2017 HSC Section 2 - Practice Management

ARTICLE IN PRESS Reprinted by permission of Surgery. 2017; 161(3):861-868.

Evaluating handoffs in the context of a communication framework

Hani Hasan, MD, a Fadwa Ali, MD, a Paul Barker, MD, a Robert Treat, PhD, b Jacob Peschman, MD, a Matthew Mohorek, MD, a Philip Redlich, MD, PhD, a,c and Travis Webb, MD, MHPE, a Milwaukee, WI

Background. The implementation of mandated restrictions in resident duty hours has led to increased handoffs for patient care and thus more opportunities for errors during transitions of care. Much of the current handoff literature is empiric, with experts recommending the study of handoffs within an established framework. Methods. A prospective, single-institution study was conducted evaluating the process of handoffs for the care of surgical patients in the context of a published communication framework. Evaluation tools for the source, receiver, and observer were developed to identify factors impacting the handoff process, and inter- rater correlations were assessed. Data analysis was generated with Pearson/Spearman correlations and multivariate linear regressions. Rater consistency was assessed with intraclass correlations. Results. A total of 126 handoffs were observed. Evaluations were completed by 1 observer ( N = 126), 2 observers ( N = 23), 2 receivers ( N = 39), 1 receiver ( N = 82), and 1 source ( N = 78). An average ( ± standard deviation) service handoff included 9.2 ( ± 4.6) patients, lasted 9.1 ( ± 5.4) minutes, and had 4.7 ( ± 3.4) distractions recorded by the observer. The source and receiver(s) recognized distractions in > 67% of handoffs, with the most common internal and external distractions being fatigue (60% of handoffs) and extraneous staff entering/exiting the room (31%), respectively. Teams with more patients spent less time per individual patient handoff (r = 0.298; P = .001). Statistically significant intra- class correlations ( P # .05) were moderate between observers (r $ 0.4) but not receivers (r < 0.4). Intraclass correlation values between different types of raters were inconsistent ( P > .05). The quality of the handoff process was affected negatively by presence of active electronic devices ( b = 0.565; P = .005), number of teaching discussions ( b = 0.417; P = .048), and a sense of hierarchy between source and receiver ( b = 0.309; P = .002). Conclusion. Studying the handoff process within an established framework highlights factors that impair communication. Internal and external distractions are common during handoffs and along with the working relationship between the source and receiver impact the quality of the handoff process. This information allows further study and targeted interventions of the handoff process to improve overall effectiveness and patient safety of the handoff. (Surgery 2016; j : j - j .)

From the Division of Education/Department of Surgery a and Academic Affairs, b Medical College of Wisconsin; and the Department of Surgery, c Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI

H ANDOFFS refer to a transfer of patient care be- tween health care providers. This process includes transfer of information and responsibility concern- ing patient care. There is no doubt that a The authors report no conflicts of interest or financial disclosures. Presented at the Academic Surgical Congress, Jacksonville, FL, February 2–4, 2016. Accepted for publication September 7, 2016. Reprint requests: Fadwa Ali, MD, Department of Surgery, Med- ical College of Wisconsin Affiliated Hospitals, 8701 Watertown Plank Road, Milwaukee, WI 53226. E-mail: fali@mcw.edu . 0039-6060/$ - see front matter 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2016.09.003

successful and comprehensive handoff process is important for quality and continuity of patient care, but the quality of handoffs is affected by many factors, including lack of standardized hand- off tools, interruptions or distractions, variation in experience of providers, information inaccuracies, and communication or social skills. 1 The implementation of mandated restrictions of resident duty hours at academic institutions has led to increased patient care handoffs and thus more opportunities for errors during these impor- tant transitions of care. Compliance with the duty- hour restrictions can lead to an average of up to 15 handoffs per patient over a 5-day hospitalization. 2 A recent survey of internal medicine and general surgery residents at the Massachusetts General

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