This document discusses improving handoffs between physicians in the emergency department. It notes that communication errors during shift changes are a common cause of treatment delays and adverse events. The document then reviews factors that can lead to errors during handoffs, including distractions, lack of standard processes, fatigue and inexperience. It proposes using multidisciplinary handoffs, clear guidelines and identifying high-risk patients to help improve safety during physician shift changes in the emergency department.

1. Improving Handoffs in the
Emergency Department
Ann Emerg Med. 2010;55:171-180.

2. INTRODUCTION AND BACKGROUND
Patient handoffs at shift change are a ubiquitous and
potentially hazardous process in emergency care.
The purpose of this article is to provide the most up-
to-date evidence and collective thinking about the
process and safety of handoffs between physicians
in the ED.

3. To Err Is Human: Building a Safer Health System
 EDs are susceptible to “high error
rates with serious consequences.”
 When sentinel events occur,
communication errors are deemed
to be the root cause in about 70%
of cases.
 84% of treatment delays are later
judged to be due to mis-
communication. Of these, 62%
are continuum-of-care issues
associated with shift changes.

4. 台大醫檢師講的是「reactive」，接電話的
器捐移植小組協調師卻誤聽為「non-
reactive」

5. Handoff Definition
A transition occurs when 2 or more workers
exchange mission-specific information,
responsibility, and authority for an operation.

6. Shift changes at the NASA Administration’s
Johnson Space Center highlight the
importance of a “question and answer period”
to detect errors in assessments and plans.

7. Los Angeles–class nuclear submariners are
trained to use “precise, unambiguous,
impersonal and efficient” language to navigate
safely.

8. Handoffs can be a source of liability and error but
also an opportunity for rescue when the re-
evaluation of a case from a fresh perspective may
result in preventing or recovering from an adverse
event.

9. Four Phases of Handoffs
1. Pre-turnover time, in which the departing
physicians prepares for the upcoming handoff
2. Arrival, in which the appearance of the oncoming
EP heralds the beginning of a new shift
3. Meeting, in which there is an exchange of
information and understandings among the
physicians
4. Post-turnover time, in which the receiving
physician assumes care and the departing
physician focuses on unfinished tasks and clarifies
critical information.

10. Stage Tasks Examples of Transition Errors
Pre- Organization and updating Poor situational awareness of current state of the ED
turnover of information and hospital
Arrival Stopping patient care tasks Delaying handoff while intermittently continuing care or
and preparing to hand off abruptly stopping care when help arrives without
care reaching closure point
Meeting Specific face-to-face Departing physician could
exchange 1. Pass incomplete or incorrect information
2. Provide information in a disorganized or confusing
manner
3. Fail to provide a clear clinical impression (what is
wrong) and plan (what needs to be done)
Receiving physician could
1. Misunderstand passed information
2. Not listen (distractions/fatigue)
3. Prematurely close: jump to a conclusion because of
patient or provider characteristics (eg, when an
intern reports to a senior resident)
Failure to include important parties (medical student,
nurses)
Post- New provider must Incoming physician could
turnover integrate new information 1. Forget key tasks or information
and begin patient care of 2. Act on a plan without careful thought (not thinking
both patients handed off critically)
and newly arriving patients

11. Providers use handoffs to develop a shared
understanding among caregivers, which includes the
patient’s clinical picture, his or her recent course,
therapies administered, rationale for pending
diagnostic tests and therapies, and likely disposition.

12. •
•
Technological
Patient Patient •
Factors Factors •
•
•
Interview
Institutional &
Team Factors Physician Environmental
Factors
Handoff •
•
•
Caregiver
Task Factors •
Factors
Physician •
•
•
Conceptual model for barriers in handoffs

13. • Patient rosters (eg whiteboards) Technological
Patient
• Electronic health records Factors
Interview
• Shift schedules
• Physician compensation methods
• Peer relationships and power balances Team Factors Physician
• Failure to recognize importance of
handoff
• Ambiguous moment of transfer of care
• Signal-to-noise ratio
Handoff
• Salience versus completeness
• Varied clinical volume, presentations, and
complexity
Task Factors
• Geographic location
• No standard approach
Physician
• No “red flags”

14. • Alertness
• Education
Patient Patient • Pain
Factors • Language barrier
• Knowledge of ownillness
• Unclear diagnosis
Interview
• Location: loud, chaotic, and lacking in privacy
Institutional & • Competing demands for time and attention
Physician Environmental • Inpatient boarding
Factors • Long ED lengths of stay
Handoff • Fatigue, stress
• Inattention
• Poor memory
Caregiver • Inexperience
Physician Factors • Knowledge deficit
• Cognitive bias
• Personal agendas after shift change

15. Signal-to-Noise Ratio
Staff interruptions, ongoing patient concerns, EMS
radio calls, temporal pressures, and the routine
chaos of the work environment can all overwhelm
the few moments of directed attention required for
safe and effective handoffs.
Disorganized handoffs themselves can add to the
distractions because extraneous data may drown
out essential messages and details.

16. Conciseness Versus Completeness
An adequate handoff can be limited to a short
phrase with a working diagnosis and a disposition in
stable patient.

17. No Standard Approach
The content, location, style, and length of handoffs
can be inconsistent and unpredictable.
This lack of standardization can make it difficult for
both the departing and receiving physician to
communicate effectively.

18. Ambiguous Moment of Transition of Care
ED staff may be confused about which physician is
in charge of the patients who were handed off.

19. No Clear High-Risk Triggers for the
Dangerous Handoffs
“Red flags” may include an uncertain diagnosis, an
unstable patient, an unclear disposition, a
consultant-driven evaluation, a pending imaging
study, deviations from a typical diagnosis or
treatment plan, a patient with a psychiatric illness,
and a prolonged stay in the ED.

20. Cognitive Bias
In the transfer of care, the receiving physician
usually relies on the clinical acumen and recall of the
departing colleague.
When the receiving physician assumes the
interpretation of the initial physician, based on
erroneous information or a faulty clinical impression,
adverse outcomes may result.

21. Economic Construct of the ED Group
Productivity based systems tend to discourage
handoffs in patient care and may financially motivate
the initiating physician to continue patient care to
disposition.
In hourly pay system, the receiving physician may
inherit multiple patients and must assume
responsibility for making the appropriate disposition
of patients in whose treatment they were not initially
involved.
Blended systems may enhance the advantages of
each while minimizing the barriers to effective
handoffs.

22. Single Versus Multidisciplinary Handoff
Single-disciplinary team
The advantage of this model is that it is efficient and focused:
physicians hear what physicians need and nurses hear what
nurses need.
Multi-disciplinary team
Different team members (eg, nurses, physicians, midlevel
providers, pharmacists) contribute to and participate in the
handoff.
The advantage of this model is that it integrates viewpoints of
different providers, builds a team approach, and enables
participants to serve as a “check and balance” for one
another.

23. Handoff Location
Central location (eg, in the provider’s work area or
in front of a computer or a whiteboard).
This method provides easy access to written patient
information computers, charts, etc), is less time
consuming, and affords greater privacy.
The advantages of bedside handoffs include being
able to introduce the patient and the receiving
physician, the ability to integrate patient input into
the transfer and update the patient on his or her
status, and an opportunity for the receiving physician
to directly assess the patient.

24. Use of Mnemonics
SBAR
5-Ps
I PASS the BATON
HANDOFF
SIGN OUT

25. SBAR
Situation
Background
Assessment
Recommendation
- Anesthesiologists, mid-level practitioners, nurse
assistants, nurses, nursing students, OR staff, PACU
staff, perioperative staff, pharmacists, physical
therapists, physicians, transporters, radiologists

26. 5-P’s
Precaution: isolation, falls, etc
Patient: identify
Precautions: allergies, isolation, falls, specialty bed
Plan of care: fluids, intake, output, IV access
Problems: assessment, review of systems, pain
scale
Purpose: goals to be achieved
- Perioperative nurses

27. I PASS the BATON
 Introduction: introduce yourself and your role
 Patient: name, identifiers, age, sex, location
 Assessment: presenting chief complaint, vital signs, symptoms, diagnosis
 Situation: current status and circumstances; including codes status, level
of certainty, recent changes, and response to treatment
 Safety concerns: critical lab values and reports, socioeconomic factors,
allergies, alerts (eg, falls, isolation)
 Background: comorbidities, previous episodes, current medications,
family history
 Actions: which were taken or are required, providing brief rationale
 Timing: level of urgency, explicit timing, and prioritization of actions
 Ownership: who is responsible (eg, nurse, doctor, team), including patient
or family responsibilities
 Next: what happens next (eg, any anticipated changes in condition or
care, the plan, any contingency plans)
- General nurses, perioperative nurses, physicians

28. HANDOFF
Hospital location
Allergies/adverse reactions/medications
Name (age, gender)/number
DNAR/Diet/DVT prophylaxis
Ongoing medical/surgical problems
Facts about this hospitalization
Follow-up
- Physicians, residents

29. SIGNOUT
Sick or DNR? (highlight sick or unstable patients,
identify DNR/DNI patients)
Identifying data (name, age, gender, diagnosis)
General hospital course
New events of the day
Overall health status/clinical condition
Upcoming possibilities with plan, rationale
Tasks to complete overnight with plan, rationale
- Internal medicine residents, medical students

30. LEGAL ASPECTS
 Handoffs are high-risk events.
 Communication breakdowns have been documented to occur
in nearly 80% of medicolegal cases.
 Faulty handoffs are specifically implicated in up to 24% of
malpractice claims in the ED.
 Theoretically, patient care may benefit from the additional
evaluation and diagnostic input of a second care provider.
In reality, care transitions frequently result in the dilution of
accountability.
 From a risk management perspective, if a patient
experiences a preventable adverse event resulting from a
faulty handoff, both departing and receiving providers are
likely to share liability.

31. STRATEGIES TO IMPROVE HANDOFFS
1. Reduce the Number of Unnecessary Handoffs
2. Limit Interruptions and Distractions as much as is
Practicable
3. Provide a Succinct Overview
4. Communicate Outstanding Tasks, Anticipate Changes,
and have a Clear Plan
5. Make Information Readily Available for Direct Review
6. Encourage Questioning and Discussion of
Assessments
7. Account for All Patients
8. Signal a Clear Moment in Transition of Care

32. Reduce the Number of Unnecessary Handoffs
Allowing a buffer time between shift changes, either
by scheduling overlapping shifts or protecting the
departing physician from acquiring new patients at
the end of the shift, may reduce delays in disposition
or incidences of miscommunication.

33. Limit Interruptions and Distractions as much as is
Practicable
The integrity of the handoff process is compromised
in loud and chaotic EDs in which the departing
provider is anxious to leave and the attention of the
receiving provider is diverted.
Choosing a quiet and dedicated space will help
protect the sanctity of the handoff process.

34. Provide a Succinct Overview
A major goal of the handoff is to encapsulate and
provide a clear summary of the patient’s visit.
Begin the presentation of each patient with a chief
complaint, followed by an assessment, plan, and
disposition, if possible.

35. Communicate Outstanding Tasks, Anticipate
Changes, and have a Clear Plan
Patients whose diagnosis or disposition is unclear
represent a population that is particularly at risk for
an adverse event from a handoff.
Departing physicians should communicate all
outstanding studies, consultations, or other
information that is still pending.
- for example, “if the repeat cardiac markers are increasing,
notify the admitting physician and redirect the patient to the
ICU”.

36. Make Information Readily Available for Direct
Review
Laboratory and imaging studies should be available
for independent review by the receiving team.

37. Encourage Questioning and Discussion of
Assessments
The receiving physician should be encouraged to
clarify issues and, if possible, discuss the rationale
behind clinical impressions.

38. Account for All Patients
Ensure that a handoff is given on every patient for
whom the receiving physician will be responsible.
If a patient has temporarily left the department (eg,
to go to dialysis), the receiving physician should be
given the same handoff as if the patient were still
physically present in the ED.

39. Signal a Clear Moment in Transition of Care
The receiving provider should take full responsibility
for the patients who were handed off and resist the
temptation to avoid getting involved.

40. To be safe, care must be seamless
為了病患安全，照護必須無接縫
http://decode-medicine.blogspot.com/