Demographic Characteristics. Our survey response rate was 60.4% (687/1138 eligible respondents). Approximately half of the training programs at our institution were represented in our participant cohort (46/95, 48%), and there were respondents from all post-graduate training years, representing over 30 specialties (Table 1).
Table 1: Distribution of Trainee Respondents by Self-Identified Specialty (n=687)
Training
Program
|
% of Total Responses
|
Training Program
|
% of Total Responses
|
Training Program
|
% of Total Responses
|
Anesthesia
|
7.8%
|
Neurosurgery
|
2.7%
|
Radiology
|
3.6%
|
Dermatology
|
2.2%
|
Obstetrics & Gynecology
|
2.6%
|
Neuroradiology
|
0.7%
|
Emergency Medicine
|
6.4%
|
Ophthalmology
|
0.4%
|
Surgery (General)
|
3.1%
|
Medicine
|
14.4%
|
Orthopedic Surgery
|
2.6%
|
Plastic Surgery
|
1.3%
|
Cardiology
|
1.3%
|
Physical Medicine & Rehab.
|
3.6%
|
Thoracic Surgery Integ.
|
1.6%
|
Critical Care Medicine
|
1.3%
|
Otolaryngology
|
1.6%
|
Urology
|
2.0%
|
Gastroenterology
|
0.2%
|
Anatomic & Clinical Pathology
|
4.7%
|
Other Medical
|
6.6%
|
Infectious Diseases
|
0.9%
|
Pediatrics
|
7.5%
|
Other Surgical
|
1.5%
|
Nephrology
|
1.3%
|
Pediatric Cardiology
|
1.5%
|
Other Pediatric
|
4.7%
|
Oncology
|
1.1%
|
Psychiatry
|
4.0%
|
Other Program (optional)
|
7.1%
|
Pulmonary/Critical Care
|
1.5%
|
Child Psychiatry
|
1.3%
|
Declined to state
|
20.0%
|
Neurology
|
2.7%
|
Radiation Oncology
|
1.5%
|
|
|
Selected Response Questions. Most respondents replied “consistently performed” to survey items about handoffs that highlighted the sickest patients, were given verbally and concisely, demonstrated active listening skills by respondents, and were learned informally from senior physicians. Other content was less consistently included. Only two-thirds of respondents reported “consistently performed” about handoffs that mentioned a patient’s code status if NOT full code, easily distinguished between patient care issues, and had checks for confirmation of understanding. Over half consistently highlighted action items and included contact phone numbers.
Findings around duty hours, feedback, and handoff content were revealing. Duty hours and the complexity of patient cases did not interfere with handoffs for most respondents. Respondents generally received informal feedback about their handoffs. Table 2 describes content that was included in handoff communications, and the frequency of how often and how consistently that content was included.
Table 2: Handoff Communication Content and Frequency of Inclusion (Answered: n=413)
Think about handoffs you have received during your training here. How often are each of the following included?
|
Very Common
|
Common
|
“Consistently Performed” = Very Common + Common
|
Highly Variable
|
Uncom-mon
|
“Inconsistently Performed” =
Highly Variable + Uncommon
|
Highlights the sickest patients
|
58.2%
|
33.3%
|
91.5%
|
6.1%
|
2.4%
|
8.5%
|
Code status mentioned if patient is NOT full code
|
33.9%
|
31.5%
|
65.4%
|
19.7%
|
15.0%
|
34.7%
|
Specifies the clinical condition of each patient (unstable, stable, etc.)
|
43.4%
|
40.2%
|
83.5%
|
11.6%
|
4.9%
|
16.5%
|
Includes up-to-date task list
|
41.6%
|
40.1%
|
81.7%
|
13.2%
|
5.1%
|
18.3%
|
Anticipatory guidance and rationale is provided (“if-then” statements)
|
35.1%
|
41.0%
|
76.2%
|
18.9%
|
4.9%
|
23.8%
|
Each separate issue is easily distinguished and described concisely
|
24.5%
|
40.1%
|
64.6%
|
30.1%
|
5.4%
|
35.5%
|
If there is nothing to do (besides monitor patient), that is also communicated
|
54.2%
|
34.6%
|
88.7%
|
7.8%
|
3.4%
|
11.2%
|
Around handoff systems and structure, most respondents rated as “inconsistently performed” to the use of standardized handoff tools and mnemonics, documentation of handoffs in the electronic medical record, verbal handoffs at the bedside or with family present, attending physician or other healthcare staff participation in handoffs, and the receipt of formal feedback about their handoffs. Standardized handoff tools were acceptable to just over half of respondents, though many qualified that the tools would need to be tailored to their specialty workflow for them to be widely adopted. Handoffs were complicated by patient care demands, lack of private space, lack of available computers, and lack of available staff. Respondents generally received their handoff education informally or through occasional housestaff conferences, and they received little formal feedback about their handoff skills. Half of the respondents did not want to change current handoff practices. Table 4 includes recommendations for institutions based on our findings.
Qualitative Analysis. We found wide variability in handoff content and process, revealing issues with both the stakeholders and the health systems in which they function. Our thematic analysis of open-ended responses revealed 5 themes: 1) handoff elements (including factors related to learning handoff elements); 2) health systems-level factors, 3) impact of the handoff, 4) agency (duty), and 5) blame and shame. We define these themes below and provide representative quotes in Table 3. In addition, we suggest an expanded conceptual framework around handoffs informed by our findings (Figure 1).
Theme 1, Handoff Elements. Our trainees described how both the content and construct of the handoff communication determined its effectiveness. The best handoffs transferred enough information to develop a shared mental model of the patient. Examples of critical handoff content included a case summary, an appraisal of illness severity, the patient’s code status, and tasks to be completed. Receivers were expected to synthesize the content provided, with ample opportunities to confirm understanding and ask questions. Trainees also focused on the importance of situational awareness as a construct, noting that effective handoffs provided anticipatory guidance, if-then action statements, escalation plans, and contact information.
Theme 2, Health-Systems Level Factors. Respondents anchored on numerous systems issues that impacted their handoffs. They identified impediments to effective handoffs that were common in the clinical learning environment, which included high patient volume and acuity, frequent interruptions, and a lack of a quiet space for sign-out. Importantly, they noted that the workplace culture itself could easily exacerbate these barriers. Trainees desired certain resources to facilitate better handoffs including formal training, protected time from other duties, participation by key personnel, and standardized workflows and policies. Issues related to duty hours and fatigue were also described.
Theme 3, Impact. The respondents described the impact of effective handoffs in two ways. First, good handoffs resulted in better patient care; therefore, they were inherently important. But some respondents also shared their emotional reactions to handoffs, good and bad, demonstrating vulnerability in their responses. Handoffs impacted their self-notion and self-worth as a physician, and they evoked a clear sense of responsibility in our trainees for the patients under their care.
Theme 4, Duty (Agency). Several professionalism concepts were associated with patient handoffs, most importantly that the respondents acted in the best interests of their patients. Some respondents described a professional duty to ensure effective handoffs, akin to the concept of agency in Arora’s framework.16,18 They reported accountability to the patient and having a sense of ownership of the patients’ care. Respondents also attributed these professional duties to teams of providers engaged in handoffs, citing the need for teamwork and a team mentality during handoffs.
Theme 5, Blame and Shame. Trainees recounted instances of blame, when providers assigned responsibility for an error to a perceived fault or wrong related to a handoff. These faults extended beyond content errors; they included judgments about provider behaviors and character, as well as unmet or unequal expectations. Conversely, shame was also evident in the responses, as respondents described painful feelings of humiliation or distress related to poor handoff experiences. Examples included guilt around perceived mistakes related to a handoff and negative self-assessments of competence.
Expanded Framework for Patient Handoffs. We view these findings as representing three domains that provide a wider and more comprehensive exploration and framework for patient handoffs: 1) an Intrapersonal Domain: comprised of factors that the individual controls, which include professionalism, engagement, preparation, emotions, and agency, among others; 2) an Interpersonal Domain that includes all interactions and communications between providers during a patient handoff, as well as the educational curriculum that informs it; and 3) a Health-Systems Domain that consists of systems-level factors, cultural influences, and the complexities of the clinical learning environment within which both other domains must operate (Figure 1).
Table 3: Representative Quotes of Trainee Handoff Experiences Informing Thematic Analysis
THEME 1: HANDOFF ELEMENTS (including factors related to learning handoff elements)
|
|
a) Handoff Structure: Content Suggestions (Please also see Table II)
|
|
“Code status was left out. This led to confusion when the patient became unstable overnight”
“Things NOT to change overnight”
“Being comfortable with hand-off being a conversation is important, I think”
“Who to call if there is a problem with the patient”
“Family phone numbers so we don't have to look for them in Epic… the contact listed…is often not the best one”
x
|
|
b) Culture: Role Modeling, Stressing Importance of Handoffs
|
|
“Culture of senior residents is most important”
“Continued reinforcement about proper hand-offs from the Attendings”
“They're important! interns need help with them!”
“It's just not emphasized enough in my opinion, and thus undervalued”
“The best way to learn good handoff/signout technique is to have a list of all pertinent information that must be given during the signout... It should be taught at the beginning of each year and then refreshed at least once during the year. Many people dismiss this type of teaching because they say it's "intuitive" or "obvious," however I've noticed that not teaching this leads to messy and unorganized handoffs”
|
|
c) Formal Training: Training Imbedded in Formal Curricula
|
|
“I-PASS study training” (multiple mentions)
“I learned this during orientation…”
“Handoff lecture, principles of dealing w/ common field-specific problems”
|
|
|
d) Observation: Learning Through Observing Others or By Being Observed
|
|
“Having the chief resident on a service demonstrate the type of handoff they expect on the first or second day of the rotation (although this is difficult since we all start each rotation on different days)”
“You really need to be observed giving sign out by a more senior resident… in order to perform this most effectively”
“I used to have my interns check each other's sign-outs (especially later in the year) and ask each other questions about things that weren't clear, or issues that they anticipated arising overnight. It helped them improve their own sign-outs for that day, and practice giving/receiving a helpful sign-out”
|
|
e) Experiential: Learning Through Trial and Error
|
|
“Just from practice, trying one thing and seeing if it works”
“Nothing can compare to living the experience of good and bad sign out. You can't teach it because you have to actually live out the effects of things going poorly to know how to improve… you can't know what you don't know”
|
|
f) Lack of Training: Perceived Lack of Training or Wish List Items for Curricula
|
|
“I have not received training”
“None. Figured it out on my own during medical student clerkships and intern year”
“I wish there could be more QI learning about these incidents”
“Our department does not have clear, written rules. It may be useful to do a hand-off lecture or something”
“The lack of a structured sign out formula so people from different services working together don't speak the same language”
“Having a handbook for trainees that contains a written policy and is frequently updated. This gets around the issue of multiple people doing things multiple ways, each claiming that their way is correct”
x
|
|
g) Feedback: Examples
|
|
“Feedback from people receiving signout. There was a lecture, but it didn't help that much”
“Coaches provide us feedback”; “Formal intermittent observation”
“Run the signout by the senior resident daily to get feedback on making it better (this improves patient care first and foremost)”
“Feedback should be done between residents... I like to ask, ‘anything I missed and should have told you?’ the next morning when I cover my service again… Assessing sign outs more formally is very difficult as these… happen 365 days of the year, between a huge variety of residents in a huge variety of settings. Active feedback between residents is the most important way to help them improve and the best way to actually get honest and valuable feedback”
|
|
THEME 2: HEALTH SYSTEMS-LEVEL FACTORS IMPACTING HANDOFFS
|
|
a) Handoff Policies and Protocols: Suggestions
|
|
“Biggest issue for me is that I forget to mention things. With a sign out template, this would be diminished”
“Please don't force anything on us. It won't be used anyway”
“A standardized format of what needs to be communicated in list format would ease the flow and make signouters less random”
“Have an order in Epic that the accepting team must submit by a certain time that indicates they have accepted care of the pt… nurses will understand the transfer of orders and care has been made”
x
|
|
b) Handoff Workflow Pressures: Within Teams/Units
|
|
“Too many patients to sign out to one provider”
“Too many patients to go into any real detail”
“When on call covering numerous patients you don't know well, there will invariably be information of situational importance not included in the sign-out”
“Feel strongly that our model of resident-to-resident handoff with chief resident supervision when possible is an effective and efficient model”
“… in high-stakes environments like the ICUs or ED, a fellow or attending should be present for sign out”
“People are often spread out through the hospital and hard to reach”
“At {facility X} we do it {handoff} all together with the charge nurse and attending which is really nice for clarifying questions, bringing up potential issues. It is unreasonable {at facility Y} because we have so many different attendings and signing out… from all over the hospital”
x
|
|
c) Handoff Workflow Pressures: Between Teams/Units
|
|
“Patients show up without sign outs, sometimes without transfer orders completely placed.
“Disconnect between nursing timing, MD timing and bed control timing”
“Needs to be a phone call between {x and y team}… and vice versa. Can be very disorganized”
“…transfers are often a complete mess, especially when they happen in the middle of the night. The nurses page the wrong team probably about 25% of the time for new admits/transfers”
“Not knowing when patients will be ready for transfer based on bed availability”
“I think instituting a two-check system whereby nursing/nursing passoff and MD/MD passoff has occurred before transport is called to transition a patient to another level of care is appropriate and indicated for all in hospital transfers…”
x
|
|
d) Scheduling Issues Impacting Handoffs
|
|
“There should be protected blocks of time which the receiving team should not be paged about transfers because it interferes with rounding or sign out”
“Someone to cover the pager during signout”
“Protected signout time makes for better handoffs with less interruptions”
“There is no designated time… to complete hand-offs, so the time spent signing out eats into seeing new patients. I know other programs… build in overlap with each transition of care…so that sign-out can occur conscientiously without too much rushing”
|
|
e) Environmental Pressures: Interruptions/Lack of Quiet Space
|
|
“Needing to respond to pages / calls during team signout / rounds so there are gaps in your information”
Regarding MD-RN Communication, what is working: “Text paging, batched calls”
“No quiet, private place to sign out, so we end up signing out in noisy rooms with lots of distractions”
“Workrooms are not large enough”
What is frustrating: “Hammer page for non-emergent stuff, or untagged pages that appear emergent for nonurgent matters, page and then when I call back within 5 mins no nurse around or they are on break”
|
|
f) Environmental Pressures: Duty Hours/Fatigue
|
|
“I don't know if other people realize how important it is. They just are tired at the end of the day and want to go home (not so much duty hour limits)”
“We will go over duty hours to signout appropriately…”
“…people feel tired to hand write a detailed handout”
“… sometimes switching service means you need to handoff and receive signout on the same day… each process will take 2-3 hours, adding on hours and hours of work, and this does not count towards ACGME hours because "you are not in the hospital"
|
|
g) Additional Needed Resources
|
|
“Need more computers…”
“Hospital-sponsored call center to field and triage outpatient calls…”
“Electronic system for handoffs, where they can be updated easily and frequently”
|
|
THEME 3: IMPACT OF THE HANDOFF
|
|
“Too many patients, it was overwhelming. I felt as though I was in an outer worldly experience. My first ever time receiving sign out”
“Patient transferred… without orders or team being notified. Patient was on comfort care but had a rapid response called because no one knew the patient. It adversely affected the patient and family wishes”
“Experiencing panic due to bad signout”
“A resident went through every patient on the list and specifically mentioned what the most likely things to go wrong were and what to do in those scenarios. The most prepared that I've ever been”
“… I have assumed care of a newly intubated patient with absolutely no changeover from the fellow who responded to the code… I needed to start all lines and put in orders immediately. I had…no help, it was 1 hour before rounds … I had never initiated {x therapy}… before, and that was the most traumatic experience of my residency thus far”
|
|
THEME 4: DUTY (AGENCY)
|
|
“There is always time to give a good sign out. Residents need to prioritize this as part of our job responsibility”
“Previous doctor was honest upon uncertainties about the patient which allowed me to take a fresh approach… rather than having a closed mind in regards to diagnosis”
“When on call covering numerous patients you don't know well, there will invariably be information of situational importance not included in the signout. There is simply no substitute for "knowing" the patient”
“Had pager signed over to me without any signout at all”
“When the …resident signed out to me … I didn't understand this sign out … I decided to go through the chart myself. I was worried about the patient and did not move them out of {unit}… later…the patient coded. It reinforced that if a sign out doesn't make sense, you should look through the chart more carefully yourself”
“…I appreciate that my attending was always available and even though we did have a bad outcome with patient, we were on same page about management… and… goals”
“When giving sign-out… she only took notes when there was 'nothing to do' and would rarely write down the action items required. This left me feeling uneasy, as it suggested to me that she was most interested in the easiest patients--which is of course the opposite of what my sign-out is intended to achieve”
"There's nothing to sign out. Call if?s." I called & said that wasn't ok. The person frustratedly ran through each pt on list w me…and if/then plans were discussed that had not been written on signout”
“I received a signout that the patient was actually discharged…when I went to check on the patient he told me… he couldn't walk… I learned from this experience to always speak with the patient, double check the chart, review labs/imaging, and essentially verify the information I received… is actually the case”
“Hand off from cross cover who doesn't know the patient”
|
|
THEME 5: BLAME AND SHAME
|
|
“Lack of interest on the part of … people participating”
“Laziness and arrogance of the residents”
“Some colleagues who don't put effort into it”
“I remember receiving a handoff… where the resident was in a hurry to leave… There wasn't any time to figure out the patient's PMH, fluid balance, or … course-- so while I was able to proceed…and the patient did fine, I was far outside my comfort zone. It could have been harmful to the patient, and certainly damaged my relationship with that resident, whom I didn't trust again”
“The resident didn't know much about the PMH, didn't know the plan… and clearly felt overwhelmed… I felt I could contribute little to the pt's care…because no one knew what was happening… It made me very angry”
“At sign-out we were briefly told to treat if… without specific instructions…We managed the patient given the nebulous information we had. To our dismay, the morning after, …{colleagues} were disappointed with our management strategies overnight. This affects our therapeutic alliance with consultants and with the patient”
“When I was on nights I was asked to perform a procedure for a patient that the day team did not have time to complete. The urgency of the procedure was not communicated during sign-out, and I didn't ask for it specifically either. The night team got around to the procedure much later on in the night, and when we actually saw the patient's condition at that time, we realized it should have been done much sooner… It made me spend more time clarifying procedure indications and urgencies moving forward”
“Patient was signed out as stable. In reality, this person had … [condition] ongoing for hours that was not well controlled nor well signed out. I called the resident to ask for clarification and this person came back to the hospital. I did not request this specifically but I think this person felt bad about it. Patient care was not really affected given the easy communication between residents”
|
|