Evaluating handoffs in the context of a communication framework.

BACKGROUND: The implementation of mandated restrictions in resident duty hours has led to increased handoffs for patient care and thus more opportunities for errors during transitions of care. Much of the current handoff literature is empiric, with experts recommending the study of handoffs within an established framework. METHODS: A prospective, single-institution study was conducted evaluating the process of handoffs for the care of surgical patients in the context of a published communication framework. Evaluation tools for the source, receiver, and observer were developed to identify factors impacting the handoff process, and inter-rater correlations were assessed. Data analysis was generated with Pearson/Spearman correlations and multivariate linear regressions. Rater consistency was assessed with intraclass correlations. RESULTS: A total of 126 handoffs were observed. Evaluations were completed by 1 observer (N = 126), 2 observers (N = 23), 2 receivers (N = 39), 1 receiver (N = 82), and 1 source (N = 78). An average (±standard deviation) service handoff included 9.2 (±4.6) patients, lasted 9.1 (±5.4) minutes, and had 4.7 (±3.4) distractions recorded by the observer. The source and receiver(s) recognized distractions in >67% of handoffs, with the most common internal and external distractions being fatigue (60% of handoffs) and extraneous staff entering/exiting the room (31%), respectively. Teams with more patients spent less time per individual patient handoff (r = -0.298; P = .001). Statistically significant intraclass correlations (P ≤ .05) were moderate between observers (r ≥ 0.4) but not receivers (r < 0.4). Intraclass correlation values between different types of raters were inconsistent (P > .05). The quality of the handoff process was affected negatively by presence of active electronic devices (ß = -0.565; P = .005), number of teaching discussions (ß = -0.417; P = .048), and a sense of hierarchy between source and receiver (ß = -0.309; P = .002). CONCLUSION: Studying the handoff process within an established framework highlights factors that impair communication. Internal and external distractions are common during handoffs and along with the working relationship between the source and receiver impact the quality of the handoff process. This information allows further study and targeted interventions of the handoff process to improve overall effectiveness and patient safety of the handoff.

Establishing a conceptual framework for handoffs using communication theory.

BACKGROUND: A significant consequence of the 2003 Accreditation Council for Graduate Medical Education duty hour restrictions has been the dramatic increase in patient care handoffs. Ineffective handoffs have been identified as the third most common cause of medical error. However, research into health care handoffs lacks a unifying foundational structure. We sought to identify a conceptual framework that could be used to critically analyze handoffs. METHODS: A scholarly review focusing on communication theory as a possible conceptual framework for handoffs was conducted. A PubMed search of published handoff research was also performed, and the literature was analyzed and matched to the most relevant theory for health care handoff models. RESULTS: The Shannon-Weaver Linear Model of Communication was identified as the most appropriate conceptual framework for health care handoffs. The Linear Model describes communication as a linear process. A source encodes a message into a signal, the signal is sent through a channel, and the signal is decoded back into a message at the destination, all in the presence of internal and external noise. The Linear Model identifies 3 separate instances in handoff communication where error occurs: the transmitter (message encoding), channel, and receiver (signal decoding). CONCLUSIONS: The Linear Model of Communication is a suitable conceptual framework for handoff research and provides a structured approach for describing handoff variables. We propose the Linear Model should be used as a foundation for further research into interventions to improve health care handoffs.