Handoffs Toolkit - Background

A handoff is a “transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient-specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient’s care.”1 One of the key features that distinguishes a handoff from other types of communication about patients is that it establishes a transfer of responsibility or control.2

In a typical academic medical center, it has been estimated that on average, 4000 interdisciplinary handoffs occur in a single day, and 1.6 million handoffs occur yearly.3 Translating this to the unit level, there are hundreds of handoffs occurring each day. For example, there are at least two patient handoffs per patient per day, communicated by 5 different levels of healthcare providers (nurse to nurse, charge nurse to charge nurse, respiratory therapist to respiratory therapist, advanced practice provider to advanced practice provider, and attending to attending). In a typical 30-bed NICU, this computes to 240 opportunities for communication, or miscommunication, in a single day. Similarly, Gray et al have estimated that a baby with a NICU stay of 6 months experiences more than 300 nursing shift handoffs during their stay.4 In addition to the handoffs occurring between providers within a unit, the frequency of between unit handoffs has also increased as hospitals become increasingly complex.2 Much of the literature on handoffs examines intra-discipline handoff at change of shift (e.g., nurse-to-nurse or physician-to-physician). However, service change, transport handoffs, and perioperative handoffs are all vulnerable transitions.

Each NICU handoff presents an opportunity for error.5 When care is “handed-off” at shift change, when patients are transferred, or when care teams change, opportunities for communication breakdowns exist. In industries that run continuous operations, evidence shows that discontinuity of tasks and personnel during shift work can give rise to communication errors. In fact, poor handover notes were identified as a major causal factor in the 1988 Piper Alpha explosion, the world’s worst offshore oil disaster.6 Data show that when information degrades because of ineffective handoffs, it strongly increases the potential for medical errors. Up to two-thirds of sentinel events are related to communication breakdowns.7,8 Preventable adverse events (AEs) have been shown to be associated with staff transitions (e.g., care by cross-covering personnel). Evidence shows that the use of tools such as computer-based sign-out procedures can reduce the risk of preventable AEs.9

Other impacts of suboptimal handoffs include delays in medical diagnosis and treatment, redundant communications, redundant procedures and tests, lower provider and patient/family satisfaction, longer hospital stays, and increased hospital admissions.10 However, a benefit of a handoff is that it provides an opportunity for medical reevaluation and improved treatment plans. Stakeholders including the Institute of Medicine, Agency for Healthcare Research and Quality, American College of Obstetricians and Gynecologists, and the Joint Commission have all identified improving handoffs as a key strategy for prevention of medical errors.

Barriers to effective handoffs include lack of time, hierarchies, defensiveness, variation in communication styles, distraction, fatigue, conflict, and workload.11,12 A more extensive list of barriers is outlined here. Strategies are needed to address these barriers and achieve more optimal handoffs.13 In the neonatal population there have been a number of successful QI efforts aimed at improving shift handoffs,14,15 transport handoffs, and perioperative handoffs,16-18 suggesting that it is possible to improve the handoff process.