Research on Hospital Handoffs

This web page is intended to provide easy access to varioius pieces of research on hospital handoffs that I have been associated with. It seems that people who are interested in one result are often interested in others. I hope this site will provide simple ‘one-stop shopping’. Perhaps it will also help bring together the many people concerned about improving the way patients are handed off in hospitals.

- michael cohen

What's here and how to use it

The web page includes:

• abstracts of papers on which I've been a co-author
• links to the full text of those papers
• a brief list of research resources developed as I've worked on handoffs
• some prelinimary and speculative notes on how handoffs might be done better

First, a word about downloading. The copies of papers made available here are only for research, either for scholarly publication or as background for policy decisions, or for critical discussions, such as might occur in articles by journalists or in blog-posts. These are uses that are exempted (in the U.S.) under the Fair Use clause of the Copyright Act. If you are not engaged in one of these activities, or if you have doubts about whether your activity qualifies as Fair Use, you should contact me via email . If your interest does qualify as Fair Use, please download any papers you wish to read in more detail.

Published papers

The papers listed below are roughly in reverse chronological order. They have been developed working with two sets of colleagues: One set are papers written with Brian Hilligoss, now an Assistant Professor at the College of Public Health of The Ohio State University, (formerly a PhD student at the The University of Michigan's School of Information). The other set were done by a group consisting of:

• Roy Ilan, MD, at Kingston General Hospital and Queen's University Medical School;
• Curtis LeBaron, at the Marriott School of Business at Brigham Young University;
• Marlys Christianson, MD, at the Rotman School of Business, University of Toronto (formerly a PhD student at Michigan); and
• Lyndon Garrett, a PhD student at The University of Michigan's Ross School of Business (and formerly and undergraduate research assistant at Brigham Young).



• The Earlier the Longer: Disproportionate Time Allocated to Patients Discussed Early in Attending Physician Handoff Sessions

  • Handoffs in hospitals have been widely recognized by both regulators and researchers as a locus of potential communication failure, with substantial risks to patient safety and quality of care. By conservative estimate, there are over half a billion patient handoff discussions annually in US hospitals. Most empirical studies have been performed in shift-change settings, where most handoffs occur, and where it is typical that responsibility for multiple patients is transferred during a single handoff session. However, theoretical analysis in the literature is entirely focused on how best to hand off a single patient. As a result, research has overlooked what has been labeled the portfolio problem: how best to allocate across multiple patients the scarce time available for a handoff session.
    
    In the first study of this issue, to our knowledge, we used video recordings of 262 patient discussions in 23 handoff sessions among experienced attending physicians in the intensive care unit (ICU) of a tertiary medical center. We found that first-discussed patients received about 50% more time than those discussed last in a session. This occurred despite the order of cases being effectively random and therefore unrelated to severity or complexity of illness.
  
  
  • with Roy Ilan, Curtis LeBaron, Marlys Christianson, Lyndon Garrett; Archives Internal Medicine ; Published online November 12, 2012 (print publication in 2013)
    Download this paper

• The Unappreciated Challenges of Between-Unit Handoffs: Negotiating and Coordinating Across Boundaries

  • Although interest in studying and improving handoffs has grown considerably in recent years, a general tendency to treat handoff as a single type of activity has resulted in overlooking important variation and in understudying one consequential type: between-unit handoffs. Using the admission handoff between emergency departments and inpatient services as an example, this conceptual article identifies 2 distinguishing structural features of between- unit transitions and demonstrates how these features create negotiation and coordination challenges that are further complicated by several contextual factors. Between-unit handoffs are distinguished from within-unit handoffs because the former are triggered by patient conditions as opposed to shift schedules and entail working across organizational boundaries rather than within them. Consequently, between-unit handoffs are challenged by several contextual factors, including interprofessional differences, unequal distributions of power among units, frequent lack of established relationships among the involved parties, infrequent face-to-face communication, a lack of awareness of the other unit’s state, and the fact that responsibility and control of patients are transferred separately. Implications for improvement are discussed.
  
  
  • with Brian Hilligoss; Annals of Emergency Medicine; 2012
    Download this paper

• Handover patterns: an observational study of critical care physicians

  • Background: Handover (or ‘handoff’) is the exchange of information between health professionals that accompanies the transfer of patient care. This process can result in adverse events. Handover ‘best practices’, with emphasis on standardization, have been widely promoted. However, these recommendations are based mostly on expert opinion and research on medical trainees. By examining handover communication of experienced physicians, we aim to inform future research, education and quality improvement. Thus, our objective is to describe handover communication patterns used by attending critical care physicians in an academic centre and to compare them with currently popular, standardized schemes for handover communication.
    Methods: Prospective, observational study using video recording in an academic intensive care unit in Ontario, Canada. Forty individual patient handovers were randomly selected out of 10 end-of-week handover sessions of attending physicians. Two coders independently reviewed handover transcripts documenting elements of three communication schemes: SBAR (Situation, Background, Assessment, Recommendations); SOAP (Subjective, Objective, Assessment, Plan); and a standard medical admission note. Frequency and extent of questions asked by incoming physicians were measured as well. Analysis consisted of descriptive statistics.
    Results: Mean (± standard deviation) duration of patient-specific handovers was 2 min 58 sec (± 57 sec). The majority of handovers’ content consisted of recent and current patient status. The remainder included physicians’ interpretations and advice. Questions posed by the incoming physicians accounted for 5.8% (± 3.9%) of the handovers’ content. Elements of all three standardized communication schemes appeared repeatedly throughout the handover dialogs with no consistent pattern. For example, blocks of SOAP’s Assessment appeared 5.2 (± 3.0) times in patient handovers; they followed Objective blocks in only 45.9% of the opportunities and preceded Plan in just 21.8%. Certain communication elements were occasionally absent. For example, SBAR’s Recommendation and admission note information about the patient’s Past Medical History were absent from 22 (55.0%) and 20 (50.0%), respectively, of patient handovers.
    Conclusions: Clinical handover practice of faculty-level critical care physicians did not conform to any of the three predefined structuring schemes. Further research is needed to examine whether alternative approaches to handover communication can be identified and to identify features of high-quality handover communication.
  
  
  • with Roy Ilan, Curtis LeBaron, Marlys Christianson, Lyndon Garrett; BMC Health Services Research 2012, 12:11
    Download this paper

• A handoff is not a telegram: an understanding of the patient is co-constructed

  • Hospital handoffs are believed to be a key locus of communication breakdown that can endanger patient safety and undermine quality of care. Substantial new efforts to better understand handoffs and to improve handoff practices are under way. Many such efforts appear to be seriously hampered, however, by an underlying presumption that the essential function of a handoff is one-way information transmission. Here, we examine social science literature that supports a richer framing of handoff conversations, one that characterizes them as co-constructions of an understanding of the patient.
  
  
  • with Brian Hilligoss and Andre-Carlos Amaral; Critical Care 2012, 16:303
    Download this paper

• Hospital Handoffs as Multifunctional Situated Routines: Implications for Researchers and Administrators

  • Patient handoffs involve the exchange of information between health professionals accompanying a transfer of responsibility for, or control of, a patient. Concerns over the safety risks of poor handoffs have resulted in regulatory pressure to standardize practice and considerable growth in research. But handoffs involve more than information transfer, and their consequences for health care organizations extend beyond the safety of patients. Using an organization theory lens, we review the literature on handoffs and propose a framework that characterizes handoffs as multifunctional, situated organizational routines. We also identify implications for researchers and hospital policymakers. Standardization and improvement efforts run the risk of causing unintended problems if they overlook the complexity of handoff and the larger organizational functions it serves. Deepening our understanding of the multifunctional, situated nature of handoff can lead to improvement efforts that not only safeguard individual patients, but also enhance the capabilities of the larger health care organization.
  
  
  • with Brian Hilligoss; Advances in Health Care Management, Volume 11, Emerald Group Publishing Limited, pp. 91-132, doi: 10.1108/S1474-8231(2011)0000011008
    Download manuscript version of this paper

• The published literature on handoffs in hospitals: deficiencies identified in an extensive review

  • Background In hospitals, handoffs are episodes in which control of, or responsibility for, a patient passes from one health professional to another, and in which important information about the patient is also exchanged. In view of the growing interest in improving handoff processes, and the need for guidance in arriving at standardised handoff procedures in response to regulatory requirements, an extensive review of the research on handoffs was conducted.
    Methods The authors have collected all research treatments of hospital handoffs involving medical personnel published in English through July 2008.
    Results A review of this literature yields four significant conclusions: (1) the definition of the handoff concept in the literature is poorly delimited; (2) the meaning of ‘to standardise’ has not been developed with adequate clarity; (3) the literature shows that handoffs perform important functions beyond patient safety, but the tradeoffs of these functions against safety considerations are not analysed; (4) studies so far do not fully establish that attempts at handoff standardisation have produced marked gains in measured patient outcomes.
    Conclusion The existing literature on patient handoffs does not yet adequately support either definitive research conclusions on best handoff practices or the standardisation of handoffs that has been mandated by some regulators.
  
  
  • with Brian Hilligoss; Qual Saf Health Care 2010;19:493e497. doi:10.1136/qshc.2009.033480
    
    Download this paper

Research Resources

During the course of working on handoffs, Brian Hilligoss and I -- mostly Brian -- developed a number of resources that could be useful to others. I am happy to make these available to researchers who may find them useful.

Four resources are available online, the first two of which are online and public:


1. A bibliography of early research on handoffs, with full text searchable abstracts. This can be accessed at http://connotea.org/user/signout .


2. An extensive summary of the handoff research literature through mid-2010. This document groups the studies into categories relevant for researchers or policy makers. It was preliminary to the publication of the paper above on “deficiencies”, which critiqued the literature, and the paper on “multifunctional routines”, which discussed new research possibilities. It is more detailed in its coverage of all relevant studies and has a larger bibliography than the later, published papers. This paper is in the University of Michigan Deep Blue permanent online archive, at http://hdl.handle.net/2027.42/61522.


3. An archive of full text copies of the literature indexed in item 1 above. While the Connotea bibliography gives reference information and abstracts, we have also created a password protected file of the fulltexts of virtually all of these items. To maintain copyright protection, this is available only by contacting either Michael Cohen or Brian Hilligoss to establish Fair Use intentions (scholarship or criticism) and receive details on establishing a password for access. Once this is done, users can click through to fulltexts from the Connotea index. This may be especially useful to users seeking to obtain copies of chapters from books or very early articles.


4. The Kingston Handover Video DataBank is a collection of video recordings of expert attending physicians handing off at week’s end in an ICU. The concept of a video data bank parallels that of a tissue bank. Data are collected ahead of individual research projects and maintained under careful and approved controls. Subsequent studies can be individually approved at later times. Researchers with a detailed plan for how they might make use of the data for new research investigations should contact the director of the Data Bank, Dr. Roy Ilan, at Kingston General Hospital or Queen's University Medical School, Kingston Ontario, Canada.



Thoughts on what we might teach about handoff

I am currently [as of late November, 2012] preparing a blog post on this issue. Once that work is complete, I will either repeat the draft text here, or, if it published, provide a link. Please revisit this page, or email me, if this question is of interest to you.




Last updated: November 21, 2012; other materials to be added from time to time.