Clinical handovers, handoffs or transitions of care (henceforth HO) occur when the responsibilities of caring for a patient are passed between clinicians. The objective of the HO is multifold. Ideally, handovers should paint a clear, up to date picture of the patient’s journey (shared mental model), emphasize “can’t miss” information (critical data sharing) and provide suggestions for “what to do if” (anticipatory guidance). Handovers during the care of patients in the healthcare setting occur frequently, by some accounts as often as every 8 minutes. Unfortunately, handovers are often informal, unorganized and fail to provide an appropriate transfer of information. There may be no healthcare setting in which handovers are more frequent, relevant, and studied than during the care of a patient undergoing surgery and anesthesia. From the time a patient arrives to the hospital for surgery to the time the patient is admitted to the post op ward or discharged to home, multiple HO will occur. These HO are a necessary part of the care of today’s complex surgical patient in a dynamic, fast-moving clinical environment. Handovers occur between nurses, between nursing staff and anesthesia caregivers, between anesthesia providers, between anesthesia and surgery, between surgery and nurses, and between anesthesia and the intensive care unit. Each HO is an opportunity for error if communication breaks down with each error having the potential for harm. Perhaps the most important aspect of poor-quality handover is that they are driven by human-human interaction and thus largely preventable. Anyone who played a game of “telephone” as a child, remembers how mangled the message becomes as it moves between and among participants.
Many strategies have been utilized to improve the purported quality of HO and eliminate the errors associated with transition of care communication. Standardization and the use of checklists are two frequent strategies employed to improve the reliability of handover content. High-risk settings such as aviation have implemented these tools with great success, and they are being increasingly employed in healthcare. Standardization of HO entails the use of a common format for transferring care and may involve a mnemonic, template, or checklist. A checklist entails the use of a common set of information and is often formatted as a list so that each item of information can be “checked off” after the item is specifically discussed. This helps to organize content, prompt the speaker to include the information, and to ensure that the receiving care team has the information it needs to continue care. Structured handover processes provide for efficient, thorough and a more or less uniform transfer of information between clinicians. Both have been shown in various studies to improve the quality of handovers, improve clinician satisfaction, reduce missed information, reduce preventable errors and probably improve patient care. As a result of these positive findings, standardization and checklists are a part of most strategies to improve HO communication and prevent associated errors.
Structured handover tools have not solved the problem of communication breakdown between clinicians. An important perspective as to why this may be the case can be found in the old adage of the person who could not see the forest for the trees. Detailed descriptions of each and every tree does not guarantee that the HO receiver knows where the forest is located or what to do if it were to catch fire. Standardization and checklists do not guarantee the transfer between clinicians of a shared mental model or anticipatory guidance. Recitation of information easily located in the medical record is often what occurs when an assessment of the expected clinical course, anticipation, and mitigation of risks to the patient is the actual goal. Structured communication tools are most effective when incorporated as part of a bundle of best practices for improving handover communication with a specific intent of reducing patient harm.
Handover bundles include strategies to create a receptive environment for communication such as encouraging face-to-face, two-way conversations, ensuring the appropriate people are present for HO, providing time for questions, encouraging the receiver to repeat back information to ensure understanding. Expectations of behaviors during patient care transitions that are essential to their effectiveness include avoidance of multitasking, creation of a distraction-free environment, and review of the patient’s medical record prior to their arrival in their receiving location. Training of caregivers in handover processes occurs in a small subset of institutions.
A quick Google search of “communication failure” returns over 600 million results spanning the spectrum of human existence. Healthcare is not immune to the effects of communication failures, but the consequences of imperfect communication have the potential to be catastrophic. Many have identified communication breakdowns as a major threat to the safety of patients and one of the main contributing factors to errors and adverse events in medicine. Efforts to improve clinician communication and the transfer of clinical information during handovers requires a bundle of strategies to prevent error. Standardization of handovers and the use of handover checklists are two crucial pieces of these bundles of best practices. Much remains unknown about how to optimize the effectiveness of communication during care transitions, but it is certainly essential to mention the ways in which the forest is at risk of catching fire and what resources are available should it occur.