A Survey of Patient Care Handoff and Sign-Out Practices Among Podiatric Surgical Residency Programs

Abstract

Background: A patient ‘‘handoff,’’ or the ‘‘sign-out’’ process, is an episode during which the responsibility of a patient transitions from one health-care provider to another. These are important events that affect patient safety, particularly because a significant proportion of adverse events have been associated with a relative lack of physician communication. The objective of this investigation was to survey podiatric surgical residency programs with respect to patient care handoff and sign-out practices. Methods: A survey was initially developed and subsequently administered to the chief residents of 40 Council on Podiatric Medical Education–approved podiatric surgical residency programs attempting to elucidate patient care handoff protocols and procedures and on-call practices. Results: Although it was most common for patient care handoffs to occur in person (60.0%), programs also reported that handoffs regularly occurred by telephone (52.5%) and with no direct personal communication whatsoever other than the electronic passing of information (50.0%). In fact, 27.5% of programs reported that their most common means of patient care handoff was without direct resident communication and was instead purely electronic. We observed that few residents reported receiving formal education or assessment/feedback (17.5%) regarding their handoff proficiency, and only 5.0% of programs reported that attending physicians regularly took part in the handoff/ sign-out process. Although most programs felt that their sign-out practices were safe and effective, 67.5% also believed that their process could be improved. Conclusions: These results provide unique information on a potentially underappreciated aspect of podiatric medical education and might point to some common deficiencies regarding the development of interprofessional communication within our profession during residency training.

A patient ‘‘handoff,’’ or the ‘‘sign-out’’ process, is an episode during which the responsibility of a patient transitions from one health-care provider to another. The quality and importance of these events has recently come into focus as one of the critical issues affecting patient safety in the contemporary, fastpaced, and evolving health-care environment. An individual patient might be expected to be handed off 15 times during a 5-day hospital stay, and large teaching hospitals experience approximately 4,000 handoffs daily, or more than 1.5 million a year.[1,2,3,4] A study from the University of California–San Francisco found that interns participated in approximately 300 handoffs during the course of a monthlong rotation and that this represented a 40% increase compared with interns before the implementation of duty hour restrictions.[1] In addition, patients undergoing surgery (and surgeons involved with the surgery) might be likely to experience even more handoffs because of the multiple transitions that occur in the preoperative, intraoperative, and postoperative phases.[5] Both resident duty hour restrictions and the overall increase in patient volume expected of individual physicians means that handoffs are occurring at a greater frequency, over a shorter period, and with more information being conveyed between providers.[6,7,8,9] It, therefore, becomes more likely that critical portions of a patient’s care have the potential to become lost in translation.

In fact, most hospital staff recognize that patient information is lost during shift handoffs.[8,10] One specific study demonstrated a progressive loss of information with each consecutive handoff, most significantly as 33% of pertinent information lost between the first and third handoffs.[11] It is even likely that the communication process varies greatly depending on the parties involved—facility to facility, doctor to doctor, nurse to nurse, or any combination thereof. Each party may value certain information and may choose to convey it accordingly. This can lead to a mismatch in an understanding of a patient’s condition and affect the care received on multiple delivery levels.[8,12,13,14]

These established lapses in communication are not simply a potential problem but have been associated with mismanaged patient care. The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) has identified communication breakdown as a leading cause of adverse outcomes in medicine.[15] Up to 80% of sentinel events have been attributed to issues involving communication, continuity of care, and care planning.[16] Communication problems were found to be a contributing factor in 26% of malpractice cases, and up to 43% of those cases involved handoff processes.[17] Communication errors have even been reported to be associated with twice as many patient deaths as clinical errors.[18]

Because of this potential for contributing to adverse events, the Joint Commission added to its National Patient Safety Goals a recommendation for hospitals to implement a standardized approach to handoff communications.[15] In response, the Accreditation Council of Graduate Medical Education (ACGME) amended their core competencies to include interpersonal and communication skills detailing that residents should ‘‘demonstrate skills that result in effective information exchange and teaming with patients, their families and professional associates (eg, fostering a therapeutic relationship that is ethically sound, uses effective listening skills with non-verbal and verbal communication; working as both a team member and at times as a leader).’’[19,20] The ACGME-accredited institutions undergo assessment of this, in part, with site visits specifically examining care transitions through the Clinical Learning Environment Review program.[21] Our site, Temple University Hospital (Philadelphia, Pennsylvania), additionally requires that all residents complete extracurricular online training through the American Medical Association Introduction to the Practice of Medicine program, including modules on care transitions and patient safety.[22]

Interestingly, podiatric surgical residency programs do not fall under the direct purview of the ACGME but rather the Council on Podiatric Medical Education (CPME), which has no specific requirement with respect to patient handoff skills other than the CPME 320 Program Standard 6.1.D competency to ‘‘communicate effectively and function in a multi-disciplinary setting...with patients, colleagues, payers and the public.’’[23]

The objective of the present investigation was to conduct a survey among podiatric surgical residency programs with respect to patient care handoff and sign-out practices.

Materials and Methods

A survey was initially developed attempting to elucidate on-call practices of podiatric surgical residency programs and patient care handoff protocols and procedures. The chief residents of 50 CPME-approved podiatric surgical residency programs were initially contacted by e-mail explaining the goals of the investigation, detailing their expected role in the project, and asking if they would be willing to participate. These residents were informed that participation was voluntary and that individual program responses would be kept anonymous. If they agreed, one electronic copy of the survey was subsequently e-mailed to each participating program and returned to us when complete. Some questions on the survey were single answer, and other questions allowed for multiple responses. A free-text portion was also available for residents to supplement or clarify any answers and to provide comments on individual or general topics. Basic frequency counts of responses were calculated.

Results

Forty of the 50 contacted podiatric surgical residency programs agreed to participate and returned surveys, for a response rate of 80.0%. Complete survey questions and results are provided in

Table 1. Podiatric Surgical Residency Handoff Survey Questions and Results.

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The first series of questions dealt with the specific on-call practices of the residency programs. Residents were asked to describe whether a single resident or a multiple-resident team was primarily responsible for daily in-patient rounding and new consultation evaluations at a single health-care institution or multiple health-care institutions and at a single emergency department or multiple emergency departments. This question was asked in multiple forms to specify practices during weekdays, at night, and on weekends. Although multiple responses were permitted for this series of questions to allow for a range of common practices, we observed that most responded only with a single answer.

During weekdays, it was most common for a single resident to be primarily responsible for a single health-care institution and a single emergency department (47.5% and 37.5%, respectively). Other programs primarily had a single resident cover multiple health-care institutions and multiple emergency departments (17.5% and 25.0%, respectively), had multiple residents cover a single healthcare institution and a single emergency department (17.5% and 17.5%, respectively), or had multiple residents covering multiple health-care institutions and multiple emergency departments (22.5% and 22.5%, respectively).

At night, it was most common for a single resident to cover either a single health-care institution or multiple health-care institutions (52.5% and 45.0%, respectively) and for a single resident to cover either a single emergency department or multiple emergency departments (47.5% and 50.0%, respectively). On weekends it was also most common for a single resident to cover either a single health-care institution or multiple health-care institutions (45.0% and 42.5%, respectively) and for a single resident to cover either a single emergency department or multiple emergency departments (42.5% and 45.0%, respectively). We observed a trend for it to be more common for podiatric surgical residency programs to expect a single resident to cover multiple health-care institutions and multiple emergency departments at night and on weekends compared with during weekdays. Most residency programs (90.0%) had residents take call on nights and weekends from home, with 7.5% of residency programs having a specific in-house ‘‘night float’’ resident rotation.

The next group of questions attempted to identify specific patient care handoff and sign-out protocols and procedures. We asked in which situations did their services regularly encounter patient care handoffs, and allowed for multiple responses. Seventy percent identified that patient care handoffs regularly occurred between an on-call resident during the week to an on-call resident on the weekend and from an on-call resident on the weekend to an on-call resident during the week. Nearly half (47.5%) identified that these regularly occurred between an on-call resident during the day to an on-call resident at night, and 45.0% identified that these occurred between an on-call resident at night to an on-call resident during the day. Thirty percent and 17.5% reported that handoffs regularly occurred between multiple residents during a given weekday and over the course of a weekend, respectively.

It was most common for a handoff to occur from one single resident to another single resident (90.0%), but programs reported that handoffs also regularly occurred from one single resident to a group of residents (47.5%), from a group of residents to one single resident (17.5%), and from a group of residents to another group of residents (15.0%).

It was most common for patient care handoffs to occur in person (60.0%), but programs also reported that handoffs regularly occurred over the telephone (52.5%) and with no direct personal communication whatsoever other than an electronic passing of information (50.0%). In fact, 27.5% of programs reported that their most common means of patient care handoff was without direct resident communication and instead was purely electronic.

The following group of questions were singleanswer only. Only 2.5% of programs reported that patient care handoffs regularly took place at the patient’s bedside, and 50.0% of programs reported that a computer was regularly available during handoffs to review laboratory test results and imaging studies. It was most common for programs to spend 1 to 2 min discussing each patient during sign-out (37.5%), with 32.5% of programs reporting that they spent 3 to 5 min, 12.5% of programs reporting that they spent 5 to 10 min, and no program reporting that they regularly spent greater than 10 min discussing each patient.

Less than half (42.5%) of programs reported that they at least attempt to use a specific time for handoffs and sign-out, but 67.5% reported that this most often was performed at varying times of convenience. Less than half (42.5%) reported receiving formal patient care handoff education from their hospital or residency program, and 17.5% reported receiving any assessment and/or feedback on their handoff proficiency. Five percent (5.0%) of programs reported that attending physicians regularly took part in the sign-out process. Twenty-five percent of programs reported that their hospital or residency program has implemented a standard handoff protocol, but 30.0% of these reported not regularly using it.

Eight-five percent of programs reported using some form of electronic sign-out. Of these, 79.4% of electronic sign-outs contained protected patient information, 76.5% were available only on a secure hospital network, and 67.6% were e-mailed to residents or attending physicians. Of the electronic sign-outs that were e-mailed, 78.3% of programs reported doing so only via secure e-mail.

Overall, 67.5% of programs believed that their handoff and sign-out practices could be improved, although 87.5% reported that their practices were safe and 90.0% reported that they were effective.

Discussion

The results of this investigation provide unique information on a potentially underappreciated aspect of podiatric medical education. We believe that these results might point to some common deficiencies with respect to the development of interprofessional communication within our profession during residency training and the patient handoff process. In our opinion, the most notable finding was that few residents reported receiving formal education (42.5%) or assessment/feedback (17.5%) with respect to handoff proficiency, as well as the finding that only 5.0% of programs reported having attending physicians regularly taking part in the handoff/sign-out process. We were also surprised at the number of programs that performed patient handoffs without any direct communication whatsoever between residents. Half of the residency programs reported commonly performing patient handoffs only via the electronic passing of information, and 27.5% of programs reported that this was their most common means of patient information transference between residents. Although most programs thought that their sign-out practices were safe and effective, more than twothirds also believed that their process could be improved.

We also found interesting the considerable variation between programs with respect to how many residents were responsible for in-patient rounding/consultations and the number of hospitals/emergency departments covered by residents. Many podiatric surgical residency programs had a single resident be responsible for covering multiple hospitals and multiple emergency departments at night (45.0% and 50.0%, respectively) and on weekends (42.5% and 45.0%, respectively), for example.

Information handoffs take place within many professional realms, not just in health care, and great importance has traditionally been placed on active learning through both observation and direct participation to improve efficiency and reduce errors. Examples of this include the manufacturing industry, business administration, and Formula 1 pit crews.[24,25] However, this emphasis on active learning might be relatively lacking in the health-care setting.[20] Khandelwal et al[26] reported that less than two-thirds of residents recounted learning handoff strategies via direct observation of other residents and that 83% of the time attendings were not present during this process. One might assume that medical school represents the first opportunity for young physicians to begin to learn how to manage patients and communicate to other health-care personnel, but only 8% to 14% of medical schools have been found to incorporate this into their curriculum.[11,20] Most of what medical students acquire is by means of informal observation of those physicians they happen to encounter during their rotations. This leads to great variability in how they might formulate their own preferred method for communicating about patients.[11] We believe that these findings emphasize that podiatric medicine residents might be better served receiving formal education and specific assessment/feedback with respect to their patient handoffs at a higher rate than we observed in this survey (42.5% and 17.5%, respectively, with only 5.0% reporting regular attending participation in the sign-out process).

Given the many possible adverse events that may result from ineffective communication or a lack of communication, many are beginning to investigate different methods to improve the efficiency and standardization of the handoff process. Pringle et al[6] noted that the benefits of participation in a ‘‘morning report’’–style handoff include safe and effective information exchange, quality improvement, multidisciplinary discussion, and resident education. Greenstein and colleagues[2] stress active rather than passive behaviors during this process, including participation in strategies such as information read back, active note-taking, responding with affirmatory statements, nodding in agreement, and making eye contact during the process. This emphasizes that the behavior of those receiving the information is equally important as the behavior of those giving the information. The process should not just be a passive transfer of information but instead a ‘‘co-construction’’ of the receiving physician’s understanding of the patient.[2] Other potential means of improvement, according to Streitenberger and colleagues,[27] include standardization, avoiding interruption, limiting intermediaries, and implementation of a read back/hear back process. The medium and setting of communication are also important. In-person handoffs are more conducive to an engaged process in which more information is relayed and greater discussion ensues.[18] The environment should be quiet and private to fully discuss each patient while decreasing conflicts that might arise because of distractions, stress, interpersonal conflicts, and language barriers.[18,28,29] We believe that these findings emphasize that podiatric medicine residents might be better served by participating in handoff and sign-out practices that involve active direct communication between providers instead of the electronic transfer of information, which was frequently observed in the present survey.

Recent technological advances have further provided physicians with potentially more efficient ways to standardize the handoff process. Secure, Health Insurance Portability and Accountability Act (HIPAA)–compliant electronic sign-out documents that can be created and autopopulated from electronic medical records have been found to be more accurate and more efficient than traditional methods.[2,29] In fact, a study by Van Eaton and colleagues[30] found that these methods created a 40% increase in the time available for residents to pre-round and that the number of patients missed on rounds decreased by 50%. There are also a variety of acronymor mnemonic-based standardized handoff protocols advocated for reproducibility. A review of the literature on handoff mnemonics from 1987 through 2008 identified 46 articles with 24 separate acronyms, for example.[17] The most common include the SBAR (situation, background, assessment, recommendation), ANTICipate (administrative information, new clinical information, specific tasks to be performed, assessment of severity of illness, contingency plans or anticipated problems), and the I-PASS (illness severity, patient summary, action list, situation awareness and contingency plan, synthesis by receiver).[17,31,32] The I-PASS specifically was found to reduce medical errors by 23% and preventable adverse events by 30% in one study after implementation in pediatric residency programs.[31] In the present survey, 85.0% of programs reported using some form of electronic sign-out that often contained protected patient information and was commonly e-mailed to residents and attendings.

Conclusions

On a personal note, we report that these results have encouraged the Temple University Hospital Podiatric Surgical Residency Program to reevaluate patient care handoff practices, and we encourage other podiatric surgical residency programs to do the same. We have made changes with respect to attending physician participation in the sign-out process, formal education of handoff strategies during the orientation process, and increased assessment/feedback of handoff proficiency, and we have implemented a new, HIPAA-secure electronic system to use during this process. We also respectfully wonder whether the CPME might want to evaluate their recommendations to podiatric medical schools and residency training programs with respect to the education and assessment of communication skills, particularly as they apply to handoff practices and proficiency.