Effective handover communication: An overview of ...

Best Practice & Research Clinical Anaesthesiology 25 (2011) 181–191

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Effective handover communication: An overview of research and improvement efforts Tanja Manser, PhD, Associate Professor SNSF a, *, Simon Foster, Research Associate b a

Department of Psychology, Industrial Psychology and Human Factors Group, University of Fribourg, Rue P.A. de Faucigny 2, CH-1700 Fribourg, Switzerland ETH Zurich, Center for Organizational and Occupational Sciences, Kreuzplatz 5, CH-8032 Zurich, Switzerland

b

Keywords: communication handover safety quality improvement

In the recent patient safety literature, there is an increasing agreement that effective patient handover is critical to patient safety by ensuring appropriate coordination among health-care providers and continuity of care. It has repeatedly been pointed out that a lack of formal training and formal systems for patient handover impede the good practice necessary to maintain high standards of clinical care. Thus, patient handover has been defined a research priority for patient safety, and research in this field is increasing rapidly. In reviewing the current state of research and improvement, we identified key areas for future research. Despite the growing evidence at the descriptive level, future research will have to take a more systematic approach to establish valid measures of handover quality and safety, establish the causal effects of handover characteristics on safe care and identify best practices in safe handover and effective interventions within and across health-care settings. Ó 2011 Elsevier Ltd. All rights reserved.

Clinical handover refers to the “transfer of professional responsibility and accountability for some or all aspects of care for a patient, or groups of patients, to another person or professional group on a temporary or permanent basis”.1 Handovers permeate the health-care system and can occur at shift changes, when clinicians take breaks, when patients are transferred within and between hospitals and during admission, referral or discharge. An increasing number of publications state that – across different health-care

* Corresponding author. Tel.: þ41 (0) 26 300 74 83; Fax: þ41 (0) 26 300 97 12. E-mail addresses: [email protected] (T. Manser), [email protected] (S. Foster). 1521-6896/$ – see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.bpa.2011.02.006

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T. Manser, S. Foster / Best Practice & Research Clinical Anaesthesiology 25 (2011) 181–191

settings – current handover processes are highly variable and potentially unreliable. Thus, patient handover has been recognised internationally as a high-risk area for patient safety, and a number of initiatives aimed at handover improvement have been launched. For example, prevention of handover error is one of the five solution areas of the ‘High 5s initiative’, a mechanism established in 2006 through collaboration between the Commonwealth Fund, the WHO World Alliance for Patient Safety and the WHO Collaborating Centre for Patient Safety to implement innovative patient safety solutions over 5 years.2 In 2007, effective communication during handover has been listed as one of the National Patient Safety Goals by the Joint Commission on Accreditation of Healthcare Organisations.3 The aim of this article is to review the current state of research and improvement efforts to establish the evidence base for effective handover practices and identify key areas for future research. In doing so, we will focus on handover situations relevant to the speciality of anaesthesiology. Where appropriate, examples from other clinical settings will be used to illustrate general issues or to compensate for a lack of studies specific to anaesthesiology. Patient handover as a priority of patient safety research Patient care is an inherently communicative activity. It is therefore not surprising that communication issues are among the most frequent contributory factors of adverse events identified in retrospective adverse-event analyses4–6 and that several observational studies highlight the frequency and negative consequences of communication breakdowns.7–9 Communication processes are particularly vulnerable at organisational interfaces, such as care transitions and shift changes. The increasing recognition of the critical importance of patient handover to the quality and safety of care is supported by studies tracing back the causes of adverse events to inadequate handover and coordination of care.6,10–12 For example, Borowitz and colleagues found that 31% of residents responding to their survey indicated something had occurred while they were on call that the handover had not prepared them for.13 Interestingly, a recent study of 334 reported handover incidents found that the most frequent type of incident besides incomplete handover (45.2%) was no handover at all (29.3%).14 Until recently, patient handover has seldom been studied systematically. This is in stark contrast to the situation in other high-risk industries in which handover has received considerable attention from human factors research for many years.15 Since patient handover has been identified as a key process to investigate to improve patient safety,1,16,17 there has been a substantial increase in research activity.18 This is reflected by several reviews of the patient handover literature that have been published recently. Most reviews focus on a specific type of handover or a specific clinical setting, such as nursing handover,19–21 physicians’ handovers in hospital settings22,23 or handovers in the perioperative care process.18,24 Across these handover settings, a number of common research questions can be identified: What is the current handover practice? What constitutes a handover that contributes to the quality and safety of patient care? How can clinicians be trained for and effectively supported during handover (e.g., through technology or standardised handover processes)? We will briefly summarise the most prominent research themes before discussing implications for handover research and practice. Current themes of handover research What is the current handover practice? Studies describing handover practice show significant variation within and across health-care settings. Despite these variations, four phases have been identified in patient handover in clinical settings: pre-handover, arrival, handover meeting and post-handover.25,26Especially for handovers of multiple patients at a time, it has been shown that pre-handover preparation – one of the safety-critical handover strategies identified in high-reliability organisations15 – is often insufficient.22,27–29 For this reason, interventions designed to improve handovers should include the preparation phase as well, not only the meeting.27 For example, in a study of emergency-department shift handovers, Lawrence and colleagues found that the outgoing staff wrote summaries before the handover meeting started.30


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Most studies examining handover practices focus on the actual handover meeting and show that the handover process is variable, unstructured and error prone.22,23,31,32 During the actual handover, environmental factors, such as noise, crowding, high workload on either side of the staff involved, are potential threats to handover quality13,33 as well as task factors, such as interruptions34 and patient care activities (e.g., attaching monitoring equipment or intravenous infusion devices), taking place in parallel to the verbal handover.27 It has been shown that handovers are often rather informal35 and that the available documentation is rarely used to aid in the verbal handover.36 Although this has not been the research focus, some studies also point to a need for additional communication when the handover is over and staff has returned to clinical work that might be worth investigating in more detail in future studies.35 In anaesthesia, one of the leading specialities in patient safety research and improvement,37 few studies have investigated patient handover.35,38–40 Research in this field is particularly important because transitions of care between anaesthesia and recovery room or intensive care unit (ICU) take place in an environment that is event-driven, time pressured and prone to concurrent distractions while the patient is in an ‘at risk’ state.35 In a qualitative, observational study aiming at a rich description of postoperative anaesthesia handovers to the recovery room, Smith and colleagues found that anaesthetists and recovery nurses often had different expectations with regard to the content and timing of information transfer and that handover communication was largely informal.35 Furthermore, intra-operative problems were frequently underplayed in the handover. The authors also highlight that the transfer of information did not automatically lead to an unambiguous transfer of professional responsibility for the patient.35,39 A study assessing handover quality based on recovery-room nurses’ perceptions after the handover40 confirmed results on the often unstructured, variable communication process during patient handover. In this study, only 32.6% of anaesthetists attained maximum scores for the quality of verbal information. In 14% of handovers, anaesthetists failed to give any of the five required points of verbal information, whereas in 33%, all five were given. Information regarding preoperative status was given in 40% of handovers, on premedication in 36.6%, on operation details in 20.7%, on the intra-operative course and complications in 15% and on intra-operative analgesia in 63.8%. A recent study by Nagpal and colleagues41 of postoperative handover after 20 major gastrointestinal surgical procedures found similar results. In their sample, 60% of patient-specific information was passed on during the verbal handover with essential information, such as allergies, being transferred in 55% and co-morbidities in 30% of the cases. During the handover process, 67% of the anaesthetic information regarding the intra-operative course and postoperative plan was transferred; information about anaesthetic complications, such as intra-operative hypotension and monitoring plan, were not communicated during the observed handovers. Surgical handover was found to be mainly written, containing 68% of the essential information. Only 30% of the procedure-specific surgical information was transferred verbally, in all the cases by the anaesthetists. In addition, the authors found that handover information degraded from theatre to recovery (55.8% of the essential information transferred) and subsequently from recovery to the ward (43.9% of the essential information transferred). What constitutes a handover that contributes to the quality and safety of patient care? What we define as handover quality depends to a large degree on what we perceive as the primary function of patient handover (e.g., information transfer, shared decision making and transfer of responsibility).42 Measures of handover quality can generally be grouped into those that assess the content, the process or the outcomes of handovers.43 While measures of handover content seem rather straightforward and usually involve key information to be transmitted (e.g., patient identity, known allergies and patient care plan), the definition of which items should be included in such a list is frequently an issue of heated discussions, and existing handover protocols vary considerably in this respect. In line with the prevalent conceptualisation of handovers as episodes of information transfer and sources of medical error, the evaluation of handover quality has mostly concentrated on the completeness and accuracy of information and related

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errors.33,44,45 These studies frequently found verbal handover to be incomplete when compared with the information available in the patient record46,47 or when compared with a pre-defined handover protocol.27 However, these studies often do not account for the fact that the handover of a small number of highly relevant items may be more effective than the handover of a larger number of less relevant items.48 Handover process measures can be grouped into environmental aspects (e.g., interruptions, noise level and workload) and in behavioural aspects (e.g., shared planning, shared decision making, critical review of existing documentation, verbal report and acknowledgement of information received). Research in this area that goes beyond the information transmission aspect is only in its beginning. For example, Apker and colleagues have provided a detailed account of the communication activities performed during handover between emergency physicians and hospitalists.49 However, it is still an open question how the various process measures translate into safe care. Outcome measures for patient handover usually include satisfaction with the handover and should also assess the safety-relevant consequences on subsequent patient care (e.g., delay in diagnosis or treatment). Only then will we move into an area where we begin to assess handover safety as well. So far, many studies investigated the satisfaction of health-care providers with the current practice of handovers in a specific clinical setting (e.g., paramedics to resuscitation room).50 In this type of study, it is important to include the perspective of transferring as well as receiving clinicians and to account for the multifaceted nature of handover quality. In a study of handover assessments in three different clinical settings (paramedic to emergency room, anaesthetist to recovery room and recovery-room nurse to ward nurse), Manser and colleagues51 found that – although information transfer was the key characteristic – overall handover quality was predicted by three factors: information transfer, shared understanding and working atmosphere. In understanding the complex dynamics of effective patient handover, it is essential not to consider the different quality aspects in isolation but to investigate their interrelations as well. So far, few studies have tried to link handover content or process characteristics with outcome measures. In a qualitative study using post-call critical incident interviews to explore the perception of interns of errors during handover that have led to problems in subsequent patient care, two main communication failures were identified: Content omissions (e.g., failure to report an active medical problem, medication, treatment, rationale for a treatment decision or pending diagnostic tests) and failure-prone communication processes (e.g., lack of face-to-face communication and illegible notes) not supporting error detection during handover.45 These failures resulted in increased uncertainty during patient care decisions, a need to obtain information from other sources and often in repetition of clinical tasks. Another retrospective study of adverse events by Horwitz and colleagues found that the omission of information during handover (e.g., medical history and vital signs) was a commonly associated factor of adverse events.33,44 We are aware of only two studies that have experimentally manipulated a handover characteristic and assessed the effect in terms of handover outcomes.52,53 In the study by Bhabra and colleagues,52 participants were given handover information and then simply had to wait until they handed the patient information over to another participant. That is, no work on the fictional patient was carried out (i.e., the context of clinical work was missing). A similar problem is present in the study by Dowding,53 in which participants had to write down a care plan after receiving a handoff, and this care plan was then judged against an expert solution. Again, no actual clinical work was carried out. Thus, before we can actually answer the question “What constitutes a handover that contributes to the quality and safety of patient care?” there is a need for randomised controlled trials to establish a causal link between certain handover characteristics and their effects. How can clinicians be trained for and effectively supported during handover? Many physicians, especially junior doctors, feel unprepared due to a lack of training with regard to handover communication,54,55 believe that their handover practice needs improvement32 and report a need for guidance on the structure of handover.56 For anaesthesia, there is guidance from professional organisations including the need for a formal handover to be given by


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the anaesthetist.57,58 However, a postal survey found little formalisation of handover processes through departmental guidelines, with 56% of departments providing guidelines for patient transfers to intensive therapy units but only 14% for handover of anaesthetised patients.59 Based on the growing empirical evidence that patient handovers in all health-care settings are highly variable in content and process, many authors recommend reducing this variability through standardisation.23,27,28,60 A primary focus of these standardisation efforts has been defining and ordering the content of the verbal handover. A second focus is the development of technology solutions to better support handover processes. In the following, we provide a brief overview of these two approaches to handover improvement. Standardising handover communication There are two approaches to the standardisation of handover communication. The first approach defines specific information content and order and generates handover protocols that are quite specific to the clinical setting.13,27,61 Catchpole and colleagues,27 for example, introduced a specific handover protocol regarding handovers from the operating theatre to the cardiac intensive care unit. Their protocol includes the handover preparation, the clinical handover tasks to be completed before the verbal handover (e.g., connecting monitoring equipment, ventilator and so on), and defines an order in which the verbal handover is conducted and specific information that has to be handed over. Similarly, Berkenstadt and colleagues61 introduced a checklist containing specific items of information to be handed over during shift handover in a medical step-down unit. The few studies evaluating the effects of standardised handover protocols provide rather weak evidence for improved handover quality, as they often define handover quality as adherence to the previously defined protocol. However, Catchpole and colleagues were able to show additional effects, such as improvements in teamwork during handover.27 The second approach to handover standardisation focusses on general interaction structures that do not define the exact content, but the topics to be covered and their order. Such structuring aids may, for example, advise the transferring person to first provide the information regarding the mechanism of injury/illness, followed by the injuries, followed by observations and vital signs and finally the treatments given.62 This approach frequently suggests the use of handover mnemonics. In a recent systematic review of improvement handover mnemonics, Riesenberg and colleagues63 identified 24 different structures, with the ‘SBAR’ (Situation, Background, Assessment, Recommendation)64 being recommended most frequently. However, Riesenberg and colleagues note that empirical examinations of these structuring aids and their effects on patient care are rare. While the effectiveness of standardisation on handover communication still has to be established in systematic outcome studies, the discussion of a standardised set of key information before surgery shows positive effects. A global study on the implementation of preoperative briefings showed improvements in team communication that were subsequently translated into a significant reduction in morbidity and mortality in surgical patients.65Despite these promising results, the specific mechanisms behind these results are unclear. Moreover, the potential unintended consequences from the standardisation approach to patient handover that have been discussed with reference to handover practices in high-reliability organisations66 should be considered carefully before implementing practice changes. Supporting handover processes through technology A seemingly straightforward way to use technology during handover is to extract a handover sheet from the hospital’s electronic medical record (EMR) system. For example, Petersen and colleagues were able to reduce the probability of adverse events during cross-coverage by introducing such a computerised sign-out sheet.67 EMR-based handover sheets were also found to improve completeness of handover information.68,69 Arora and colleagues70 systematically reviewed studies reporting interventions to improving patient handovers, and found that technology solutions were associated with a reduction in preventable adverse events, improved satisfaction with handoff quality and improved provider identification. They note, however, that the reviewed studies have several methodological problems limiting the interpretation of findings. Moreover, some of the technological solutions aimed at supporting patient handover are solely designed to improve accuracy of information transfer neglecting behavioural and cultural aspects22 and

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it has been claimed that they may not necessarily improve communication.71 More comprehensive studies are needed to inform the design of information technology solutions and to rigorously evaluate their potential to support or even enhance the overall handover process, including activities performed before, during and after handover.69,72 Moving handover research and improvement efforts forward Based on this overview, two areas in handover research emerge that deserve an accentuated focus in the future: (1) improved research designs to overcome current methodological problems and (2) broadening the understanding of patient handover to a team task and not just a one-way transfer of information. Methodological approaches in handover research The methodological approach and the implemented study design determine the level of evidence generated by any research study. Jeffcott and colleagues73 have stated a need to employ a mixture of qualitative and quantitative methods to fully explore the complexities of handover. In reviewing the current handover literature, we identified six prototypical research approaches to patient handover (across various clinical settings, sometimes combined in a single study): Clinician’s general assessment of handover practice Health-care providers are asked in surveys, interviews or focus groups to evaluate handover practices and quality issues in general.24,28,45,74–77 Clinician’s assessment of a specific handover Health-care providers are approached after handover or at the end of a shift to evaluate different aspects of the handover, for example, how the staff involved worked together, whether the information given was complete or how they rate the overall quality of that handover.29,34,40,51,58,74,78 Behavioural observation Most observational studies defined a behavioural standard for a specific handover and then compared health-care providers’ actual behaviour during handover to this standard. Typical examples for this approach are checklists specifying information to be transmitted or equipment checks to be performed during handover.27,58–60,74 Other studies used observation as part of an ethnographic fieldstudy approach aiming at elaborate descriptions of clinicians’ handover behaviours to tap into the nature of patient handover.35,79–82 Retrospective adverse-event studies In these studies, adverse outcomes are analysed and retrospectively attributed to handover characteristics using case studies,26 retrospective reports by the receiving clinician,13,33 malpractice claims12 or anonymous incident reports.14,67 Observational effect studies These studies try to link handover characteristics to some kind of effect (e.g., 30-day patient outcomes in a retrospective chart review) in an observational study design.68,83 Experimental effect studies Potential effects of patient handovers are defined and linked with handover characteristics in a randomised controlled trial. Effects may be, for example, the amount of information transferred during a subsequent handover52 or the quality of the care plan written after handover.53 With regard to the design and reporting of research studies, systematic reviews assessing the quality of published handover research for nursing handover20 and for residents’ and attending physicians’ handovers23 show, however, that there are flaws in many studies. The flaws identified in these reviews highlight important methodological issues that have to be addressed when moving this


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field forward. Especially, systematic effect studies are necessary to understand how handover characteristics influence patient safety outcomes. Team-based approaches to patient handover A widespread view of patient handover is still that of a one-way transfer of information. As a logical consequence, many improvement efforts focus on the design of the information transmission from the transferring clinician perspective; some even try to minimise the impact of potentially flawed verbal communication in a dynamic, busy, clinical environment by gradually substituting verbal handovers with technological solutions. This view neglects the active role and the responsibility of the receiver in shaping an effective information exchange and functions of handover communication that go beyond the mere transmission of data (e.g., training, socialisation, encouraging/maintaining group cohesion, transfer of responsibility and clarification of roles).1,15,73,75,84 A health-care provider’s “mental model”85 of a patient’s health condition, including the rationale for treatment decisions, uncertainties and anticipations of problems has to travel with the patient across the division of labour. Establishing such a shared understanding between transferring and receiving clinicians is a complex communicative process that is vulnerable to external stressors, such as time pressure, fatigue, hierarchical status and poorly defined responsibilities. In the anaesthesia context, an observational study has highlighted safety-relevant aspects of postoperative patient handover to the recovery room that go beyond accurate and complete information transfer, such as the negotiation of responsibility for the patient between anaesthetist and recovery-room nurse and the voicing of concerns by recovery-room staff.39 In contrast to the view of patient handover as a source of medical error, it has been pointed out that care transitions provide an important ‘audit-point’ essential for potential recovery from failure.35,86,87 This line of research conceptualises patient handover as a team-based activity, an episode of shared cognition/shared sense making between health-care providers86 and an opportunity for collaborative cross-checking.15,88 In this view, handovers are a source of resilience for health-care systems (i.e., the ability to adapt to or absorb variability in a complex work system).89 Thus, a team-based approach to patient handover that takes into account the multiple functions of handover that go beyond information transfer is a promising approach to improve patient handover. Conclusions There is wide agreement that patient handover is a key process to improve patient safety, and that formal systems for patient handover combined with formal training on effective handover communication will promote patient safety in all areas of health-care.1,16,17,90 It has been pointed out that human factors’ research is integral to interdisciplinary research aimed at understanding and improving patient handover.90 The contribution of human factors’ science in supporting current research and improvement efforts ranges from the definition and measurement of technical as well as non-technical skills related to patient handover to the design, implementation and evaluation of handover processes and supporting tools as well as targeted educational interventions. The evidence base for effective handover practices is still evolving and the multitude of studies on patient handover in a variety of clinical settings using a broad spectrum of research methods is difficult to integrate. Meanwhile, a number of interventions to assist clinical handover improvement have been developed already, mainly focussing on a standardisation of the information transfer. Systematic evaluations of these interventions on subsequent patient care are generally lacking. As Riesenberg and colleagues have stated: “There is a remarkable consistency in the anecdotally suggested strategies; however, there remains a paucity of evidence to support these strategies” (p. 1775).23 Empirical results linking detailed analyses of handover processes with measures of handover quality and ideally also with outcome variables are urgently needed to provide a sound basis for the future development of effective guidelines and training efforts. These results need to consider the specifics of various handover settings91 and the related patient and provider needs. Otherwise, standardisation efforts are unlikely to be accepted by health-care professionals,92 and, thus, to effectively improve patient care.

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Practice points There is abundant evidence regarding the negative consequences of poor communication at patient handover in health-care. Organisational, cultural, behavioural and environmental factors have been found to undermine the effectiveness of intra- and interprofessional communication across a variety of health-care settings. There is a lack of formal education in patient handover at all levels of clinical training. Improvement efforts focus on the standardisation of handover processes and communication, technological support for handover and improved teamwork across care transitions.

Research agenda Establish valid, robust and feasible measures of handover quality and safety. Include experienced clinicians in the study of handover practices, to improve the understanding of provider characteristics (e.g., expertise) in shaping information needs and information processing of receiving clinicians as well as the ability of transferring clinicians to adapt handover communication to the receiving clinicians’ needs. Establish the causal effects of handover characteristics on the quality of the subsequent care through randomised controlled trials (e.g., using full-scale patient simulation). Establish the evidence base for best practices in safe handover and for monitoring, evaluating and training these best practices. Compare the effectiveness of different interventions and the respective implementation strategies within and across settings (e.g. discipline, intra- or interprofessional, -and single or multiple patients).

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