To establish protocol and standards within the Emory University School of Medicine residency and fellowship programs to ensure the quality and safety of patient care when transfer of responsibility occurs during duty hour shift changes and other scheduled or unexpected circumstances.
A handoff is defined as the communication of information to support the transfer of care and responsibility for a patient/group of patients from one provider to another. Transitions of care are necessary in the hospital setting for various reasons. The transition/hand-off process is an interactive communication process of passing specific, essential patient information from one caregiver to another. Transition of care occurs regularly under the following conditions:
1. Change in level of patient care, including inpatient admission from an outpatient procedure or diagnostic area or ER and transfer to or from a critical care unit.
2. Temporary transfer of care to other healthcare professionals within procedure or diagnostic areas
3. Discharge, including discharge to home or another facility such as skilled nursing care
4. Change in provider or service change, including change of shift for nurses, resident sign-out, and rotation changes for residents.
Individual programs must design schedules and clinical assignments to maximize the learning experience for residents as well as to ensure quality care and patient safety, and adhere to general institutional policies concerning transitions of patient care. Examples of strategies which have successfully minimized transitions include day/night teams, staggering of intern/resident/attending switch times and/or days to maintain continuity, outpatient clinic “pods” or teams, etc. All training programs must design call and shift schedules to minimize transitions in patient care. Schedule overlaps should include time to allow for face-to face handoffs to ensure availability of information and an opportunity to clarify issues.
The transition/hand-off process should involve face-to-face interaction with both verbal and written/computerized communication, with opportunity for the receiver of the information to ask questions or clarify specific issues. The hand-off process may be conducted by telephone conversation. The transition process should include, at a minimum, the following information in a standardized format that is universal across all services:
1. Identification of patient, including name, medical record number, and date of birth
2. Identification of admitting/primary/supervising physician and contact information
3. Diagnosis and current status/condition (level of acuity) of patient
4. Recent events, including changes in condition or treatment, current medication status, recent lab tests, allergies, anticipated procedures and actions to be taken
5. Outstanding tasks – what needs to be completed in immediate future
6. Outstanding laboratories/studies – what needs follow up during shift
7. Changes in patient condition that may occur requiring interventions or contingency plans
Each residency program must develop components ancillary to the institutional transition of care policy that integrate specifics from their specialty field. Programs are required to develop scheduling and transition/hand-off procedures to ensure that:
1. Residents comply with specialty specific/institutional duty hour requirements
2. Faculty are scheduled and available for appropriate supervision levels according to the requirements for the scheduled residents.
3. All parties involved in a particular program and/or transition process have access to one another’s schedules and contact information. All call schedules should be available on department-specific password-protected websites and also with the hospital operators.
4. Patients are not inconvenienced or endangered in any way by frequent transitions in their care.
5. All parties directly involved in the patient’s care before, during, and after the transition have opportunity for communication, consultation, and clarification of information.
6. Safeguards exist for coverage when unexpected changes in patient care may occur due to circumstances such as resident illness, fatigue, or emergency.
7. Programs should provide an opportunity for residents to both give and receive feedback from each other or faculty physicians about their handoff skills.
Each program must include the transition of care process in its curriculum.
Residents must demonstrate competency in performance of this task. There are numerous mechanisms through which a program might elect to determine the competency of trainees in handoff skills and communication. These include:
1. Direct observation of a handoff session by a supervisory level clinician by a peer or by a more senior trainee
2. Evaluation of written handoff materials by clinician or by a peer or by a more senior trainee
3. Didactic sessions on communication skills including in-person lectures, web-based training, review of curricular materials and/or knowledge assessment
4. Assessment of handoff quality in terms of ability to predict overnight events
5. Assessment of adverse events and relationship to sign-out quality through:
o Reporting hotline
o Chart review
Programs must develop and utilize a method of monitoring the transition of care process and update as necessary. Monitoring of handoffs by the program to ensure:
1. There is a standardized process in place that is routinely followed
2. There consistent opportunity for questions
3. The necessary materials are available to support the handoff (including, for instance, written sign-out materials, access to electronic clinical information)
4. A setting free of interruptions is consistently available, for handoff processes that include face-to-face communication
5. Patient confidentiality and privacy are ensured in accordance with HIPAA guidelines