Communication breakdown plays a part in the majority of adverse events in healthcare. Physician to physician handoffs are particularly prone to communication errors, yet have been shown to be more complete when systematized according to a standardized bundle. However, the degree to which individual elements of this bundle, including written versus verbal handoffs, contribute to effective communication is not known. Interventions that improve thoroughness of handoffs have also not been widely studied.
Purpose:
This quality improvement project sought to measure the completeness of written handoffs among internal medicine residents at baseline, and to evaluate how implementation of an EMR-based tool affected handoff completeness.
Description:
The authors evaluated all written handoffs from general and specialty (hematology, oncology, cardiology) internal medicine inpatient units staffed by internal medicine interns and residents from a randomly chosen representative sample of days in April and May 2015 at Stanford University Medical Center, focusing on content elements. The intervention was then implemented in June 2015 with post-intervention data collected in August-September 2016.
The EMR-based tool provided a mix of scaffolding/frameworks for completion and automatically pulling in objective data. This included radio buttons that prompted users to select whether the illness severity categorized the patient as stable, a “watcher”, or unstable. It also automatically pulled in EMR data on the patient’s 24-hour vitals, common lab tests, and code status. Finally, it provided text boxes labeled “Active Issues”, “Action List (To-Dos)”, and “If/Thens” for residents to fill in.
Baseline analysis showed that while the overwhelming majority of written handoffs included a patient summary, code status, to-do list, contingencies, and some information about patients’ medications, only a minority gave important lab values, information about patients’ recent vital signs, an illness severity assessment, or the patient’s allergies. Post-implementation analysis found large increases in signout completeness, with inclusion at or above 96% for all elements apart from allergies. These effects were particularly profound for the illness severity assessment and for data automatically pulled in to the written handoff, as these elements had been relatively incomplete at baseline; for example, illness severity assessment inclusion increased from 1% of handoffs at baseline to 99% of handoffs after the intervention. These data are shown in the associated figure.
Conclusions:
EMR-based handoff interventions can be highly effective at improving handoffs, which leads to fewer medical errors and better patient care.