Barriers and Enablers of Effective Handovers

November 30, 2021

We wanted to highlight a recent article by several members of the Education Working Group of the Perioperative Multicenter Handoff Collaborative (MHC). The article by Drs. Michael and Riesenberg was published in the November issue of Anesthesia & Analgesia (https://pubmed.ncbi.nlm.nih.gov/34673728/) and does an excellent job of providing an overview of both the barriers and enablers of establishing structured, evidence-based handoff practices both within and across institutions.  The work of the MHC is specifically focused on these efforts and is designed to facilitate collaboration across institutions toward the development and implementation of safe and reliable care transitions.  This article serves as a summary of the challenges and opportunities we face in our effort to reduce the harms associated patient handoffs and care transitions in the perioperative setting. 

Handoffs, defined as transfers of patient information and responsibility between health care providers, are vulnerable to communication errors.  The perioperative patient is particularly at risk due to multiple care transitions (often across both specialties and physical locations) at a time in which their clinical status may also be changing simultaneously. 

Much work remains to be done to develop, study and implement best practices across institutions and perioperative disciplines.  Collaborations across facilities allow us to learn from one another and to further build upon the efforts and expertise of our peers. 

Our pediatric colleagues have had great success with their multicenter development of the I-PASS handoff system.  I-PASS, which is a framework based on Illness Severity, Patient Summary, Action List, Situation awareness and contingency planning, and Synthesis by receiver, and has demonstrated improved patient outcomes. Medical error is reduced following its implementation. (https://pubmed.ncbi.nlm.nih.gov/25372088/) Comprehensive educational and implementation resources tools have been developed so that each center is not “re-inventing the same wheel”.  (https://pubmed.ncbi.nlm.nih.gov/30800994/)  Using the experience of the I-PASS model as a guide, the authors go on to discuss attributes which favor or impede successful implementation of a structured handover processes.

Institutional Focused Considerations

Barriers
  • Difficulty in creating a universal tool that serves the needs of a wide variety of professional needs and incorporates specialty-dependent content.
  • Wide spectrum of practice structures and cultures across institutions.
  • Electronic Medical Record (EMR) systems vary considerably between organizations. Limits the ability to embed meaningful, standardized handover processes within the EMR.
  • Absence of external stimuli showing shortcomings of current state or feedback on current practices makes change challenging.
  • Handoff processes are often not explicitly taught. Sustained organizational commitment required to sustain interventions.
Enablers
  • Buy-in of senior and local leadership is required to establish need for change in the handoff process.
  • Institutional support and resources are required to support this work.
  • This work must be explicitly prioritized by the organization to raise the profile of the project and to ensure it is implemented broadly.
  • External funding has been shown to increase the longevity and success rate of handoff interventions.

Research-Focused Considerations

Barriers
  • Difficult to gain consensus across various organizations regarding core elements or format that will be useful across clinical contexts.
  • Identification of research instruments with high inter-rater reliability may be challenging.
  • Difficult to ensure consistency of research implementation across different organizations.
Enablers
  • Less duplication of effort. Once the IRB proposal is written, all center benefit.
  • Institutions that share the same EMR can share tools that have been developed and data can be pooled.
  • Larger sample sizes improve the power of the study and allow differences in process or outcome measures to be detected.

Other Considerations

Enablers
  • The Joint Commission mandates that “the organization’s process of handoff communication provides for the opportunity for discussion between the giver and receiver of patient information.” This standard motivates safety organizations to establish resource guidelines for handover implementations across organizations.
  • Support by specialty specific organizations raises the profile of this work. I-PASS was supported by two large pediatric organizations. The MHC is sponsored by the Anesthesia Patient Safety Foundation (APSF) which shares its commitment to taking a multidisciplinary approach for reducing patient harms in the perioperative setting.
  • MHC is committed to interdisciplinary coordination to ensure that structured handovers meet the needs of the wide spectrum of professionals who care for patients in the perioperative space.
  • The ACGME and AAMC now are also requiring sponsoring institutions to develop structured handoff processes in addition to providing a comprehensive curriculum for teaching and evaluating its effectiveness.