2017 HSC Section 2 - Practice Management

ARTICLE IN PRESS

Hasan et al

personnel entering and leaving the room was the most common type of distraction. The frequency of distractions during the handoff was highlighted in other studies. In a recent study of surgical handoffs at 3 University of California, San Francisco (UCSF), teaching hospitals, distractions occurred in 48% of handoffs. 9 Interestingly, the authors report that pagers and patient-related telephone calls were the most common distractions. In other studies, most observed handoffs were interrupted $ 1 for every ser- vice. 10,11 Our study also demonstrated that distrac- tions negatively affect the quality and process of delivery and reception of the handoff. Our linear regression analysis shows that the process of handoff delivery was negatively affected by the number of side or teaching discussions and the number of personnel entering or exiting the room. We hypothesize that distractions affect the mo- mentum of the handoff process and divert attention from important, patient-related information. Con- trary to our results, the UCSF study showed that distractions increase the duration of the handoff process but do not affect the quality of the handoff process. 9 While the authors suggested that surgery residents developed tolerance to distractions, the UCSF study did not report any solicited feedback from the residents providing or receiving handoffs regarding whether they felt distractions impacted the quality of the handoff process. The authors’ re- sults were based solely on the observers’ evaluation of the handoff process. In our study, we surveyed both the source and the receiver in addition to the observers. Identifying distractions is important for quality improvement of the handoff process, because the most common distractions should be amenable to interventions. Residency programs could encourage minimization of side and teaching conversations during the handoff process. Nursing personnel could also be encouraged to minimize pages during handoff time except for urgent, patient-related issues. Similar to the sterile cockpit rule in the aviation industry that requires pilots to refrain from nonessential activities during critical phases of flights, including takeoff and landing, hospitals can consider instituting a no- page policy during handoffs. 10,12 In our study, the quality of handoff delivery was rated significantly better by the observer when a PGY-2 or higher level resident delivered the handoff compared with a PGY-1 resident, despite the receiver scores not showing a difference based on the source PGY level. This finding has not been reported previously. We hypothesize that the ability to provide pertinent patient information and

identify potential complications or issues improves with experience. Handling distractions during handoffs may also require multitasking, a skill that improves with experience. Prior studies have shown that multitasking is a complex cognitive process that improves with practice. 13 In an observed, simu- lated handoff experience with need to handoff mul- tiple patients, residents with prior training in handoff or prior handoff experience achieved bet- ter scores based on assessing their handoff delivery using a 5-item checklist. 14 This finding suggests that handoff training during medical school or begin- ning of residency may be beneficial. Our study demonstrated that the quality of handoff delivery and reception is impacted posi- tively by a good relationship between the source and receiver. Furthermore, we identified this relationship as an important predictor of the quality of the handoff process. This observation was supported by 2 findings: the presence of hierarchy negatively affected the evaluation of the handoff process, and the source-receiver rela- tionship correlated directly with the overall hand- off process score, both positively and negatively. To our knowledge, prior handoff studies have not examined the working relationship between the handoff participants as a predictor of quality, although our study of communication theory iden- tified the relationship between the source and receiver and hierarchy as important psychologic distractions when relaying a message. 4 Developing a hierarchy-free environment during handoffs, as well as improving the source-receiver relationship, should be further studied as a means for improving communication and ultimately patient care. When comparing the responses of different participants, we identified 2 themes. Observers were mostly congruent with one another, while different participant types were mostly incongruent. The observers only disagreed on the evaluation of the handoff reception, likely due to the passive nature of receiving information, making it difficult for a third party observer to evaluate accurately. In contrast, when comparing the source to the receivers or observers, the observers agreed on the overall presence of distractions, but the source/ receiver/observer gave divergent responses in terms of type of distractions, evaluating the handoff de- livery/reception process, and the handoff environ- ment. The divergent responses occurred due to the source and receiver being focused on their respec- tive tasks during the handoff, while the observers were focused on evaluating the process and account- ing for distractions. Furthermore, our work suggests that the source and receiver could be sensitive to

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