Handoffs in Emergency Departments: A Mixed-Methods Study on Physician Perspectives, Preferences, and Strategies

Abstract

Background/Objectives: Among the factors contributing to medical errors and misdiagnosis, patient handoffs play a significant role. The negative impact of handoffs includes miscommunications, omissions, and information loss. Patient handoffs are inherent to emergency department (ED) patient care and are recognized as high-risk events. The aim of this study was to use a mixed-methods approach, incorporating a retrospective chart review and qualitative analysis, to understand emergency physicians’ perceptions of handoffs, including their impact on patient safety, patient flow, and patient satisfaction, as well as the strategies employed to manage handoffs and their perceived efficacy. Methods: A seven-question online survey was distributed to 120 attending ED physicians employed across a large academic health system comprising six hospitals. Additionally, a 3-year retrospective chart review provided insights into avoidable handoffs in the ED. Results: The survey responses showed that 69% of physicians believed that handoffs reduced patient safety, 55% felt that they reduced patient satisfaction, and 66% perceived them as contributing to longer patient stays. Additionally, 86% of physicians preferred to hand off no more than two patients, while 79% preferred to receive no more than two. Thematic content analysis identified key factors influencing physician preferences, including ownership, patient safety, patient flow, cooperation and colleagueship, and the challenges of continuing workups. To minimize handoffs, ED physicians primarily reported strategies such as staying late after shifts, restricting patient signups, and planning patient disposition toward the end of their shifts. Lastly, retrospective data analysis suggested that implementing one-hour overlapping shifts and restricting patient signups could reduce ED handoffs by 30%. Conclusions: ED physicians perceive handoffs as affecting patient safety, patient satisfaction, and patient flow negatively and prefer fewer handoffs. Overlapping shifts and selective patient signup strategies may reduce handoffs.

1. Introduction

According to the Centers for Disease Control and Prevention (CDC), approximately 151 million visits were made to emergency departments (EDs) in the US in 2019 [1]. Although patient visits to EDs dropped by as much as 40% during the early stage (March–April 2020) of the Coronavirus Disease 2019 (COVID-19) pandemic, the numbers have increased over the past months and are close to pre-pandemic levels [2,3]. EDs act as a healthcare safety net and are one of the primary access points to patients seeking medical care, accounting for about 70% of inpatient hospital admissions in the US [4]. The overwhelming volume of patient arrivals and the diverse nature of patients seeking medical care make an ED one of the most complex healthcare environments, which predisposes it to overcrowding and medical errors [5].

Multiple studies have reported that EDs are one of the hospital departments with the highest error rates and misdiagnosis rates [6,7]. Primary sources of errors in ED include interruptions, miscommunications, and the loss of information [8,9]. Handoffs, the transfer of a patient’s care and responsibility from one physician to another, are often fraught with errors (e.g., miscommunications, omissions, errors, and information loss) [10,11]. The negative impact of handoffs on patient safety is well documented. For instance, a study of 1163 patient handoffs in the ED found that hypotension in 117 patients and hypoxia in 156 patients went unreported in 66 (42%) and 116 (74%) cases, respectively, while 166 handoffs (14%) contained errors or omissions in vital sign communication [10]. In another study that analyzed 110 ED handoff sessions encompassing 992 patients, errors and omissions were observed in 130 (13.1%) and 447 (45.1%) handoffs [11]. Moreover, a study that investigated insurance claims involving missed ED diagnoses that harmed patients observed that 24% of the cases involved poor handoffs where critical information was missed [12]. While most studies investigating handoffs in the ED have reported a negative impact on patient safety, we identified one study that included 1680 patients in the ED where a systematic physician cross-check (where two physicians cross-check a patient) had lower adverse events than the standard care group [13]. However, this is not the same as a handoff, as this was a targeted intervention that could require more physician hours and potentially increase the patient’s length of stay.

The literature broadly indicates that handoffs in the ED negatively impact patient safety. However, given the 24/7 nature of ED operations, handoffs are unavoidable, as physicians must transfer the care of their patients at the end of their shifts to incoming physicians. Most prior studies have focused on improving the quality of handoffs rather than minimizing the number of handoffs and have investigated the efficacy of handoff standardization, templates, checklists, bedside handoffs, mnemonics, providing dedicated space, and computerized sign-out systems [14,15,16,17,18,19]. Although these effectively improve the quality of handoffs and thereby improve patient safety, strategies aiming to reduce the number of handoffs remain limited. One strategy to minimize handoffs is to use a dedicated fast-track area for low-severity patients where physicians are assigned to expedite care, improving throughput and reducing the burden on other physicians [20]. Another strategy is overlapping waterfall shifts, where physician shifts are staggered/overlapped, allowing outgoing physicians to focus on discharges/admissions during the final hour of the shift while incoming physicians handle new patients [21,22,23].

While prior studies indicate the impact of handoffs on patient safety, none has investigated how it impacts the patient’s length of stay, patient satisfaction, physician perceptions of handoffs, and strategies to minimize handoffs. The focus of this study was to utilize a mixed-methods research approach, including a retrospective chart review supported by a qualitative analysis of the narrative stories from attending ED physicians from a large academic health system comprising six hospitals about their perspectives of handoffs’ impacts on patient safety, patient flow, patient satisfaction, and strategies to manage handoffs.

2. Methods

This study was conducted at a large academic health system comprising six hospitals that staffed over 120 ED physicians. Prisma Health is the largest healthcare system in South Carolina and serves as a tertiary referral center for the entire Upstate region. The flagship academic Department of Emergency Medicine at Prisma Health Greenville Memorial Hospital is an Urban, Adult Level 1, and Pediatric Level 2 Trauma Center, Stroke and ST-Elevation Myocardial Infarction (STEMI) Comprehensive Center, caring for over 106,000 patients annually. This study was considered IRB-exempt by the Institutional Review Board of the institution.

An online 7-question survey was distributed to 120 attending EM physicians via the email faculty listserv using the Qualtrics XM survey tool [24]. Informed consent was obtained prior to starting the voluntary and anonymous survey. The survey aimed to capture physicians’ perceptions of handoffs’ impacts on patient safety, patient flow, and patient satisfaction. It also explored their preferences regarding the number of handoffs, willingness to extend shifts, and strategies for managing handoff processes. As defined in the earlier section, handoffs refer to the transfer of patient care responsibilities between providers during shift changes. Handoffs are inherent to ED operations, requiring physicians to transfer the care of their patients at the end of their shifts to incoming physicians. Our partner ED also follows this approach to maintain continuity of care and patient safety during shift changes. This study focused on specific factors based on our literature review and expert opinions. Our survey focused on three key pillars of ED patient care and operations: patient safety, patient flow, and patient satisfaction. Research has consistently shown that communication breakdowns during handoffs are a major contributor to preventable adverse events. Effective handoffs are also essential for maintaining smooth patient flow, minimizing bottlenecks, and avoiding delays that can increase a patient’s length of stay. Further, ensuring a streamlined continuity of care improves patient care quality and enhances the overall patient experience. Next, we asked how many patients the physicians would prefer to hand off at the end of their shift and receive at the beginning, helping us gauge their attitudes toward handoffs and their underlying reasoning. Additionally, we investigated whether physicians make a conscious effort to minimize handoffs at the end of their shifts and for those who do, we requested insights into specific strategies they use. Finally, we assessed providers’ willingness to extend their shifts (with compensation) as a potential approach to reducing handoff frequency. This question is critical for balancing the benefits of fewer handoffs with the risks of provider fatigue, which could compromise patient safety. The questions were designed as multiple-choice, multiple-answer, and open-ended questions. The survey questions were developed by a senior attending physician along with a professor from the Dept. of Industrial Engineering and were vetted by other research team members and human factors professors. Additionally, the survey was reviewed with EM leadership and research team members to ensure clarity and relevance. Although the survey was not formally validated as a standardized instrument, the questions were carefully reviewed to ensure that they effectively addressed the study’s objectives. The demographic information of participants was also collected. The survey used in this research study is available as Supplementary Material titled Survey.

This study utilized a mixed-methods research approach, combining a survey and a retrospective chart analysis. Participants completed the survey in the months between June and December 2021. The authors were blinded to any information that could individually identify any responder. Descriptive statistics were used to analyze multiple-choice and multiple-answer responses. Additionally, a thematic content analysis was performed on the narrative responses received to the open-ended questions. Two researchers read the statements to become familiar with the data, and each separately classified overarching thematic codes representing the narrative statements. Following this, the final codes were generated by both authors working together, and responses were compared and grouped into specific themes. This was shared with the research team, and any inconsistencies were discussed and resolved. However, in this study, there were no disagreements during the independent coding process. The various themes generated for open-ended responses were considered major themes if at least 10% of physicians reported them as a reason for their preference. To explore relationships between categorical survey responses, we used cross-tabulation and Chi-squared tests. Cross-tabulation was selected to systematically examine how different physician perspectives on handoffs were distributed across relevant categorical variables, such as patient safety perceptions, patient flow, and preferred handoff strategies. The Chi-squared test was used to determine whether these observed relationships were statistically significant rather than occurring by chance. This approach allows for an objective evaluation of associations between physician preferences and the factors influencing handoff decisions.

The retrospective chart review used 3 years of data (January 2019–December 2021), which included all patient arrivals for the respective years along with patient characteristics, including their Emergency Severity Index (ESI) level, chief complaint, arrival time, admission time, disposition time, departure time, unique physician identifier, longest physician, and length of stay. Other standard reports were merged using a unique patient identifier to gain additional details, including imaging and consult orders. Descriptive statistics and statistical tests were performed to identify if there were significant differences between the patients who required handoffs vs. those who did not require handoffs. For all statistical tests, the significance was determined at an α = 0.05, and 95% CIs were generated.

3. Results

3.1. Subjective Data

3.1.1. Demographics and Clinical Experience

A total of 86 responses were collected, with a 72% response rate from 120 attending EM physicians. Among these, responses from 3 physicians had to be dropped as they were incomplete, leaving 83 responses (69%) for final analysis. The self-declared demographics of respondents were 43% (n = 36) women and 57% (n = 47) men. Regarding years of emergency medicine experience, 59% of respondents had less than or equal to 10 years of practice, 18% had 11 to 20 years of practice, and the remaining 23% were in practice for more than 20 years.

3.1.2. Physician Perceptions of Handoffs

In total, 69% of physicians reported handoffs to have a negative impact on patient safety, whereas 25% reported handoffs to positively impact patient safety, and the remaining 6% reported handoffs to have no impact on patient safety. When considering patient satisfaction, 55% of physicians reported handoffs to have a negative impact. In contrast, 13% of physicians reported handoffs to have a positive impact, and the remaining 31% reported handoffs to have no impact on patient satisfaction. Finally, when analyzing the patient length of stay, 66% of physicians reported handoffs to lead to a higher patient length of stay, 8% reported handoffs to reduce the patient length of stay, and 25% reported handoffs to have no impact on the length of stay (see Figure 1).

3.1.3. Physician Preference on Handing off Patients

Next, we analyzed the physicians’ responses regarding their preference for the number of patients to hand off or receive during the shift changes between an outgoing and an incoming physician. Figure 2 presents the survey responses on preferences for handing off or receiving patients.

When considering the number of patients to hand off, 44% of physicians reported that they prefer to hand off 0 patients, 42% of physicians reported they would prefer to hand off 1–2 patients, and 11% reported they would prefer to hand off as many as 3–4 patients to the oncoming physician. Additionally, the thematic content analysis of responses relating to the physicians’ reasoning for their preference revealed five major themes (see

Table 1. Themes based on physicians’ reasoning for their preference on patients they hand off.

Themes	Definitions	Physicians Supporting the Theme (%)
Patient safety	Any incident that leads to a negative impact on patient care, including errors and adverse events.	47%
Cooperation and colleagueship	Being respectful of a colleague and mindful of their preferences and difficulties.	26%
Ownership	Physician preference to provide care for patients from signup until disposition.	19%
Beyond physician control (prefer fewer handoffs)	Physicians prefer to have no/fewer handoffs. However, they recognize that a physician cannot dictate the number of handoffs for various reasons, including ED being a complex system that depends on various ancillary units, patient arrivals, and system state.	17%
Patient flow	Any incident that leads to an increased patient length of stay or slows down the ED.	15%

).

Among these, patient safety emerged as a major theme, where 47% of physicians reported handing off no/fewer patients as it has a negative impact on patient safety. Specific comments from physicians included “bad outcomes can occur with changing care teams” and “important information often gets left out”.

Cooperation and colleagueship emerged as the second most popular theme, with 26% selecting this as one of the main reasons to hand off no/fewer patients. Reducing the oncoming physician burden appeared to be a major subtheme where physicians reported, “Fewer patients to hand off means less work for the oncoming physician” and “I do not like to burden others with my unfinished business”.

The third major theme was ownership, where 19% of physicians reported providing care for patients from signup until disposition as a reason for not handing off their patients. Additional insight included physicians’ comments such as “Better to own your patient(s) than turf decision making and disposition to a colleague (when/if possible)”.

The fourth major theme was beyond physician control (prefer fewer handoffs), and 17% of physicians selected this option. From the physician responses, it was evident that they prefer fewer handoffs, but the dependencies of ED on other departments, inpatient beds, and the state of the ED made it unimportant, with comments such as “everyone’s preference would be fewer handoffs, but that isn’t practical as it all depends on the state of the ED at the time!” and “If possible, patients should never be handed off. However, our systems processes cannot occur in a timely fashion (i.e., lab, XR, CT resulting timely)”.

The last major theme was patient flow, where 15% of physicians preferred not to hand off their patients as they believed handoffs to have a negative impact on patient flow in the ED. In alignment with physician perceptions of handoffs (Q1) on patient flow, physicians believed that handoffs increased the patient length of stay and commented that “handoff patients will likely get less attention, less efficiently dispositioned, leading to higher LOS”. Additionally, physicians reported that avoiding handoffs would lead to “smoother transition and lesser wait times”.

Although not a major theme (<10% of physicians supporting the theme), a few physicians reported compensation, negative perception by colleagues, complexity of ED, and dependencies on other departments as factors influencing their preference to avoid handoffs. A few of the physician responses included “Handoffs decrease my Relative Value Units (RVUs)” and “Many physicians don’t like taking over incomplete workups”.

3.1.4. Physician Preferences on Receiving Handoff Patients

Next, we summarize physician responses regarding their preferences for the number of patients they would prefer to be handed off at the beginning of their shift. As Figure 3 shows, 43% of physicians reported that they would prefer to receive 0 patients, 36% of physicians reported that they would prefer to receive at most 1–2 patients, and 16% reported that they would prefer to receive at most 3–4 patients.

Further, the thematic content analysis of responses relating to the physicians’ reasoning for their preference revealed four major themes (see

Table 2. Themes based on physicians’ reasoning for their preference on receiving handoff patients.

Themes	Definitions	Physicians Supporting the Theme (%)
Challenges of continuing workup	Various difficulties associated with continuing care for a patient who was handed off by another physician.	55%
Patient safety	Any incident that leads to a negative impact on patient care, including errors and adverse events.	28%
Beyond physician control (prefer fewer handoffs)	Physicians prefer to have no/fewer handoffs. However, they recognize that a physician cannot dictate the number of handoffs for various reasons, including ED being a complex system that depends on various ancillary units, patient arrivals, and system state.	25%
Ownership	Physician preference to provide care for patients from signup until disposition.	23%

). Among these themes, 55% of physicians reported challenges of continuing workup as the primary reason for preferring no/fewer handoffs. On further analyzing physician responses, the primary concern was associated with handoffs negatively impacting their productivity and efficiency, where physicians commented, “Handoffs slow the workflow, and it takes time to review medical records and history”. Moreover, physicians reported, “without handoffs, at the beginning of the shift, there will be maximal efficiency and less cognitive load”.

Patient safety emerged as the second prominent theme, with over 28% of physicians reporting this as the reason for avoiding handoffs. Most physicians’ responses built upon the cognitive load factor where they said, “fewer handoff patients decreases the cognitive burden of the oncoming physician, increasing patient safety”. Another aspect of physician response was underpinned by trust in their own decision-making and ownership, where they reported, “fewer errors are made without handoffs, and taking full ownership of the patient”.

The third major theme was beyond physician control (prefer fewer handoffs), and 25% of physicians selected this option. On analyzing physician responses, it was evident that they prefer fewer handoffs, but the dependencies of ED on other departments and the work culture in the ED made it trivial to have a preference where physicians commented, “Of course, fewer is always easier. But it really makes no difference. You get what you get. Period.” and “It’s always ideal to receive NONE, but I know this is not practical”.

The fourth and final major theme that emerged from the thematic analysis was ownership, reported by 23% of physicians, where physicians reported being more comfortable “to start each patient from scratch”, relying on their own decision-making, and “taking full ownership of the patient”.

Although not a major theme (< 10% physicians supporting the theme), a few physicians reported compensation, concerns with changing treatment plans, and additional work as a few other reasons why they prefer to receive no/fewer handoff patients. One physician noted, “I reassess the patients as new patients at handoff, which is added work, but added RVUs for me, but also creates the potential for errors”. Another physician noted, “I’ve had many, many, many patients who almost had bad outcomes if I had only acted on “sign out” directives versus a whole-patient reassessment”.

3.1.5. Physician Efforts and Strategies to Minimize Handoffs

When asked if physicians make a conscious effort to reduce handoffs in the ED, 77% responded that they always make a conscious effort to minimize handoffs. Additionally, 18% reported that they frequently try to minimize handoffs, and the remaining 5% reported that they try sometimes. No physician (0%) responded that they rarely or never make a conscious effort to minimize handoffs. Furthermore, on performing a thematic content analysis on the optional follow-up question, which asked physicians regarding their strategies to minimize handoffs (if they selected always, frequently, or sometimes), we observed three major themes: (a) restrict patient signup, (b) stay late, and (c) plan patient disposition (see

Table 3. Themes generated based on physicians’ strategies to reduce/avoid handoffs.

Themes	Sub Theme	Definition
Restrict Patient Signup	Selective Patient Signup No Patient Signup	Physicians sign up only less complex patients at the end of their shift. Physicians do not sign up any patients during the end of their shift.
Plan Patient Disposition	--	Physicians strategize how to dispose of patients during the end of their shift to avoid handoffs. Strategies include prioritizing testing and imaging, coordinating with nurses, and contacting labs and imaging.
Stay Late	--	Physicians stay beyond the shift end time to care for patients and/or their paperwork.

).

Among the three themes, the most prominent theme was restrict patient signup, reported by 61% of physicians. Within this theme, we classified two sub-themes based on physician response, where 61% reported that they follow a selective patient signup approach, 23% reported that they follow a no patient signup, and 16% reported that they use both. Definitions of both sub-themes are provided in Table 3. Most physicians reported “Cherry-picking patients or decreasing the number of patients seen in the last 1.5 h of the shift”, allowing them to disposition patients in an expedited manner before the end of their shift. However, some physicians reported using a stricter approach where they “Do not pick up patients near the end of their shift (30 min–1 h)”, allowing them to focus on existing patients and wrapping up their care. Some physicians reported that their decision to cherry-pick or complete restriction on patient signup was based on ED coverage, where they preferred the latter approach during double coverage.

The second prominent theme was plan patient disposition, which was reported by 39% of physicians. One physician reported, “I make a concerted effort to disposition patients at least 30 min before my shift ends so the hospitalist/consulting services can call me back”. A great number of physicians also reported conscious planning, where they reported “keeping track of whether imaging studies/tasks are getting done, expedite labs and imaging and pestering the poor nurses” towards the end of their shift.

The final theme that emerged among strategies was to stay late, selected by 37% of physicians. Most physicians responded, “Staying over a lot is in the best interest of patients”, especially when waiting on little things, “as it opens up the opportunity for miscommunication and errors”. Another common response that emerged as reasoning for staying late was, “The next attending will likely not have the time or investment for each handoff patient”.

3.1.6. Physician Perspectives on Shift Length

The final question in the survey investigated the physicians’ willingness to extend their current shift length of 8 h if compensated. The logic for implementing this question was based on prior research, which suggested that overlapping shifts (waterfall shifts) can help reduce handoffs in the ED. We observed that 82% of physicians were willing to extend their shift if compensated, and 18% reported that they would not extend their current 8 h shift. Among the respondents willing to extend their shift, 8% were willing to extend it by 30 min, 60% by 60 min, 4% by 90 min, and 10% by 120 min.

On analyzing the responses of physicians not willing to extend their shift, we observed a common theme where physicians commented that “they would feel obligated to stay beyond the new regular hours to wrap up the patient care”, leading to higher chances of exhaustion. Along the same lines, another common comment was finding “a balance between leaving on time (maximizing physician recuperation and self-care) and staying late to finish up all my patients myself”.

In contrast, on investigating the responses from physicians willing to extend their shift, the primary theme that emerged was changing the work culture where physicians commented that “they would want more dedicated transitional hour where they don’t feel obligated to sign up for new patients”. This insight does not suggest that physicians are asking for 2 h transitional hours, whereas they are more focused on changing work culture where a physician reported, “I would like for it to be normal not to pick up any patients in the last hour of the shift”. Moreover, some responses built over these physician comments where physicians commented, “They always stay late 30 min–1 h+ to clean up their patients without overtime compensation”.

3.1.7. Physician Feedback and Bivariate Relationship

Finally, multiple perspectives emerged on evaluating the open-text responses to the question asking for additional feedback, including the lack of inpatient bed availability and trust among physicians. In alignment with the literature, physicians had strong comments regarding inpatient hospital beds where they reported, “inpatient bed holds are crippling the ability to get patients through the system”. Trust appeared to be a critical factor, especially in a large health system where a physician commented, “With a large group, it becomes hard to know who will follow up with your patients to reassess and ensure good care. How much do I trust this person?”.

Finally, we observed that the factors (average years of practice and sex) did not have any significant (p-value > 0.05) impact on their preferences (see

Table 4. Bivariate analysis on preferences and other factors.

Factor	Variable	p-Value
Practice	Impact of handoffs on patient safety	0.588
	Impact of handoffs on length of stay	0.295
	Impact of handoffs on patient satisfaction	0.985
	Effort to minimize handoffs	0.295
	Willingness to extend shift	0.180
	Number of patients you prefer to hand off	0.287
	Number of patients you prefer to receive	0.534
Sex	Impact of handoffs on patient safety	0.254
	Impact of handoffs on length of stay	0.548
	Impact of handoffs on patient satisfaction	0.848
	Effort to minimize handoffs	0.551
	Willingness to extend shift	0.638
	Number of patients you prefer to hand off	0.511
	Number of patients you prefer to receive.	0.236
Impact of handoffs on patient safety	Effort to minimize handoffs	0.262
	Willingness to extend shift	0.295
	Number of patients you prefer to hand off	0.226
	Number of patients you prefer to receive	0.405
Impact of handoffs on length of stay	Effort to minimize handoffs	0.405
	Willingness to extend shift	0.250
	Number of patients you prefer to hand off	0.855
	Number of patients you prefer to receive	0.181
Impact of handoffs on patient satisfaction	Effort to minimize handoffs	0.157
	Willingness to extend shift	0.723
	Number of patients you prefer to hand off	0.578
	Number of patients you prefer to receive	0.177

). Furthermore, on investigating if physicians’ willingness to extend their shift and effort to minimize handoffs were influenced by their perceptions of handoffs’ impact on patient safety, length of stay, and satisfaction, we observed no significant (p-value > 0.05) association (see Table 4).

Finally, investigating if physicians’ perceptions of handoffs’ impacts on patient safety, length of stay, and satisfaction had an impact on the number of patients they prefer to hand off at the end of their shift or receive during the beginning of the shift, we found no significant (p-value > 0.05) relationship (see Table 4). This finding is informative because irrespective of whether physicians perceived handoffs to negatively or positively impact patient safety, length of stay, and satisfaction (question in the survey), they preferred fewer handoffs. Specifically, 80% of physicians preferred to hand off or receive at most two patients, with over 45% preferring to receive or hand off no patients.

From the subjective findings, it is evident that ED physicians prefer to receive or hand off no/patients. Additionally, the majority of physicians perceive patient handoffs to negatively impact patient safety, patient flow, and patient satisfaction. Further, we identified that most physicians were willing to extend their shift if compensated, and their existing strategies to minimize handoffs involved staying late, restricting patient signup, and planning patient disposition. Based on these inputs and the literature, we aimed to evaluate if overlapping/transition hours could help reduce handoffs in the ED using retrospective data.

3.2. Objective Data

First, we investigated the number of handoffs in the ED over the previous three years. A patient was considered to be handed off if more than one attending physician provided care to the patient during their visit. Patients cared for by physician assistants were not included in the analysis as our survey population included only attending physicians, and advanced practice providers did not see patients in the main ED. Across the three years, the average proportion of patients handed off compared to patient arrival was 30%. Additionally, on average, 48% of patients who were handed off involved cases where the first physician was not the longest providing care (see

Table 5. Avoidable handoffs in the emergency department.

Year	Total Patient Arrivals	Patients Handed Off	First Physician Not the Longest	Avoidable Handoffs
2019	65,179	19,359 (30%)	9057 (47%)	5801 (30%)
2020	70,601	22,188 (31%)	10,614 (48%)	6636 (30%)
2021	77,706	23,223 (30%)	11,619 (50%)	7459 (32%)
Average	71,162	21,590 (30%)	10,430 (48%)	6632 (31%)

).

Avoidable handoffs were defined in two ways: (a) cases where the patient’s time in the ED was less than 60 min before being picked up by a physician, or (b) cases where the patient’s total ED length of stay (LOS) was between 60 and 120 min, and the first physician involved was not the one who provided care for the longest duration. In the first scenario, a physician signs up to care for a patient but hands them off to the next shift physician within an hour. For example, Physician 1 picks up a patient at 4:30 p.m. and hands them off at 5:00 p.m. to the incoming Physician 2. In the second scenario, two physicians are involved in a patient’s care, the total LOS is between 60 and 120 min, and the initial provider does not remain the primary caregiver. For instance, a patient is signed up by a physician at 3:45 p.m., discharged at 5:15 p.m., and the second physician provides most care during the stay.

Based on institutional context and the supporting literature, we defined avoidable handoffs using a 60 min cutoff. In our ED, as in many others, physician shifts are typically 8 h in length. Our survey found that most physicians (60%) were willing to extend their shifts by up to 60 min, effectively creating a 9 h work period. This willingness aligns with the common practice of using overlapping waterfall shifts, where incoming and outgoing shifts overlap by one hour, to reduce the number of handoffs and improve continuity of care. Prior research has used this final hour of overlap as a meaningful threshold, showing that one-hour overlapping shifts can reduce patient handoffs by up to 32.5% [22]. Moreover, combining the overlapping shift policy with the physician-suggested strategy of restricting patient signups near the end of a shift, the study observed that handoffs could be reduced by as much as 41% compared to current ED practices [22].

Clinical workflow patterns and expert opinions also support using a 60 min window as a meaningful cutoff [21,23,25,26]. The final hour of the shift is when physicians often evaluate whether they can reasonably complete care (discharge disposition) for a signed-up patient or should defer responsibility to the incoming provider. New patients picked up during this time are typically in the early stages of assessment, with diagnostics and treatment plans still evolving, leading to a handoff. Therefore, handoffs during this period can result in redundancy, information loss, or fragmented care, making them more likely to be avoidable with better shift coordination.

Furthermore, our second criterion—that the first physician was not the longest provider during the encounter—acknowledges clinical complexity. In such cases, the initial provider likely recognized that ongoing care (e.g., labs, imaging, and consultations) would extend beyond their shift and may be better managed by the incoming physician. However, when this occurs within a relatively short ED LOS (60–120 min), the resulting handoff may still be avoidable with better shift planning or extended coverage.

Collectively, these factors support the 60 min cutoff as a clinically relevant and operationally practical benchmark for defining avoidable handoffs. This approach is grounded in physician workflow patterns, existing shift structures, and prior evidence showing that overlapping schedules and patient signup restrictions can significantly reduce unnecessary care transitions.

4. Discussion

Patient handoff, the transition of patient care from one physician to another, is a high-risk event that potentially leads to patient harm and delays in a care setting like the ED [10,11,27,28]. Although a well-researched topic in terms of patient safety, to our knowledge, none of the studies have investigated physicians’ perceptions of how handoffs impact the patient’s length of stay and patient satisfaction. Further, none have tried to comprehend physician perceptions of handoffs and their strategies to minimize handoffs, or used data-driven methods to quantify avoidable handoffs.

From the subjective responses, we first observed that most ED physicians (at least 55%) perceived handoffs as having a negative impact on patient safety, patient length of stay, and patient satisfaction. This finding regarding patient safety aligns with multiple studies that reported similar findings [10,11,12]. However, the new findings from this survey provide additional insights that physicians’ perceived handoffs also increase the patient length of stay and reduce patient satisfaction in the ED. On investigating physician preference for patient handoffs, about 80% of ED physicians preferred to hand off or receive no more than two patients while ending or beginning their shift. Moreover, irrespective of physician perceptions of handoffs’ (positive or negative) impacts on patient safety, patient satisfaction, and length of stay, the statistical analysis showed that they preferred to hand off or receive fewer patients. We identified ED physicians’ mental models and drivers for this preference using thematic content analysis. These included a few major themes: ownership, patient safety, patient flow, cooperation and colleagueship, and challenges of continuing workup. While studies have identified patient flow and safety as motivators in prior studies, the additional observations from this study provide new insights and motivation for developing strategies that reduce handoffs in the ED [29,30].

The information gleaned from this study regarding current strategies used by physicians to minimize handoffs in the ED, such as overlapping shifts and transitional hours at the end of the shift, builds upon the existing literature and provides a great starting point for fine-tuning and implementing them in the ED workflow [11,19,21,31]. Moreover, these observations provide new insights that ED administrators and leadership should consider while developing new shift designs and shift schedules.

To assist leadership in evaluating strategies without implementation, we performed a retrospective chart review and observed that utilizing overlapping shifts has the potential to reduce handoffs by as much as 30%. Prior studies using empirical testing and computer simulations have reported similar findings with a reduction in handoffs [21,23]. However, the 30% reduction noted here is based on data from a large academic Level 1 Trauma Center and a one-hour overlap/transition window. Hence, this finding cannot be directly translated to other medium-sized and lower patient volumes EDs and would require analysis specific to the ED under consideration.

From a shift scheduling standpoint, 82% of physicians working in this health system were willing to increase their current shift length beyond 8 h, with 60% preferring to extend it by 1 h. The new preferred shift length (9 h) is within the American College of Emergency Physicians (ACEP) recommendation which notes that shifts should last 12 hours or less [32]. Although studies have compared the impact of shorter vs. longer shifts in the ED, most have focused on analyzing an 8 h shift to a 12 h shift [33,34,35,36,37]. These studies reported mixed findings, with some observing no significant differences between the two shifts and others reporting 8 h shifts to be better regarding productivity, work–life balance, and wellbeing. However, we identified two studies, one among EM attendings and the other among EM residents, that compared 8, 9, and 12 h shifts [38,39]. The study among attending physicians reported higher productivity while working an 8 or 9 h shift compared to the 12 h, and residents preferred working a 9 h shift over 8 or 12 h shifts. Based on the literature and the findings reported in this study, it is evident that 8 h shifts are preferred over 12 h, but implementing a 9 h shift among ED attendings should be further explored, given the potential benefits [38]. Irrespective of the physicians’ willingness and unwillingness to extend shifts, both groups provided critical feedback regarding taking action to change the ED work culture to improve physician wellbeing and reduce the chances of burnout. Physician comments provide critical insights and raise a philosophical question pertinent to an ED work culture where ED physicians are wired to consider that staying beyond actual working hours is a norm and mostly without overtime compensation. This calls for the proactive development and testing of strategies, interventions, and policies to create change and improve ED physician wellbeing. We would recommend that, for those willing to extend their shifts, the additional hour can be used as the overlapping hour, and for other EDs who have a longer shift length or where physicians are unwilling to extend their current shift, we recommend using the last hour of their current shift as the transition.

5. Limitations

While this research allowed us to better understand ED physicians’ preferences and perceptions of handoffs, strategies for minimizing handoffs, and opportunities for reducing handoffs, there are several limitations to consider. First, this study did not empirically test an overlapping (waterfall) shift schedule, and the findings are based on physician perceptions rather than observed outcomes, which limits our ability to draw conclusions about the actual effectiveness or feasibility of proposed strategies. Second, this study was conducted at a large, urban academic ED and may not be applicable to other ED settings, such as rural or smaller EDs with different staffing models and patient volumes.

Third, although the response rate was relatively high (72%) and aligns with the literature suggesting that physician survey response rates typically average around 53%, with >60–65% considered strong in healthcare research [40], the potential for non-responder bias remains. Physicians who chose to participate may have held stronger or more polarized views on handoffs, potentially influencing the overall findings. Non-respondents may differ systematically in their experiences or attitudes, which could result in the under- or overestimation of certain themes, such as the importance of minimizing handoffs or perceptions of shift overlap strategies. Without a comparison between respondents and non-respondents, we are unable to assess the magnitude or direction of this potential bias. Future studies should aim for broader participation across varied physician groups and settings to better understand the representativeness of the findings and mitigate the risk of non-response bias.

Fourth, while our study identified associations between physician characteristics and their handoff preferences, the lack of multivariable analysis limits both the strength and interpretability of these associations. Without the ability to simultaneously adjust for multiple variables, we could not isolate the independent effects of specific factors such as years of clinical experience, time of day or shift type, and patient acuity—all of which are likely to influence perceptions and behaviors related to handoffs. For instance, a more experienced physician may view handoffs differently than a junior colleague, but without controlling for experience, it is unclear whether the associations we observed are driven by the factor of interest or by underlying confounders. As a result, some findings may reflect indirect associations rather than true causal relationships. This represents a methodological limitation, as it restricts our ability to draw definitive conclusions about which physician characteristics are most meaningfully associated with handoff preferences. Future studies should be designed with larger and more diverse samples, as well as comprehensive data collection that includes key covariates, to enable more robust multivariable modeling and a clearer understanding of the underlying drivers of handoffs.

Furthermore, while many physicians expressed a preference for minimizing handoffs, this may not solely reflect a concern for patient safety. It could also represent a coping strategy aimed at reducing workload or minimizing the emotional and cognitive demands of transitions in care. Importantly, while reducing handoffs is generally viewed as beneficial for continuity and safety, it may inadvertently increase physician fatigue or burnout, especially if fewer handoffs result in longer or more demanding shifts, potentially compromising safety in other ways. Finally, we recognize that the ED is a place of change and gridlock, and our current method does not account for additional factors, such as the impact of nurses, consults, and ancillary departments (labs, imaging, etc.), which could impact avoidable handoffs.

6. Conclusions

This mixed-methods research conducted at the largest healthcare system in the state of South Carolina observed that irrespective of the ED physicians’ clinical experiences, they perceived handoffs to affect patient safety, patient satisfaction, and patient flow negatively and preferred fewer handoffs. Additionally, all physicians reported making conscious efforts to avoid handoffs, and their existing strategies included restricting patient signup, planning patient disposition, and staying late beyond shift end time. Finally, this study observed that utilizing one-hour overlapping shifts (waterfall shifts) could reduce handoffs by as much as 30% in this large academic ED. Future research should explore the balance between handoff reduction and physician wellbeing to better understand its impact on patient safety and workflow efficiency. Additionally, incorporating objective patient outcomes (e.g., adverse events and errors) in relation to handoff frequency would provide a more balanced perspective and allow for a more comprehensive evaluation of the risks and benefits associated with different handoff strategies. Future empirical testing is also needed to understand the impact of nurses, consults, and ancillary departments (labs, imaging, etc.), which could influence avoidable handoffs and overall patient flow.