aspects of care that are not already documented in the health record.

Our data are limited in that they were collected in a single institution over few nights with few interns. Our processes may not be representative, and our expectations for provider communication may not be the norm. Although a night float system of coverage is not the only model of providing care, it is common, and our handoff tool is similar to those reported in the literature. One area of concern is that our handback expectations may be less robust than other institutions. Despite this limitation, the larger issues of information transfer and sensemaking are generally applicable. Although we collected data over only 18 nights, we did obtain information on almost 300 calls, giving us a robust sample of actual issues that residents were called to resolve. Interns are the most involved in actually providing night coverage. Their response rate was 55%, slightly below our overall response rate of 59.6%, but representing the majority of interns. A 2‐step process of sign‐out may have ramifications on care transitions; however, these data were collected at night. Because the handoff tool information is the day team's responsibility, the process may have less impact on these results.

Coverage and care transfers are part of the inpatient landscape, and it may be unreasonable to expect care to be delivered by a group of providers who know the patient with the same level of depth at all hours of the day. By understanding that fostering effective care for patients requires providers to pay attention to not only how they transfer information, but also how they collectively make sense of what is happening, we will enable safer care.

Disclosures: The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (CDA 07‐022). Investigator salary support was provided through this funding, and through the South Texas Veterans Health Care System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Parts of these data were presented at the 2013 SGIM National Meeting in Denver, Colorado. The authors report no conflicts of interest.

For hospitalized patients, restrictions on resident duty hours and the hospitalist movement have led to fragmentation in care.[1] After 2003 duty‐hour regulations were implemented, one study estimated an increase of 11% in care transfers for a given patient, whereas another study reported that an individual intern participated in 40% more handoffs.[2, 3] Although these changes have represented an improvement in safety with reduced provider fatigue and increased expertise in inpatient care, tradeoffs in safety may occur. Communication breakdown during care transfers has been implicated in many medical errors,[4, 5, 6] and the ability to safely transfer a patient's care has been identified as a necessary clinical skill.[7] The Accreditation Council on Graduate Medical Education has mandated that training programs include education to ensure effective handoff processes.[8] The Joint Commission has developed a toolset for improving handoffs.[9] Taking cues from the military and other industries that operate continuously, approaches designed to standardize handoffs have been developed.[3, 10, 11, 12]

The use of handoff tools has been reported to reduce the time required to transfer care from one provider to another,[13] but evidence that these handoff tools improve quality of care is limited.[14, 15] Concern that patients have poorer outcomes in care transitions remains, particularly at night when many patients are cared for by covering or night float providers.[6] Studies regarding the outcomes of patients at night have had mixed results.[16, 17, 18] Uncertainty is inherent in the trajectories of individual patients and in the systems in which they receive care.[19] The recognition of uncertainty reframes care transitions from a problem of improving information transfer to a problem of navigating uncertainty, or making sense. Sensemaking is an activity through which providers come to understand what is happening with a patient, in a way that allows them to take action.[20]

We sought to better understand how to support providers' ability to make sense and act in uncertain situations, focusing on night float resident physicians. We hoped to better understand overnight encounters and the information needed to navigate them. We approached the issue in two ways: first, through assessing resident attitudes and perceptions of handoffs using survey methodology, and second, through assessing actual calls night float residents receive and strategies they use to navigate these scenarios. We focused on handoffs between the primary team and covering nighttime providers. Our goal was to use this information to understand what approaches could better support care transitions and handoff practices.

METHODS

RESULTS

DISCUSSION

Our goal was to understand how to better support care transitions and handoff processes. Our residents report that current approaches to care transitions are safe and useful. Although this perception is reassuring, it is difficult to know whether this reflects the actual delivery of safe care. A minority of residents report giving and receiving do not do lists, which are important aspects of care when giving guidance to a covering physician. Also, we find discrepancies between our survey results and nighttime call collection data in important areas. Although residents report that the written sign‐out is useful, it was deemed useful for resolving a clinical issue only 27% of the time. Previous reports have found variable and conflicting rates of written sign‐out utilization, as well as variable quality of a written sign‐out,[21, 22, 23] and our data support infrequent usage. Residents were much more likely to access the electronic medical record than they were to use the handoff tool. Additionally, although residents report documentation, very little actual documentation occurred. The high rates of calls for routine and pain‐related notifications are notable and should be examined further for areas of potential improvement. Preemptive orders for routine, common, and benign conditions are often not employed as strategy and their omission can lead to higher workloads for nighttime physicians. Additionally, education and training may be necessary to help housestaff understand how such a strategy is safely implemented, such as a specific regimen for mild pain, and why it is helpful beyond reducing nighttime workload, such as a proactive approach to clinical care.

Several important insights emerge from our results. First, the electronic health record is accessible, and providers use it frequently. This raises the question of the need for a handoff tool for information transfer. When data can be easily accessed, their presence in a physical tool may be less important. Because electronic health records can easily be leveraged to populate handoff tools, having a brief tool that minimizes information transfer but better supports clinical reasoning may be more effective.

Second, our data highlight the need to focus on the handback, or providing information back to the returning day team. Our experience and previous studies support that this process is not adequately developed.[24, 25] There is little opportunity for communication between the covering and primary providers, and there is little documentation. In our observations, 3.8% of calls resulted in documentation, whereas the majority of respondents to the survey state it is performed frequently or always. The reason for this discrepancy is unclear, but fostering more of a mentality that considers all of the providers involved in patient care to be part of the same team may help address this issue.

Third, clinical services assume providers have what they need to provide care in the form of the handoff instrument. In fact, providers have handoff instruments, but whether they need them is unclear. Based on these observations, overnight physicians are able to provide care in the vast majority of cases without the use of the handoff tool.

Fourth, our data demonstrate the social or relational nature of providing clinical coverage. The single most frequent action taken by covering residents was speaking to the nurse. This may not be surprising; however, when we reframe transitions of care and handoffs as a relational issue, we are forced to reframe potential strategies to improve these transitions. The problem we need to address is not only of information transfer; it is also of making sense of what is happening.

How do we make handoff tools more effective sensemaking tools? More focus on contingency statements might be an approach. These have the dual benefit of helping the covering provider to make sense using the primary team's reasoning, as well as improving the primary team's reasoning by making the potential complications more explicit. Another approach could be to reinforce relational actions, through providing guidance on who to call if there is a change in the status of the patient. We found that the night intern rarely discussed care with supervising physicians, indicating weak integration of the night team. The handoff tool could thus strengthen the network of providers caring for the patient. A tool that emphasizes sensemaking may be a tool that captures the nonroutine aspects of care that are not already documented in the health record.

Our data are limited in that they were collected in a single institution over few nights with few interns. Our processes may not be representative, and our expectations for provider communication may not be the norm. Although a night float system of coverage is not the only model of providing care, it is common, and our handoff tool is similar to those reported in the literature. One area of concern is that our handback expectations may be less robust than other institutions. Despite this limitation, the larger issues of information transfer and sensemaking are generally applicable. Although we collected data over only 18 nights, we did obtain information on almost 300 calls, giving us a robust sample of actual issues that residents were called to resolve. Interns are the most involved in actually providing night coverage. Their response rate was 55%, slightly below our overall response rate of 59.6%, but representing the majority of interns. A 2‐step process of sign‐out may have ramifications on care transitions; however, these data were collected at night. Because the handoff tool information is the day team's responsibility, the process may have less impact on these results.

Coverage and care transfers are part of the inpatient landscape, and it may be unreasonable to expect care to be delivered by a group of providers who know the patient with the same level of depth at all hours of the day. By understanding that fostering effective care for patients requires providers to pay attention to not only how they transfer information, but also how they collectively make sense of what is happening, we will enable safer care.

Disclosures: The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (CDA 07‐022). Investigator salary support was provided through this funding, and through the South Texas Veterans Health Care System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Parts of these data were presented at the 2013 SGIM National Meeting in Denver, Colorado. The authors report no conflicts of interest.

For hospitalized patients, restrictions on resident duty hours and the hospitalist movement have led to fragmentation in care.[1] After 2003 duty‐hour regulations were implemented, one study estimated an increase of 11% in care transfers for a given patient, whereas another study reported that an individual intern participated in 40% more handoffs.[2, 3] Although these changes have represented an improvement in safety with reduced provider fatigue and increased expertise in inpatient care, tradeoffs in safety may occur. Communication breakdown during care transfers has been implicated in many medical errors,[4, 5, 6] and the ability to safely transfer a patient's care has been identified as a necessary clinical skill.[7] The Accreditation Council on Graduate Medical Education has mandated that training programs include education to ensure effective handoff processes.[8] The Joint Commission has developed a toolset for improving handoffs.[9] Taking cues from the military and other industries that operate continuously, approaches designed to standardize handoffs have been developed.[3, 10, 11, 12]

The use of handoff tools has been reported to reduce the time required to transfer care from one provider to another,[13] but evidence that these handoff tools improve quality of care is limited.[14, 15] Concern that patients have poorer outcomes in care transitions remains, particularly at night when many patients are cared for by covering or night float providers.[6] Studies regarding the outcomes of patients at night have had mixed results.[16, 17, 18] Uncertainty is inherent in the trajectories of individual patients and in the systems in which they receive care.[19] The recognition of uncertainty reframes care transitions from a problem of improving information transfer to a problem of navigating uncertainty, or making sense. Sensemaking is an activity through which providers come to understand what is happening with a patient, in a way that allows them to take action.[20]

We sought to better understand how to support providers' ability to make sense and act in uncertain situations, focusing on night float resident physicians. We hoped to better understand overnight encounters and the information needed to navigate them. We approached the issue in two ways: first, through assessing resident attitudes and perceptions of handoffs using survey methodology, and second, through assessing actual calls night float residents receive and strategies they use to navigate these scenarios. We focused on handoffs between the primary team and covering nighttime providers. Our goal was to use this information to understand what approaches could better support care transitions and handoff practices.

METHODS

RESULTS

DISCUSSION

Our goal was to understand how to better support care transitions and handoff processes. Our residents report that current approaches to care transitions are safe and useful. Although this perception is reassuring, it is difficult to know whether this reflects the actual delivery of safe care. A minority of residents report giving and receiving do not do lists, which are important aspects of care when giving guidance to a covering physician. Also, we find discrepancies between our survey results and nighttime call collection data in important areas. Although residents report that the written sign‐out is useful, it was deemed useful for resolving a clinical issue only 27% of the time. Previous reports have found variable and conflicting rates of written sign‐out utilization, as well as variable quality of a written sign‐out,[21, 22, 23] and our data support infrequent usage. Residents were much more likely to access the electronic medical record than they were to use the handoff tool. Additionally, although residents report documentation, very little actual documentation occurred. The high rates of calls for routine and pain‐related notifications are notable and should be examined further for areas of potential improvement. Preemptive orders for routine, common, and benign conditions are often not employed as strategy and their omission can lead to higher workloads for nighttime physicians. Additionally, education and training may be necessary to help housestaff understand how such a strategy is safely implemented, such as a specific regimen for mild pain, and why it is helpful beyond reducing nighttime workload, such as a proactive approach to clinical care.

Several important insights emerge from our results. First, the electronic health record is accessible, and providers use it frequently. This raises the question of the need for a handoff tool for information transfer. When data can be easily accessed, their presence in a physical tool may be less important. Because electronic health records can easily be leveraged to populate handoff tools, having a brief tool that minimizes information transfer but better supports clinical reasoning may be more effective.

Second, our data highlight the need to focus on the handback, or providing information back to the returning day team. Our experience and previous studies support that this process is not adequately developed.[24, 25] There is little opportunity for communication between the covering and primary providers, and there is little documentation. In our observations, 3.8% of calls resulted in documentation, whereas the majority of respondents to the survey state it is performed frequently or always. The reason for this discrepancy is unclear, but fostering more of a mentality that considers all of the providers involved in patient care to be part of the same team may help address this issue.

Third, clinical services assume providers have what they need to provide care in the form of the handoff instrument. In fact, providers have handoff instruments, but whether they need them is unclear. Based on these observations, overnight physicians are able to provide care in the vast majority of cases without the use of the handoff tool.

Fourth, our data demonstrate the social or relational nature of providing clinical coverage. The single most frequent action taken by covering residents was speaking to the nurse. This may not be surprising; however, when we reframe transitions of care and handoffs as a relational issue, we are forced to reframe potential strategies to improve these transitions. The problem we need to address is not only of information transfer; it is also of making sense of what is happening.

How do we make handoff tools more effective sensemaking tools? More focus on contingency statements might be an approach. These have the dual benefit of helping the covering provider to make sense using the primary team's reasoning, as well as improving the primary team's reasoning by making the potential complications more explicit. Another approach could be to reinforce relational actions, through providing guidance on who to call if there is a change in the status of the patient. We found that the night intern rarely discussed care with supervising physicians, indicating weak integration of the night team. The handoff tool could thus strengthen the network of providers caring for the patient. A tool that emphasizes sensemaking may be a tool that captures the nonroutine aspects of care that are not already documented in the health record.

Our data are limited in that they were collected in a single institution over few nights with few interns. Our processes may not be representative, and our expectations for provider communication may not be the norm. Although a night float system of coverage is not the only model of providing care, it is common, and our handoff tool is similar to those reported in the literature. One area of concern is that our handback expectations may be less robust than other institutions. Despite this limitation, the larger issues of information transfer and sensemaking are generally applicable. Although we collected data over only 18 nights, we did obtain information on almost 300 calls, giving us a robust sample of actual issues that residents were called to resolve. Interns are the most involved in actually providing night coverage. Their response rate was 55%, slightly below our overall response rate of 59.6%, but representing the majority of interns. A 2‐step process of sign‐out may have ramifications on care transitions; however, these data were collected at night. Because the handoff tool information is the day team's responsibility, the process may have less impact on these results.

Coverage and care transfers are part of the inpatient landscape, and it may be unreasonable to expect care to be delivered by a group of providers who know the patient with the same level of depth at all hours of the day. By understanding that fostering effective care for patients requires providers to pay attention to not only how they transfer information, but also how they collectively make sense of what is happening, we will enable safer care.

Disclosures: The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (CDA 07‐022). Investigator salary support was provided through this funding, and through the South Texas Veterans Health Care System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Parts of these data were presented at the 2013 SGIM National Meeting in Denver, Colorado. The authors report no conflicts of interest.

In this issue of the Journal of Hospital Medicine, the results of 2 inpatient handoff studies further shape our evolving understanding of in‐hospital care transitions. Schouten and colleagues,[1] report no difference in adverse outcomes when admissions were handed off to the primary team using face‐to‐face compared to nonface‐to‐face interactions. Meanwhile, Hanson and colleagues[2] report that a written handoff tool is used infrequently by covering interns.

Schouten et al.'s study attempted to isolate the impact of the verbal portion of the handoff between admitting and accepting team by evaluating whether early adverse outcomes differed between patients whose teams performed a face‐to‐face handoffs compared to those who did not. Their study was a retrospective chart review, and no additional process changes, training, or instruction regarding handoffs were implemented or measured. Handoffs occurred primarily between advanced practice providers, hospitalists, and a small number of resident physicians, so generalizability of this study to other institutions may be limited. No difference in adverse events was noted between admissions with face‐to‐face compared to those without face‐to‐face handoffs (2.6% vs 3.2%). Unfortunately, this study was likely underpowered to detect significant changes in adverse events, with a sample size of 805 total patients with a 3% baseline rate of adverse events (by our estimate, over 5000 patients would be needed in each group10,000 overallto detect a 30% relative difference in event rates). Further, this study did not examine other outcomes that could be impacted by the handoff process such as provider efficiency or patient experience.

Face‐to‐face handoffs, the gold standard for handoffs between providers, was 1 of the sign‐out approaches examined in a study by Graham and colleagues.[3] This study, in contrast to the Schouten et al. study, prospectively evaluated adverse events before and after implementation of face‐to‐face handoffs, with structured written sign‐out from the primary team to nighttime covering physicians. Prior to implementation, handoffs consisted of a double handoff involving an intermediary physician and unstructured written sign‐out. Although no statistically significant reduction in adverse events was found in the Graham et al. study, significant improvements were noted in physician satisfaction, documentation of key elements in handoffs, and reduced data omissions; importantly, a trend of fewer near misses was noted comparing the pre‐ and postintervention periods. Although the Schouten et al. and Graham et al. studies suggest questionable benefit of face‐to‐face handoffs, we would caution that limitations in sample size and methodological sensitivity to detect adverse events in both studies could explain the lack of association between face‐to‐face handoffs and reduced adverse events. Furthermore, the promising findings of fewer data omissions and near misses in the intervention group in the Graham et al. study suggest benefit from a multipronged approach to improving handoffs including both face‐to‐face interactions and a structured written component.

In this issue, Hanson and colleagues also evaluated the use of a handoff tool by cross‐covering interns in a convenience sample of overnight clinical interactions. Despite finding that standard written documentation was considered beneficial by nearly all respondents (94.3%), the interns reported that the handoff tool was used in only 27.7% of encounters. This pales in comparison to the use of the nurse or chart in 94.4% of cross‐coverage encounters. The authors speculate that a handoff tool, for many years the only timely source of information, may not be as useful when information can be easily accessed in an electronic health record. Yet, in a prior systematic review that included 6 studies of computerized handoff tools, Li and colleagues found that computerized handoff tools may improve physician efficiency, enhance the completeness of handoff information, and even potentially reduce adverse events.[4]

The Schouten et al. and Hanson et al. studies raise important questions for the fields of hospital medicine and patient safety. Is it time to do away with the written and verbal portions of the handoff process? Should the handoff of patients simply consist of transferring a list of patients to covering providers? We do not believe this is the correct course of action. Rather, we recommend a more evolutionary, not revolutionary, interpretation of these results, especially when considered as part of a broader story of in‐hospital transitions of care.

For example, a recently published evaluation of a resident handoff‐improvement program in 9 hospitals and 10,740 patient admissions by Starmer and collegues[5] focused on a handoff bundle, I‐PASS, which is a pneumonic for Illness severity, Patient summary, Action items, Situation awareness and contingency planning, Synthesis by receiver. The authors report a reduction in medical errors and preventable adverse events without significant increases in the duration of oral handoff per patient. The handoff in this study included both oral and written elements in the I‐PASS format. Implementation was multipronged, and the I‐PASS bundle included (1) use of the I‐PASS pneumonic to standardize handoffs; (2) resident physician training in handoffs and communication through a 2‐hour workshop, followed by a 1‐hour role‐playing and simulation session, and a computer module for practice; (3) faculty development and observation with use of direct‐observation tools to provide structured feedback to residents; (4) active surveillance for errors (rather than relying on self‐report); and (5) a sustainability campaign to promote continuation of culture change. The complexity and robust nature of the I‐PASS handoff bundle suggests that having multiple structured components included in a handoff program with active, rather than retrospective, evaluation might increase the likelihood of improved, sustained outcomes. In addition, one might also conclude from the Starmer et al. study that it takes commitment from all levels, including residents, faculty, and administration, to improve handoffs between teams for inpatient care.

We commend Schouten et al. and Hanson et al. on their contributions to the literature, but believe that the story of the in‐hospital handoff has yet to be fully written. Although results from these 2 articles may cause speculation about the value of oral and written handoffs, we believe that the balance of evidence favors the use of a multipronged approach that involves both structured oral and written handoffs to improve the value and efficiency of handoffs. In addition, findings from the I‐PASS study support dedicated handoff training for providers, evaluation of handoffs using structured tools, and active surveillance for medical errors. Future areas of work should include a systematic review of the inpatient handoff literature and further evaluation of precisely which specific intervention components (eg, structured content of handoffs, sensemaking content) or modes of delivery (eg, face‐to‐face vs other) are most likely to reduce medical errors and improve patient outcomes. As the hospital medicine movement continues to grow, handoffs will continue to be paramount. Establishing the safest method to complete handoffs to promote patient safety should be a common goal for hospitalists.

The handoff story is still in evolution; as hospitalists, we are poised to be its author.

In this issue of the Journal of Hospital Medicine, the results of 2 inpatient handoff studies further shape our evolving understanding of in‐hospital care transitions. Schouten and colleagues,[1] report no difference in adverse outcomes when admissions were handed off to the primary team using face‐to‐face compared to nonface‐to‐face interactions. Meanwhile, Hanson and colleagues[2] report that a written handoff tool is used infrequently by covering interns.

Schouten et al.'s study attempted to isolate the impact of the verbal portion of the handoff between admitting and accepting team by evaluating whether early adverse outcomes differed between patients whose teams performed a face‐to‐face handoffs compared to those who did not. Their study was a retrospective chart review, and no additional process changes, training, or instruction regarding handoffs were implemented or measured. Handoffs occurred primarily between advanced practice providers, hospitalists, and a small number of resident physicians, so generalizability of this study to other institutions may be limited. No difference in adverse events was noted between admissions with face‐to‐face compared to those without face‐to‐face handoffs (2.6% vs 3.2%). Unfortunately, this study was likely underpowered to detect significant changes in adverse events, with a sample size of 805 total patients with a 3% baseline rate of adverse events (by our estimate, over 5000 patients would be needed in each group10,000 overallto detect a 30% relative difference in event rates). Further, this study did not examine other outcomes that could be impacted by the handoff process such as provider efficiency or patient experience.

Face‐to‐face handoffs, the gold standard for handoffs between providers, was 1 of the sign‐out approaches examined in a study by Graham and colleagues.[3] This study, in contrast to the Schouten et al. study, prospectively evaluated adverse events before and after implementation of face‐to‐face handoffs, with structured written sign‐out from the primary team to nighttime covering physicians. Prior to implementation, handoffs consisted of a double handoff involving an intermediary physician and unstructured written sign‐out. Although no statistically significant reduction in adverse events was found in the Graham et al. study, significant improvements were noted in physician satisfaction, documentation of key elements in handoffs, and reduced data omissions; importantly, a trend of fewer near misses was noted comparing the pre‐ and postintervention periods. Although the Schouten et al. and Graham et al. studies suggest questionable benefit of face‐to‐face handoffs, we would caution that limitations in sample size and methodological sensitivity to detect adverse events in both studies could explain the lack of association between face‐to‐face handoffs and reduced adverse events. Furthermore, the promising findings of fewer data omissions and near misses in the intervention group in the Graham et al. study suggest benefit from a multipronged approach to improving handoffs including both face‐to‐face interactions and a structured written component.

In this issue, Hanson and colleagues also evaluated the use of a handoff tool by cross‐covering interns in a convenience sample of overnight clinical interactions. Despite finding that standard written documentation was considered beneficial by nearly all respondents (94.3%), the interns reported that the handoff tool was used in only 27.7% of encounters. This pales in comparison to the use of the nurse or chart in 94.4% of cross‐coverage encounters. The authors speculate that a handoff tool, for many years the only timely source of information, may not be as useful when information can be easily accessed in an electronic health record. Yet, in a prior systematic review that included 6 studies of computerized handoff tools, Li and colleagues found that computerized handoff tools may improve physician efficiency, enhance the completeness of handoff information, and even potentially reduce adverse events.[4]

The Schouten et al. and Hanson et al. studies raise important questions for the fields of hospital medicine and patient safety. Is it time to do away with the written and verbal portions of the handoff process? Should the handoff of patients simply consist of transferring a list of patients to covering providers? We do not believe this is the correct course of action. Rather, we recommend a more evolutionary, not revolutionary, interpretation of these results, especially when considered as part of a broader story of in‐hospital transitions of care.

For example, a recently published evaluation of a resident handoff‐improvement program in 9 hospitals and 10,740 patient admissions by Starmer and collegues[5] focused on a handoff bundle, I‐PASS, which is a pneumonic for Illness severity, Patient summary, Action items, Situation awareness and contingency planning, Synthesis by receiver. The authors report a reduction in medical errors and preventable adverse events without significant increases in the duration of oral handoff per patient. The handoff in this study included both oral and written elements in the I‐PASS format. Implementation was multipronged, and the I‐PASS bundle included (1) use of the I‐PASS pneumonic to standardize handoffs; (2) resident physician training in handoffs and communication through a 2‐hour workshop, followed by a 1‐hour role‐playing and simulation session, and a computer module for practice; (3) faculty development and observation with use of direct‐observation tools to provide structured feedback to residents; (4) active surveillance for errors (rather than relying on self‐report); and (5) a sustainability campaign to promote continuation of culture change. The complexity and robust nature of the I‐PASS handoff bundle suggests that having multiple structured components included in a handoff program with active, rather than retrospective, evaluation might increase the likelihood of improved, sustained outcomes. In addition, one might also conclude from the Starmer et al. study that it takes commitment from all levels, including residents, faculty, and administration, to improve handoffs between teams for inpatient care.

We commend Schouten et al. and Hanson et al. on their contributions to the literature, but believe that the story of the in‐hospital handoff has yet to be fully written. Although results from these 2 articles may cause speculation about the value of oral and written handoffs, we believe that the balance of evidence favors the use of a multipronged approach that involves both structured oral and written handoffs to improve the value and efficiency of handoffs. In addition, findings from the I‐PASS study support dedicated handoff training for providers, evaluation of handoffs using structured tools, and active surveillance for medical errors. Future areas of work should include a systematic review of the inpatient handoff literature and further evaluation of precisely which specific intervention components (eg, structured content of handoffs, sensemaking content) or modes of delivery (eg, face‐to‐face vs other) are most likely to reduce medical errors and improve patient outcomes. As the hospital medicine movement continues to grow, handoffs will continue to be paramount. Establishing the safest method to complete handoffs to promote patient safety should be a common goal for hospitalists.

The handoff story is still in evolution; as hospitalists, we are poised to be its author.

In this issue of the Journal of Hospital Medicine, the results of 2 inpatient handoff studies further shape our evolving understanding of in‐hospital care transitions. Schouten and colleagues,[1] report no difference in adverse outcomes when admissions were handed off to the primary team using face‐to‐face compared to nonface‐to‐face interactions. Meanwhile, Hanson and colleagues[2] report that a written handoff tool is used infrequently by covering interns.

Schouten et al.'s study attempted to isolate the impact of the verbal portion of the handoff between admitting and accepting team by evaluating whether early adverse outcomes differed between patients whose teams performed a face‐to‐face handoffs compared to those who did not. Their study was a retrospective chart review, and no additional process changes, training, or instruction regarding handoffs were implemented or measured. Handoffs occurred primarily between advanced practice providers, hospitalists, and a small number of resident physicians, so generalizability of this study to other institutions may be limited. No difference in adverse events was noted between admissions with face‐to‐face compared to those without face‐to‐face handoffs (2.6% vs 3.2%). Unfortunately, this study was likely underpowered to detect significant changes in adverse events, with a sample size of 805 total patients with a 3% baseline rate of adverse events (by our estimate, over 5000 patients would be needed in each group10,000 overallto detect a 30% relative difference in event rates). Further, this study did not examine other outcomes that could be impacted by the handoff process such as provider efficiency or patient experience.

Face‐to‐face handoffs, the gold standard for handoffs between providers, was 1 of the sign‐out approaches examined in a study by Graham and colleagues.[3] This study, in contrast to the Schouten et al. study, prospectively evaluated adverse events before and after implementation of face‐to‐face handoffs, with structured written sign‐out from the primary team to nighttime covering physicians. Prior to implementation, handoffs consisted of a double handoff involving an intermediary physician and unstructured written sign‐out. Although no statistically significant reduction in adverse events was found in the Graham et al. study, significant improvements were noted in physician satisfaction, documentation of key elements in handoffs, and reduced data omissions; importantly, a trend of fewer near misses was noted comparing the pre‐ and postintervention periods. Although the Schouten et al. and Graham et al. studies suggest questionable benefit of face‐to‐face handoffs, we would caution that limitations in sample size and methodological sensitivity to detect adverse events in both studies could explain the lack of association between face‐to‐face handoffs and reduced adverse events. Furthermore, the promising findings of fewer data omissions and near misses in the intervention group in the Graham et al. study suggest benefit from a multipronged approach to improving handoffs including both face‐to‐face interactions and a structured written component.

In this issue, Hanson and colleagues also evaluated the use of a handoff tool by cross‐covering interns in a convenience sample of overnight clinical interactions. Despite finding that standard written documentation was considered beneficial by nearly all respondents (94.3%), the interns reported that the handoff tool was used in only 27.7% of encounters. This pales in comparison to the use of the nurse or chart in 94.4% of cross‐coverage encounters. The authors speculate that a handoff tool, for many years the only timely source of information, may not be as useful when information can be easily accessed in an electronic health record. Yet, in a prior systematic review that included 6 studies of computerized handoff tools, Li and colleagues found that computerized handoff tools may improve physician efficiency, enhance the completeness of handoff information, and even potentially reduce adverse events.[4]

The Schouten et al. and Hanson et al. studies raise important questions for the fields of hospital medicine and patient safety. Is it time to do away with the written and verbal portions of the handoff process? Should the handoff of patients simply consist of transferring a list of patients to covering providers? We do not believe this is the correct course of action. Rather, we recommend a more evolutionary, not revolutionary, interpretation of these results, especially when considered as part of a broader story of in‐hospital transitions of care.

For example, a recently published evaluation of a resident handoff‐improvement program in 9 hospitals and 10,740 patient admissions by Starmer and collegues[5] focused on a handoff bundle, I‐PASS, which is a pneumonic for Illness severity, Patient summary, Action items, Situation awareness and contingency planning, Synthesis by receiver. The authors report a reduction in medical errors and preventable adverse events without significant increases in the duration of oral handoff per patient. The handoff in this study included both oral and written elements in the I‐PASS format. Implementation was multipronged, and the I‐PASS bundle included (1) use of the I‐PASS pneumonic to standardize handoffs; (2) resident physician training in handoffs and communication through a 2‐hour workshop, followed by a 1‐hour role‐playing and simulation session, and a computer module for practice; (3) faculty development and observation with use of direct‐observation tools to provide structured feedback to residents; (4) active surveillance for errors (rather than relying on self‐report); and (5) a sustainability campaign to promote continuation of culture change. The complexity and robust nature of the I‐PASS handoff bundle suggests that having multiple structured components included in a handoff program with active, rather than retrospective, evaluation might increase the likelihood of improved, sustained outcomes. In addition, one might also conclude from the Starmer et al. study that it takes commitment from all levels, including residents, faculty, and administration, to improve handoffs between teams for inpatient care.

We commend Schouten et al. and Hanson et al. on their contributions to the literature, but believe that the story of the in‐hospital handoff has yet to be fully written. Although results from these 2 articles may cause speculation about the value of oral and written handoffs, we believe that the balance of evidence favors the use of a multipronged approach that involves both structured oral and written handoffs to improve the value and efficiency of handoffs. In addition, findings from the I‐PASS study support dedicated handoff training for providers, evaluation of handoffs using structured tools, and active surveillance for medical errors. Future areas of work should include a systematic review of the inpatient handoff literature and further evaluation of precisely which specific intervention components (eg, structured content of handoffs, sensemaking content) or modes of delivery (eg, face‐to‐face vs other) are most likely to reduce medical errors and improve patient outcomes. As the hospital medicine movement continues to grow, handoffs will continue to be paramount. Establishing the safest method to complete handoffs to promote patient safety should be a common goal for hospitalists.

The handoff story is still in evolution; as hospitalists, we are poised to be its author.

Handoffs are key events in the care of hospitalized patients whereby vital information is relayed between healthcare providers. Resident duty hour restrictions and the popularity of shift‐based work schedules have increased the frequency of inpatient handoffs.[1, 2] Failures in communication at the time of patient handoff have been implicated as contributing factors to preventable adverse events.[3, 4, 5, 6] With patient safety in mind, accreditation organizations and professional societies have made the standardization of hospital handoff procedures a priority.[7, 8] A variety of strategies have been utilized to standardize handoffs. Examples include the use of mnemonics,[9] electronic resources,[10, 11, 12] preformatted handoff sheets,[13, 14, 15, 16] and optimization of the handoff environment.[17] The primary outcomes for many of these studies center on the provider by measuring their retention of patient facts[18, 19] and completion of tasks[14, 16] after handoff, for example. Few studies examined patient‐centered outcomes such as transfer to a higher level of care,[20] length of stay,[11] mortality,[21] or readmission rate.[22] A study in the pediatric population found that implementation of a handoff bundle was associated with a decrease in medical errors and preventable adverse events.[23]

The Society of Hospital Medicine recommends that patient handoffs consist of both a written and verbal component.[8] Providers in our division work on 3 shifts: day, evening, and night. In 2009, we developed a face‐to‐face morning handoff, during which night‐shift providers hand off patient care to day‐shift providers incorporating an electronically generated service information list.[17] Given that the evening shift ends well before the day shift begins, the evening‐shift providers do not participate in this face‐to‐face handoff of care for patients they admit to day providers.

We wished to compare the clinical outcomes and adverse events of patients admitted by the night‐shift providers to those admitted by the evening‐shift providers. We hypothesized that transfer of care using a face‐to‐face handoff would be associated with fewer adverse events and improved clinical outcomes.

METHODS

The study was deemed exempt by the Mayo Clinic Institutional Review Board.

Setting

The division's shift schedule during the study period is depicted in Figure 1. Day‐shift providers included a physician and nurse practitioner (NP) or physician assistant (PA) on each of 7 teams. Each service had an average daily patient census between 10 and 15 patients with 3 to 4 new admissions every 24 hours, with 1 to 2 of these admissions occurring during the evening and night shifts, on average. The day shift started at 7:45 _am and ended at 7:45 _pm, at which time the day teams transitioned care of their patients to 1 of 2 overnight NP/PAs who provided cross‐cover for all teams through the night. The overnight NP/PAs then transitioned care back to the day teams at 7:45 _am the following morning.

Figure 1

Two evening‐shift providers, both physicians, including a staff hospitalist and a hospital medicine fellowship trainee, admitted patients without any cross‐cover responsibility. Their shifts had the same start time, but staggered end times (2 _pm10 _pm and 2 _pmmidnight). At the end of their shifts, the evening‐shift providers relayed concerns or items for follow‐up to the night cross‐cover NP/PAs; however, this handoff was nonstandardized and provider dependent. The cross‐cover providers could also choose to pass on any relevant information to day‐shift providers if thought to be necessary, but this, again, was not required or standardized. A printed electronic handoff tool (including the patient's problem list, medications, vital signs, laboratory results, and to do list as determined by the admitting provider) as well as all clinical notes generated since admission were made available to day‐shift providers who assumed care at 7:45 _am; however, there was no face‐to‐face handoff between the evening‐ and day‐shift providers.

Two night‐shift physicians, including a moonlighting board‐eligible internal medicine physician and staff hospitalist, also started at staggered times, 6:45 _pm and 10 _pm, but their shifts both ended at 7:45 _am. These physicians also admitted patients without cross‐cover responsibilities. At 7:45 _am, in a face‐to‐face meeting, they transitioned care of patients admitted overnight to day‐shift providers. This handoff occurred at a predesignated place with assigned start times for each team. During the meeting, printed electronic documents, including the aforementioned electronic handoff tool as well as all clinical notes generated since admission, were made available to the oncoming day‐shift providers. The face‐to‐face interaction between night‐ and day‐shift providers lasted approximately 5 minutes and allowed for a brief presentation of the patient, review of the diagnostic testing and treatments performed so far, as well as anticipatory guidance regarding potential issues throughout the remainder of the hospitalization. Although inclusion of the above components was encouraged during the face‐to‐face handoff, the interaction was not scripted and topics discussed were at the providers' discretion.

Patients admitted during the evening and night shifts were assigned to day‐shift services primarily based on the current census of each team, so as to distribute the workload evenly.

RESULTS

Of 805 patients admitted between 6:45 _pm and midnight during the study period, 305 (37.9%) patients were handed off to day‐shift providers without face‐to‐face handoff, and 500 (62.1%) patients were transferred to the care of day‐shift providers with the use of a face‐to‐face handoff.

Baseline characteristics of both groups are depicted in Table 1. Demographic characteristics, including age, gender, and race, were not significantly different between groups. The mean Charlson Comorbidity Index score was not significantly different between the groups without and with a face‐to‐face handoff. In addition, the presence of medical comorbidities including type 2 diabetes mellitus, hypertension, coronary artery disease, hyperlipidemia, heart failure, body mass index (BMI) <18, active cancer, and current cigarette smoking were not significantly different between the 2 groups. There was a trend to a significantly increased proportion of patients with a BMI >30 in the group without face‐to‐face handoff (P=0.05).

Results for the outcomes of this study are depicted in Table 2. The frequency of rapid response team calls, code team calls, transfers to a higher level of care, and death in the hospital in the 12 hours following the first morning handoff of the admission were not significantly different between the 2 groups. Both 30‐day readmission rate and LOS (median and mean) were not significantly different between groups.

There was no significant difference between the 2 groups in the frequency of adverse events resulting in harm for any of the categories (categories EI). Total adverse events between groups were also compared. Adverse events per 100 admissions were not significantly different between the group without face‐to‐face handoff compared to the group with face‐to‐face handoff. The percentage of admissions with an adverse event was also similar between groups.

DISCUSSION

We found no significant difference in the rate of rapid response team calls, code team calls, transfers to a higher level of care, death in hospital, or adverse events when comparing patients transitioned to the care of day‐shift providers with or without a face‐to‐face handoff. We hypothesize that a reason adverse events were no different between the 2 groups may be that providers were more vigilant when they did not receive a face‐to‐face handoff from the previous provider. As a result, providers may have dedicated additional time reviewing the medical record, speaking with the patients, and communicating with other healthcare providers to ensure a safe care transition. Similarly, other studies found no significant reduction in adverse events when using a standardized handoff.[10, 13, 29] This may be because patient handoff is 1 of a multitude of factors that impact the rate of adverse events, and a handoff may play a less vital role in a system where documentation of care for a given patient is readily accessible, uniform, and detailed. A face‐to‐face interaction itself in a patient handoff may be less pertinent if key information can be communicated through other channels, such as an electronic handoff tool, email, or phone.

Another potential explanation for the lack of a significant difference in patient outcomes with and without a face‐to‐face handoff is related to the study design and inherent rate of the events measured. With the exception of 30‐day readmission rate and LOS, the outcomes of the study were recorded only if they occurred in the 12 hours following the first morning handoff of the admission. This was done in an attempt to isolate the effect of the nonface‐to‐face versus face‐to‐face handoff on the first morning of the admission, and to avoid confounding effects by subsequent transitions of care later in the hospitalization. The frequency of hospital admissions in which an adverse event occurred during this relatively short 12‐hour window was approximately 3% for all patients in the study. With 805 total patients in the study, there may have been insufficient statistical power to detect a difference in the rate of outcomes, if a difference did exist, considering the event rate for both groups and the sample size.

There are several additional limitations to our study. First, the GTT was designed to be applied across the entirety of a hospitalization. By screening for adverse events over the span of only 12 hours for each hospitalization, the sensitivity of the tool may have been diminished, with a proportion of adverse events not captured, even when the sequence of events leading to patient harm began during the 12 hours in question. Second, this is a retrospective study, and all adverse events may not be documented in the medical record. Third, although not formally structured and infrequent, some evening‐shift providers did send an email or call the oncoming day‐shift provider to discuss patients admitted. This process, however, was provider dependent, unstructured, uncommon, and erratic, and thus we were not able to capture it from medical record review. Finally, the patients in this study were deemed low acuity upon triage prior to admission. A face‐to‐face handoff may be less important in ensuring patient safety when caring for low‐acuity compared to high‐acuity patients, considering the rapidity at which the critically ill can deteriorate.

Handoffs of patient care in the hospital have certainly increased in recent years. Consequently, communication among providers is undoubtedly important, with patient safety being the primary goal. Our work suggests that a face‐to‐face component of a handoff is not vital to ensure a safe care transition. Because of the increasing frequency of handoffs, providers' ability to do so face‐to‐face will likely be challenged by time and logistical constraints. Future work is needed to delineate the most effective components of the handoff so that we can design information transfer that promotes safe and efficient care, even without a face‐to‐face interaction.

Handoffs are key events in the care of hospitalized patients whereby vital information is relayed between healthcare providers. Resident duty hour restrictions and the popularity of shift‐based work schedules have increased the frequency of inpatient handoffs.[1, 2] Failures in communication at the time of patient handoff have been implicated as contributing factors to preventable adverse events.[3, 4, 5, 6] With patient safety in mind, accreditation organizations and professional societies have made the standardization of hospital handoff procedures a priority.[7, 8] A variety of strategies have been utilized to standardize handoffs. Examples include the use of mnemonics,[9] electronic resources,[10, 11, 12] preformatted handoff sheets,[13, 14, 15, 16] and optimization of the handoff environment.[17] The primary outcomes for many of these studies center on the provider by measuring their retention of patient facts[18, 19] and completion of tasks[14, 16] after handoff, for example. Few studies examined patient‐centered outcomes such as transfer to a higher level of care,[20] length of stay,[11] mortality,[21] or readmission rate.[22] A study in the pediatric population found that implementation of a handoff bundle was associated with a decrease in medical errors and preventable adverse events.[23]

The Society of Hospital Medicine recommends that patient handoffs consist of both a written and verbal component.[8] Providers in our division work on 3 shifts: day, evening, and night. In 2009, we developed a face‐to‐face morning handoff, during which night‐shift providers hand off patient care to day‐shift providers incorporating an electronically generated service information list.[17] Given that the evening shift ends well before the day shift begins, the evening‐shift providers do not participate in this face‐to‐face handoff of care for patients they admit to day providers.

We wished to compare the clinical outcomes and adverse events of patients admitted by the night‐shift providers to those admitted by the evening‐shift providers. We hypothesized that transfer of care using a face‐to‐face handoff would be associated with fewer adverse events and improved clinical outcomes.

METHODS

The study was deemed exempt by the Mayo Clinic Institutional Review Board.

Setting

The division's shift schedule during the study period is depicted in Figure 1. Day‐shift providers included a physician and nurse practitioner (NP) or physician assistant (PA) on each of 7 teams. Each service had an average daily patient census between 10 and 15 patients with 3 to 4 new admissions every 24 hours, with 1 to 2 of these admissions occurring during the evening and night shifts, on average. The day shift started at 7:45 _am and ended at 7:45 _pm, at which time the day teams transitioned care of their patients to 1 of 2 overnight NP/PAs who provided cross‐cover for all teams through the night. The overnight NP/PAs then transitioned care back to the day teams at 7:45 _am the following morning.

Figure 1

Two evening‐shift providers, both physicians, including a staff hospitalist and a hospital medicine fellowship trainee, admitted patients without any cross‐cover responsibility. Their shifts had the same start time, but staggered end times (2 _pm10 _pm and 2 _pmmidnight). At the end of their shifts, the evening‐shift providers relayed concerns or items for follow‐up to the night cross‐cover NP/PAs; however, this handoff was nonstandardized and provider dependent. The cross‐cover providers could also choose to pass on any relevant information to day‐shift providers if thought to be necessary, but this, again, was not required or standardized. A printed electronic handoff tool (including the patient's problem list, medications, vital signs, laboratory results, and to do list as determined by the admitting provider) as well as all clinical notes generated since admission were made available to day‐shift providers who assumed care at 7:45 _am; however, there was no face‐to‐face handoff between the evening‐ and day‐shift providers.

Two night‐shift physicians, including a moonlighting board‐eligible internal medicine physician and staff hospitalist, also started at staggered times, 6:45 _pm and 10 _pm, but their shifts both ended at 7:45 _am. These physicians also admitted patients without cross‐cover responsibilities. At 7:45 _am, in a face‐to‐face meeting, they transitioned care of patients admitted overnight to day‐shift providers. This handoff occurred at a predesignated place with assigned start times for each team. During the meeting, printed electronic documents, including the aforementioned electronic handoff tool as well as all clinical notes generated since admission, were made available to the oncoming day‐shift providers. The face‐to‐face interaction between night‐ and day‐shift providers lasted approximately 5 minutes and allowed for a brief presentation of the patient, review of the diagnostic testing and treatments performed so far, as well as anticipatory guidance regarding potential issues throughout the remainder of the hospitalization. Although inclusion of the above components was encouraged during the face‐to‐face handoff, the interaction was not scripted and topics discussed were at the providers' discretion.

Patients admitted during the evening and night shifts were assigned to day‐shift services primarily based on the current census of each team, so as to distribute the workload evenly.

RESULTS

Of 805 patients admitted between 6:45 _pm and midnight during the study period, 305 (37.9%) patients were handed off to day‐shift providers without face‐to‐face handoff, and 500 (62.1%) patients were transferred to the care of day‐shift providers with the use of a face‐to‐face handoff.

Baseline characteristics of both groups are depicted in Table 1. Demographic characteristics, including age, gender, and race, were not significantly different between groups. The mean Charlson Comorbidity Index score was not significantly different between the groups without and with a face‐to‐face handoff. In addition, the presence of medical comorbidities including type 2 diabetes mellitus, hypertension, coronary artery disease, hyperlipidemia, heart failure, body mass index (BMI) <18, active cancer, and current cigarette smoking were not significantly different between the 2 groups. There was a trend to a significantly increased proportion of patients with a BMI >30 in the group without face‐to‐face handoff (P=0.05).

Results for the outcomes of this study are depicted in Table 2. The frequency of rapid response team calls, code team calls, transfers to a higher level of care, and death in the hospital in the 12 hours following the first morning handoff of the admission were not significantly different between the 2 groups. Both 30‐day readmission rate and LOS (median and mean) were not significantly different between groups.

There was no significant difference between the 2 groups in the frequency of adverse events resulting in harm for any of the categories (categories EI). Total adverse events between groups were also compared. Adverse events per 100 admissions were not significantly different between the group without face‐to‐face handoff compared to the group with face‐to‐face handoff. The percentage of admissions with an adverse event was also similar between groups.

DISCUSSION

We found no significant difference in the rate of rapid response team calls, code team calls, transfers to a higher level of care, death in hospital, or adverse events when comparing patients transitioned to the care of day‐shift providers with or without a face‐to‐face handoff. We hypothesize that a reason adverse events were no different between the 2 groups may be that providers were more vigilant when they did not receive a face‐to‐face handoff from the previous provider. As a result, providers may have dedicated additional time reviewing the medical record, speaking with the patients, and communicating with other healthcare providers to ensure a safe care transition. Similarly, other studies found no significant reduction in adverse events when using a standardized handoff.[10, 13, 29] This may be because patient handoff is 1 of a multitude of factors that impact the rate of adverse events, and a handoff may play a less vital role in a system where documentation of care for a given patient is readily accessible, uniform, and detailed. A face‐to‐face interaction itself in a patient handoff may be less pertinent if key information can be communicated through other channels, such as an electronic handoff tool, email, or phone.

Another potential explanation for the lack of a significant difference in patient outcomes with and without a face‐to‐face handoff is related to the study design and inherent rate of the events measured. With the exception of 30‐day readmission rate and LOS, the outcomes of the study were recorded only if they occurred in the 12 hours following the first morning handoff of the admission. This was done in an attempt to isolate the effect of the nonface‐to‐face versus face‐to‐face handoff on the first morning of the admission, and to avoid confounding effects by subsequent transitions of care later in the hospitalization. The frequency of hospital admissions in which an adverse event occurred during this relatively short 12‐hour window was approximately 3% for all patients in the study. With 805 total patients in the study, there may have been insufficient statistical power to detect a difference in the rate of outcomes, if a difference did exist, considering the event rate for both groups and the sample size.

There are several additional limitations to our study. First, the GTT was designed to be applied across the entirety of a hospitalization. By screening for adverse events over the span of only 12 hours for each hospitalization, the sensitivity of the tool may have been diminished, with a proportion of adverse events not captured, even when the sequence of events leading to patient harm began during the 12 hours in question. Second, this is a retrospective study, and all adverse events may not be documented in the medical record. Third, although not formally structured and infrequent, some evening‐shift providers did send an email or call the oncoming day‐shift provider to discuss patients admitted. This process, however, was provider dependent, unstructured, uncommon, and erratic, and thus we were not able to capture it from medical record review. Finally, the patients in this study were deemed low acuity upon triage prior to admission. A face‐to‐face handoff may be less important in ensuring patient safety when caring for low‐acuity compared to high‐acuity patients, considering the rapidity at which the critically ill can deteriorate.

Handoffs of patient care in the hospital have certainly increased in recent years. Consequently, communication among providers is undoubtedly important, with patient safety being the primary goal. Our work suggests that a face‐to‐face component of a handoff is not vital to ensure a safe care transition. Because of the increasing frequency of handoffs, providers' ability to do so face‐to‐face will likely be challenged by time and logistical constraints. Future work is needed to delineate the most effective components of the handoff so that we can design information transfer that promotes safe and efficient care, even without a face‐to‐face interaction.

Handoffs are key events in the care of hospitalized patients whereby vital information is relayed between healthcare providers. Resident duty hour restrictions and the popularity of shift‐based work schedules have increased the frequency of inpatient handoffs.[1, 2] Failures in communication at the time of patient handoff have been implicated as contributing factors to preventable adverse events.[3, 4, 5, 6] With patient safety in mind, accreditation organizations and professional societies have made the standardization of hospital handoff procedures a priority.[7, 8] A variety of strategies have been utilized to standardize handoffs. Examples include the use of mnemonics,[9] electronic resources,[10, 11, 12] preformatted handoff sheets,[13, 14, 15, 16] and optimization of the handoff environment.[17] The primary outcomes for many of these studies center on the provider by measuring their retention of patient facts[18, 19] and completion of tasks[14, 16] after handoff, for example. Few studies examined patient‐centered outcomes such as transfer to a higher level of care,[20] length of stay,[11] mortality,[21] or readmission rate.[22] A study in the pediatric population found that implementation of a handoff bundle was associated with a decrease in medical errors and preventable adverse events.[23]

The Society of Hospital Medicine recommends that patient handoffs consist of both a written and verbal component.[8] Providers in our division work on 3 shifts: day, evening, and night. In 2009, we developed a face‐to‐face morning handoff, during which night‐shift providers hand off patient care to day‐shift providers incorporating an electronically generated service information list.[17] Given that the evening shift ends well before the day shift begins, the evening‐shift providers do not participate in this face‐to‐face handoff of care for patients they admit to day providers.

We wished to compare the clinical outcomes and adverse events of patients admitted by the night‐shift providers to those admitted by the evening‐shift providers. We hypothesized that transfer of care using a face‐to‐face handoff would be associated with fewer adverse events and improved clinical outcomes.

METHODS

The study was deemed exempt by the Mayo Clinic Institutional Review Board.

Setting

The division's shift schedule during the study period is depicted in Figure 1. Day‐shift providers included a physician and nurse practitioner (NP) or physician assistant (PA) on each of 7 teams. Each service had an average daily patient census between 10 and 15 patients with 3 to 4 new admissions every 24 hours, with 1 to 2 of these admissions occurring during the evening and night shifts, on average. The day shift started at 7:45 _am and ended at 7:45 _pm, at which time the day teams transitioned care of their patients to 1 of 2 overnight NP/PAs who provided cross‐cover for all teams through the night. The overnight NP/PAs then transitioned care back to the day teams at 7:45 _am the following morning.

Figure 1

Two evening‐shift providers, both physicians, including a staff hospitalist and a hospital medicine fellowship trainee, admitted patients without any cross‐cover responsibility. Their shifts had the same start time, but staggered end times (2 _pm10 _pm and 2 _pmmidnight). At the end of their shifts, the evening‐shift providers relayed concerns or items for follow‐up to the night cross‐cover NP/PAs; however, this handoff was nonstandardized and provider dependent. The cross‐cover providers could also choose to pass on any relevant information to day‐shift providers if thought to be necessary, but this, again, was not required or standardized. A printed electronic handoff tool (including the patient's problem list, medications, vital signs, laboratory results, and to do list as determined by the admitting provider) as well as all clinical notes generated since admission were made available to day‐shift providers who assumed care at 7:45 _am; however, there was no face‐to‐face handoff between the evening‐ and day‐shift providers.

Two night‐shift physicians, including a moonlighting board‐eligible internal medicine physician and staff hospitalist, also started at staggered times, 6:45 _pm and 10 _pm, but their shifts both ended at 7:45 _am. These physicians also admitted patients without cross‐cover responsibilities. At 7:45 _am, in a face‐to‐face meeting, they transitioned care of patients admitted overnight to day‐shift providers. This handoff occurred at a predesignated place with assigned start times for each team. During the meeting, printed electronic documents, including the aforementioned electronic handoff tool as well as all clinical notes generated since admission, were made available to the oncoming day‐shift providers. The face‐to‐face interaction between night‐ and day‐shift providers lasted approximately 5 minutes and allowed for a brief presentation of the patient, review of the diagnostic testing and treatments performed so far, as well as anticipatory guidance regarding potential issues throughout the remainder of the hospitalization. Although inclusion of the above components was encouraged during the face‐to‐face handoff, the interaction was not scripted and topics discussed were at the providers' discretion.

Patients admitted during the evening and night shifts were assigned to day‐shift services primarily based on the current census of each team, so as to distribute the workload evenly.

RESULTS

Of 805 patients admitted between 6:45 _pm and midnight during the study period, 305 (37.9%) patients were handed off to day‐shift providers without face‐to‐face handoff, and 500 (62.1%) patients were transferred to the care of day‐shift providers with the use of a face‐to‐face handoff.

Baseline characteristics of both groups are depicted in Table 1. Demographic characteristics, including age, gender, and race, were not significantly different between groups. The mean Charlson Comorbidity Index score was not significantly different between the groups without and with a face‐to‐face handoff. In addition, the presence of medical comorbidities including type 2 diabetes mellitus, hypertension, coronary artery disease, hyperlipidemia, heart failure, body mass index (BMI) <18, active cancer, and current cigarette smoking were not significantly different between the 2 groups. There was a trend to a significantly increased proportion of patients with a BMI >30 in the group without face‐to‐face handoff (P=0.05).

Results for the outcomes of this study are depicted in Table 2. The frequency of rapid response team calls, code team calls, transfers to a higher level of care, and death in the hospital in the 12 hours following the first morning handoff of the admission were not significantly different between the 2 groups. Both 30‐day readmission rate and LOS (median and mean) were not significantly different between groups.

There was no significant difference between the 2 groups in the frequency of adverse events resulting in harm for any of the categories (categories EI). Total adverse events between groups were also compared. Adverse events per 100 admissions were not significantly different between the group without face‐to‐face handoff compared to the group with face‐to‐face handoff. The percentage of admissions with an adverse event was also similar between groups.

DISCUSSION

We found no significant difference in the rate of rapid response team calls, code team calls, transfers to a higher level of care, death in hospital, or adverse events when comparing patients transitioned to the care of day‐shift providers with or without a face‐to‐face handoff. We hypothesize that a reason adverse events were no different between the 2 groups may be that providers were more vigilant when they did not receive a face‐to‐face handoff from the previous provider. As a result, providers may have dedicated additional time reviewing the medical record, speaking with the patients, and communicating with other healthcare providers to ensure a safe care transition. Similarly, other studies found no significant reduction in adverse events when using a standardized handoff.[10, 13, 29] This may be because patient handoff is 1 of a multitude of factors that impact the rate of adverse events, and a handoff may play a less vital role in a system where documentation of care for a given patient is readily accessible, uniform, and detailed. A face‐to‐face interaction itself in a patient handoff may be less pertinent if key information can be communicated through other channels, such as an electronic handoff tool, email, or phone.

Another potential explanation for the lack of a significant difference in patient outcomes with and without a face‐to‐face handoff is related to the study design and inherent rate of the events measured. With the exception of 30‐day readmission rate and LOS, the outcomes of the study were recorded only if they occurred in the 12 hours following the first morning handoff of the admission. This was done in an attempt to isolate the effect of the nonface‐to‐face versus face‐to‐face handoff on the first morning of the admission, and to avoid confounding effects by subsequent transitions of care later in the hospitalization. The frequency of hospital admissions in which an adverse event occurred during this relatively short 12‐hour window was approximately 3% for all patients in the study. With 805 total patients in the study, there may have been insufficient statistical power to detect a difference in the rate of outcomes, if a difference did exist, considering the event rate for both groups and the sample size.

There are several additional limitations to our study. First, the GTT was designed to be applied across the entirety of a hospitalization. By screening for adverse events over the span of only 12 hours for each hospitalization, the sensitivity of the tool may have been diminished, with a proportion of adverse events not captured, even when the sequence of events leading to patient harm began during the 12 hours in question. Second, this is a retrospective study, and all adverse events may not be documented in the medical record. Third, although not formally structured and infrequent, some evening‐shift providers did send an email or call the oncoming day‐shift provider to discuss patients admitted. This process, however, was provider dependent, unstructured, uncommon, and erratic, and thus we were not able to capture it from medical record review. Finally, the patients in this study were deemed low acuity upon triage prior to admission. A face‐to‐face handoff may be less important in ensuring patient safety when caring for low‐acuity compared to high‐acuity patients, considering the rapidity at which the critically ill can deteriorate.

Handoffs of patient care in the hospital have certainly increased in recent years. Consequently, communication among providers is undoubtedly important, with patient safety being the primary goal. Our work suggests that a face‐to‐face component of a handoff is not vital to ensure a safe care transition. Because of the increasing frequency of handoffs, providers' ability to do so face‐to‐face will likely be challenged by time and logistical constraints. Future work is needed to delineate the most effective components of the handoff so that we can design information transfer that promotes safe and efficient care, even without a face‐to‐face interaction.