The Art of HANDOFFS: A Mnemonic for Teaching the Safe Transfer of Critical Patient Information

JULY 11, 2007
Alice Brownstein, MD, and Anneliese Schleyer, MD, Harborview Medical Center, University of Washington, Seattle
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Alice Brownstein, MD

Associate Director, Emergency Services, Harborview Medical Center
Assistant Professor, Division of General Internal Medicine

Anneliese Schleyer, MD, MHA

Director, Hospitalist Service, Harborview Medical Center
Assistant Professor, Division of General Internal Medicine

University of Washington, Seattle


With the advent of mandatory work-hour restrictions and an increasing number of hospitalist programs, patient care is frequently being transferred among multiple physicians. Each handoff brings with it a risk for errors and near-misses, as well as challenges to high-quality care. Programs are being developed to aid in the handoff process, but potential pitfalls remain, such as providing too much information and omitting salient points. To our knowledge, no standardized dataset exists for ensuring complete and relevant handoffs. We therefore propose the mnemonic HANDOFFS to facilitate the transfer of this critical information. This article discusses the uses and benefits of this mnemonic and how to incorporate it into hospital patient care.

With the advent of mandatory work-hour restrictions for residents1 and the development of hospitalist programs,2 patients are often cared for by several physicians during a 24-hour period. In 2004, an estimated 34.9 million people were discharged from hospitals in the United States, with an average length of stay of 4.8 days.3 Assuming that the care of each patient was handed off twice a day, a minimum of 335 million patient handoffs occurred.

With each handoff, there is an incremental increased risk for errors, near-misses, and challenges to high-quality care. The covering physicians are less aware of the patient's history, thus slowing the evaluation of new developments. This often leads to unnecessary testing and diagnostic procedures.4 The primary physician is informed of events after they have occurred and does not have direct involvement in the decision-making.

Frequent handoffs may cause communication breakdowns, with a resulting delay in care. It is often difficult for consultants to communicate directly with the primary physician, since that physician is no longer in the hospital.5 The impact of multiple transfers of care on patient satisfaction is unknown, but it is reasonable to postulate that it makes it more difficult for patients to identify their primary doctor.6

To ensure continuous, seamless care throughout a patient's hospitalization, it is standard practice for one physician to hand off care to another physician by providing information about the patient. To minimize potential errors from multiple handoffs, a standard set of critical information must be developed and taught to house staff; providing unambiguous instructions for potential adverse events has been shown to decrease the potential for error.7

Mnemonics are excellent teaching tools and have been used in all fields of medicine.8-13 We have developed the mnemonic HANDOFFS to help establish a standardized dataset containing information relevant to patient handoffs and to aid in the teaching of this important skill.


Patient Vignette

To illustrate the use of this mnemonic, we have chosen the following typical scenario for a patient, Mr X, who was handed off to several physicians within the hospital in a 24-hour period.

Mr X is a 43-year-old man who was admitted to our hospital because of upper gastrointestinal (GI) bleeding. His history includes alcohol abuse and withdrawal seizures. He takes no medications and has no known drug allergies. He is hemodynamically stable and does not have abdominal pain. At the time that his care was transferred for the first time that day from the short-call team to the long-call team, the primary physician was notified that the patient's esophagogastroduodenoscopy (EGD) examination revealed a gastric ulcer. When the patient was handed off for the second time that day, from the long-call team to the night-float team, the relevant information was given, using the mnemonic HANDOFFS.

Hospital location
Patient located on:
3e hospital, room 13

Consider including any special room/bed/ward features here, such as telemetry or isolation.

Allergies/adverse reactions/medications
Mr X reported:
No known drug allergies
Medications
• Pantoprazole drip
• Lorazepam, per institutional alcohol withdrawal protocol
• Thiamine 100 mg/day for 3 days
• Multivitamin, with folate, 1 daily

Specify medication dosages if this information may be helpful to the covering physician. For example, doses of pain medications can be invaluable to the covering physician called in response to a complaint of ongoing pain. It is essential that the medication and allergy list be updated every day, with every admission.

Name (age, gender)/number
Mr X
43-year-old man
Medical record number XXXXXXX

Note if there are duplicate names of patients on the same ward.

DNAR?/Diet/DVT prophylaxis

DNAR (do not attempt resuscitation)?
Full code

A patient's code status should be addressed for every hospitalization, updated daily, and documented both in the chart and on the handoff sheet.

Diet
Clear liquid diet after procedure

Information about diet can be critically important; for example, if a patient should not be eating after midnight in preparation for a procedure, or if a patient cannot safely take anything, including pills, by mouth, it should be included.

DVT prophylaxis
Serial compression device and compression stockings

If the patient cannot receive pharmacologic deep-vein thrombosis (DVT) prophylaxis (eg, he has a documented history of heparin-induced thrombocytopenia or is actively bleeding), this should be documented in the handoff sheet.

Ongoing medical/surgical problems
Mr X's medical/surgical problems are:
• Upper GI bleed
• Alcohol abuse
• History of withdrawal seizures

This medical/surgical problem list needs to be noted at admission and updated every day. When considering a patient's medical history, problems that are active and may affect current care should be included. For example, the history of withdrawal seizures would help focus the differential diagnosis of seizures or tachycardia. In contrast, a history of degenerative arthritis of the hands would be unlikely to affect this patient's care, would slow down the handoff, and may obscure more important problems and thus does not need to be included.

Facts about this hospitalization
1. Hemodynamically stable: blood pressure, 110/70 mm Hg
2. Serial hematocrit posttransfusion of 2 units of blood; hematocrit stable at 30% at 2 time points
3. Two 16-gauge intravenous (IV) lines in place, access required
4. Status post-EGD performed this afternoon revealed gastric ulcer; status postsclerotherapy, no varices noted.

The following facts about a patient's hospitalization should be included in a handoff if applicable:

1. Important vital sign information. For example, if a patient is admitted for a chronic obstructive pulmonary disease exacerbation, baseline oxygen saturation values are helpful for decision-making.

2. Significant laboratory data. If you are asking the covering physicians to follow up on a laboratory test, they must know what the baseline value was to be able to make treatment decisions efficiently.

3. Access. Patients may lose IV access. Covering physicians will appreciate knowing that the patient does not need central access immediately. It is also helpful to document if the patient has a central line in place should associated complications occur, such as an IV line infection, DVT, or pneumothorax.

4. Procedures and results. When covering physicians know the results of procedures that have been performed, they can consider possible complications of the procedure when they are called to deal with patient issues. They can also use the procedure results in medical decision-making. For example, if they are called about shortness of breath in a patient who has had a negative pulmonary computed tomography angiogram and venous duplex evaluation of the legs that afternoon, the differential diagnosis will be narrowed.

5. List the consultants involved; be specific. This will enable the covering physicians to call the appropriate consultant. For example, for issues related to a patient's laminectomy, a neurosurgeon will be called, not a hospitalist.

6. Blood or blood product availability. If unstable patients have blood products in-house (in the event that they need to receive blood or may need a procedure or surgery), let the covering physicians know, so blood products will not be ordered or wasted.

Follow-up on?
Overnight, Mr X's patient-care needs include:
Please check hematocrit at 18:00 hours and every 6 hours thereafter. If the repeat hematocrit is less than 25%, transfuse 2 units of red blood cells and call the gastroenterology department.

Include specific information about what the covering physicians need to review and what to do with the results. Indicate what should be done with the information obtained, in the form of an "If...then..." statement.

Include relevant laboratory data trends if not noted above in the facts about this hospitalization. If you are asking someone to check a chemistry panel to assess the response to treatment of hyponatremia, note previous sodium levels. Indicate when test results should be available, and verify that the tests have been ordered before you leave.

If you anticipate that a patient may need a procedure based on new test results, discuss your handoff plans with the patient and obtain his or her consent in advance if necessary.

Scenarios
Mr X is at high risk for rebleeding. If hemodynamically unstable or dependent on transfusions to maintain a steady hematocrit level, consider transfer to the intensive care unit (ICU) and contact the gastroenterology or general surgery department. If he develops tachycardia, consider rebleeding versus alcohol withdrawal. If you are called about abdominal pain, assess the patient, since he is currently pain-free.

In general, these are the guidelines for documenting scenarios:
1. Anticipate worst-case scenarios.
2. Note if you are particularly concerned about a specific patient.
3. Indicate whether the patient may need to be assessed in person. For example, "Check serial abdominal exams for new-onset abdominal pain."
4. If you think the patient may require transfer to the ICU, notify the ICU team (if applicable) before handing off the patient, and document that the ICU team is aware of the possibility. Document whom you talked to, if applicable.
5. If the patient is likely to die (eg, is receiving comfort care), include contact information for the family or legal next-of-kin.

Vignette Follow Up

In the morning, you pick up your handoff sheet from the covering physician (the third physician for Mr X in the past 24 hours), and your colleague gives you feedback.
Overnight, Mr X developed abdominal pain. Your colleague went to examine the patient and found guarding in the epigastric region.
Because you had mentioned on your handoff sheet that his abdomen was nontender and soft on initial examination, the covering physician knew that a significant change had occurred.
The repeat hematocrit was 31%, up from 30%, and the patient was not orthostatic on examination, reducing the possibility of rebleeding as a cause.
From your handoff sheet, the covering physician knew that Mr X had an EGD examination earlier that day, and he became concerned about a potential complication from the procedure.
An acute abdominal x-ray series was performed, revealing free air. The general surgery department was consulted, and Mr X was taken to the operating room emergently.
Your colleague reported that your handoff sheet provided the salient information that facilitated a rapid treatment plan.

Conclusion

It is the experience of the authors that handoffs can be difficult. There are many potential pitfalls, including providing too much information or omitting salient points on the handoff sheet. It is also challenging to learn how to prioritize multiple calls when caring for patients you did not admit. Giving and receiving handoffs takes practice, and to our knowledge there has been little formal investigation about how to best hone this skill. It is our hope that the mnemonic HANDOFFS will help standardize the patient information shared between physicians. It is our belief that learning the fine art of handoffs early in a physician's career, and continuing to refine this skill, will promote a high quality of care and encourage patient advocacy.

PRACTICE POINTS


  • The potential for errors increases significantly when critical patient information is not communicated among the many covering physicians.
  • Physicians need to learn the art of handoffs early in their career and continue to refine this skill to ensure high-quality patient care.
  • Use the HANDOFFS mnemonic as a standardized guide to facilitate the safe transfer of patient information.
  • Include salient points on the handoff sheet, but omit information that is not pertinent to the decision-making process for the specific patient.

SELF-ASSESSMENT TEST

1. All these statements about patient handoffs are true, except:

  1. Handoffs have increased since mandatory workhour restrictions were put in place
  2. The addition of hospitalists to the hospital team have reduced the number of handoffs
  3. Handoff sheets should include information about all consultants involved in the patient's care
  4. Medication and allergy information on handoff sheets should be updated daily

2. Which information in the history should not be included in the handoff sheet of a patient with a history of alcohol abuse who is admitted to the hospital for upper GI bleeding?

  1. Withdrawal seizures
  2. Degenerative arthritis of the hands
  3. Heparin-induced thrombocytopenia
  4. Arrhythmias

3. The "A" in the HANDOFFS mnemonic refers to all the following information, except:

  1. Accident/injury
  2. Allergies
  3. Adverse drug reactions
  4. Medication dosages

4. Which of the following options is not part of the "D" in the HANDOFFS mnemonic?

  1. Do not attempt resuscitation
  2. Nothing by mouth
  3. DVT prophylaxis contraindicated
  4. Drug/alcohol status

5. Which of the following should not generally be included on the handoff sheet of a patient admitted for dyspnea?

  1. Results of pulmonary computed tomography angiography
  2. Results of venous duplex examination
  3. Oxygen saturation level at admission
  4. Total cholesterol level at admission

(Answers at end of references list)

References

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  2. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
  3. Kozak LJ, DeFrances CJ, Hall MJ. National hospital discharge survey: 2004 annual summary with detailed diagnosis and procedure data. Vital Health Stat 13. 2006;162:1-209.
  4. Petersen LA, Brennan TA, O'Neil AC, et al. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121:866-872.
  5. Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med. 2005;142:352-358.
  6. Fletcher KE, Saint S, Mangrulkar RS. Balancing continuity of care with residents' limited work hours: defining the implications. Acad Med. 2005;80:39-43.
  7. Spear SJ, Schmidhofer M. Ambiguity and workarounds as contributors to medical error. Ann Intern Med. 2005;142:627-630.
  8. Snow L, Rapp MP, Kunik M. Pain management in persons with dementia. BODIES mnemonic helps caregivers relay pain-related signs, symptoms to physicians and nursing staff. Geriatrics. 2005;60:22-25.
  9. Hobgood C, Harward D, Newton K, et al. The educational intervention "GRIEV_ING" improves the death notification skills of residents. Acad Emerg Med. 2005;12:296-301.
  10. Paranzino GK, Butterfield P, Nastoff T, et al. I PREPARE: development and clinical utility of an environmental exposure history mnemonic. AAOHN J. 2005;53:37-42.
  11. Bush B, Shaw S, Cleary P, et al. Screening for alcohol abuse using the CAGE questionnaire. Am J Med. 1987;82:231-235.
  12. Goske MJ, Reid JR, Yaldoo-Poltorak D, et al. RADPED: an approach to teaching communication skills to radiology residents. Pediatr Radiol. 2005;35:381-386.
  13. 13. Leonard R. A mnemonic for SLE diagnostic criteria. Ann Rheum Dis. 2001;60:638.

Answers: 1. B; 2. B; 3. A; 4. D; 5. D.



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