Handoffs: A story in evolution

In this issue of the Journal of Hospital Medicine, the results of 2 inpatient handoff studies further shape our evolving understanding of in-hospital care transitions. Schouten and colleagues, report no difference in adverse outcomes when admissions were handed off to the primary team using face-to-face compared to non–face-to-face interactions. Meanwhile, Hanson and colleagues report that a written handoff tool is used infrequently by covering interns. Schouten et al.’s study attempted to isolate the impact of the verbal portion of the handoff between admitting and accepting team by evaluating whether early adverse outcomes differed between patients whose teams performed a face-to-face handoffs compared to those who did not. Their study was a retrospective chart review, and no additional process changes, training, or instruction regarding handoffs were implemented or measured. Handoffs occurred primarily between advanced practice providers, hospitalists, and a small number of resident physicians, so generalizability of this study to other institutions may be limited. No difference in adverse events was noted between admissions with face-to-face compared to those without face-to-face handoffs (2.6% vs 3.2%). Unfortunately, this study was likely underpowered to detect significant changes in adverse events, with a sample size of 805 total patients with a 3% baseline rate of adverse events (by our estimate, over 5000 patients would be needed in each group—10,000 overall—to detect a 30% relative difference in event rates). Further, this study did not examine other outcomes that could be impacted by the handoff process such as provider efficiency or patient experience. Face-to-face handoffs, the gold standard for handoffs between providers, was 1 of the sign-out approaches examined in a study by Graham and colleagues. This study, in contrast to the Schouten et al. study, prospectively evaluated adverse events before and after implementation of face-to-face handoffs, with structured written sign-out from the primary team to nighttime covering physicians. Prior to implementation, handoffs consisted of a “double handoff” involving an intermediary physician and unstructured written sign-out. Although no statistically significant reduction in adverse events was found in the Graham et al. study, significant improvements were noted in physician satisfaction, documentation of key elements in handoffs, and reduced data omissions; importantly, a trend of fewer “near misses” was noted comparing the preand postintervention periods. Although the Schouten et al. and Graham et al. studies suggest questionable benefit of face-to-face handoffs, we would caution that limitations in sample size and methodological sensitivity to detect adverse events in both studies could explain the lack of association between face-to-face handoffs and reduced adverse events. Furthermore, the promising findings of fewer data omissions and near misses in the intervention group in the Graham et al. study suggest benefit from a multipronged approach to improving handoffs including both face-to-face interactions and a structured written component. In this issue, Hanson and colleagues also evaluated the use of a handoff tool by cross-covering interns in a convenience sample of overnight clinical interactions. Despite finding that standard written documentation was considered beneficial by nearly all respondents (94.3%), the interns reported that the handoff tool was used in only 27.7% of encounters. This pales in comparison to the use of the nurse or chart in 94.4% of cross-coverage encounters. The authors speculate that a handoff tool, for many years the only timely source of information, may not be as useful when information can be easily accessed in an electronic health record. Yet, in a prior systematic review that included 6 studies of computerized handoff tools, Li and colleagues found that computerized handoff tools may improve physician efficiency, enhance the completeness of handoff information, and even potentially reduce adverse events. The Schouten et al. and Hanson et al. studies raise important questions for the fields of hospital medicine and patient safety. Is it time to do away with the written and verbal portions of the handoff process? Should the handoff of patients simply consist of transferring a list of patients to covering providers? We do not believe this is the correct course of action. Rather, we recommend a more evolutionary, not revolutionary, interpretation of these results, especially when considered as part of a broader story of in-hospital transitions of care. *Address for correspondence and reprint requests: Christine Jones, MD, Department of Medicine, Division of General Internal Medicine, Hospital Medicine Section, University of Colorado, Mail Stop F782, 12401 East 17th Avenue, Aurora, CO 80045; Telephone 720-848-4289; Fax 720-8484293; E-mail: christine.jones@ucdenver.edu