The Joint Commission Center for Transforming Healthcare has cited communication as the most frequent root cause in sentinel events, with failed patient handoffs playing a “role in an estimated 80% of serious preventable adverse events.” Handoff, or transfer of patient care information, occurs formally and informally many times each day, within and between care teams, across all levels of care providers and between institutions. Handoff at rehabilitation admission is at a particularly high risk for communication failure, potentially affecting patient safety. This review of the patient handoff literature discusses the importance of safe handoff, the information to be included, barriers to handoff, and improvement methodologies.
Improve the effectiveness of communication among caregivers. —National Patient Safety Goal 2, The Joint Commission
The Joint Commission (TJC) Center for Transforming Healthcare has cited communication as the most frequent root cause in sentinel events, with failed patient handoffs playing a “role in an estimated 80% of serious preventable adverse events.” Beyond the identification of this prominent culprit, there is limited consensus about what leads to communication failures or how to prevent them. Handoff, or transfer of patient care information, occurs formally and informally many times each day. Handoff takes place within and between care teams, across all levels of care providers, and between institutions. Handoff at rehabilitation admission is at a particularly high risk for communication failure, and this review of the patient handoff literature discusses handoff safety, barriers, specific requirements and recommendations, and improvement methodologies.
As part of the postacute care (PAC) continuum, patients admitted to rehabilitation medicine settings, including acute rehabilitation (AR) and subacute rehabilitation (SAR) facilities, are often transferred with insufficient or inaccurate information from the referring hospital. This presents a significant safety issue, especially as rehabilitation units accept many multimorbid and acutely postoperative patients who frequently require ongoing acute-level care. These patients have a potentially higher risk of complications than patients discharged home, and certain information is essential for providing safe and effective care.
Handoff has been defined as, “The transfer of responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis.” Admission to a rehabilitation unit may represent the most dramatic transfer of care in our health care system, as full responsibility and accountability for possibly all aspects of care change. Other types of transfers, such as from one hospital intensive care unit (ICU) to another, might involve more critical patient scenarios, but there is often more commonality between those units than exists between any medical or surgical ward and a rehabilitation facility.
With a rehabilitation admission, changes often include the level of care (ICU vs step-down vs ward), individual members of the primary team, specialty of the primary team (physicians and nurses), the addition of other team players (therapists), and even a change of the hospital center itself. Less obvious are changes in pharmacy formulary, team structure and hierarchy (including presence or absence of residents or physician extenders), reimbursement algorithms, and the availability of subspecialty consultants familiar with the patient. The rehabilitation admission handoff, therefore, presents a tremendous opportunity for miscommunication, communication deficits, and inaccuracies.
Despite the potential patient safety risks of inadequate patient handoff, published research is limited and best practices have yet to be universally established. Most studies have focused on inpatient intershift handoffs (ie, nursing shift change), intrafacility handoffs (ie, emergency room [ER] to ward) and discharge to home. To our knowledge, there are no peer-reviewed articles reporting the state of handoff practices to the acute rehabilitation setting, although studies have been presented at national meetings. Unfortunately, many quality improvement projects and studies are performed for institutional advancement rather than academic enterprise, and are not submitted for publication.
As the science of handoff remains in its formative stages, no universal standardized handoff protocol for admission to AR or SAR hospitals has been established. TJC and the World Health Organization (WHO) have identified handoff standardization as a key element in improving patient safety ; however, specific handoff elements and methods of standardization have not yet been firmly established in daily clinical practice.
To determine the most appropriate content for handoff, the purpose and importance of handoff must first be reviewed. The definition cited previously is broad, and specific clinical scenarios require tailored handoffs. For example, an orthopedic patient may have specific weight-bearing restrictions or deep vein thrombosis (DVT) prophylaxis instructions that have direct implications for therapy and medical management. Even if the patient does not have any restrictions, simply because the patient is on a service with such a high prevalence of such restrictions, this becomes a very relevant pertinent negative for handoff. Case-specific criteria, such as these, both reinforce the need for standardization and render it a challenging process.
Importance of handoff
Each patient handoff poses a potential safety risk, and a TJC study found that handoffs were defective 37% of the time. Defective handoffs may lead to treatment delays, inappropriate treatment, increased length of stay, and even serious adverse events. An Australian study found that 11% of 30,000 preventable adverse events resulting in disability were a result of poor communication, compared with only 6% that were a result of practitioner oversight. In the United States, one malpractice insurance company reported that the leading cause of claims resulting from patient transfer was communication breakdown.
Among all points of transfer, communication breakdown at discharge has been found to be a leading cause of adverse events. Discharge summaries are often not available at the time of the first outpatient follow-up (<34%), and those completed by the time of follow-up often lacked important content, such as discharge medications, test results, and tests pending at discharge. The latter has been directly associated with adverse events. In addition, an absent discharge summary at outpatient follow-up has been found to increase the risk of hospital readmission. A medical reconciliation that lacks explanations for any changes in home medications may also result in adverse events.
As discharge information from the acute hospital often forms the basis for admission orders in a rehabilitation facility, this becomes a focus of concern for patient safety. Any deficits or inaccuracies in discharge paperwork present a significant safety issue, especially considering that patients on admission to AR facilities are generally less medically stable than those discharged home. Disturbingly, our study of information received at the time of admission to AR found that the more medically complex patients (greater number of medical comorbidities) arrived with significantly less complete information. Similarly, an evaluation of discharge paperwork received by SAR facilities found that only 33.5% of packets contained all applicable measures, with a defect rate ranging from 24.0% to 39.0% across 5 hospitals.
Handoff elements
Although poor communication is prevalent and associated with negative outcomes, the delineation of handoff elements and types of handoff information that are most important remains unresolved. Other than the association between omitted pending test results and adverse events, we found no other study that linked the absence of a particular element to an adverse event. Our previously mentioned AR study failed to correlate the absence of any one piece of relevant information with adverse events, although there were very few adverse events overall.
The criteria for evaluating handoffs or discharge packets vary among studies. The core elements include TJC requirements with additional elements determined by the study authors. TJC requires a medical reconciliation and 6 discharge summary elements. Additional elements apply if the hospital uses an electronic medical records (EMR) system and wishes to qualify for federal benefits.
The discharge summary, according to TJC Standard RC.02.04.01, should state:
- •
Reason for hospitalization
- •
Procedures performed
- •
Care, treatment, and services provided
- •
Condition at discharge
- •
Information provided to patient and family
- •
Follow-up care.
Although not explicitly required, others have thought it reasonable to expect activity restrictions, weight-bearing status, and diet instructions to be included also.
Instructions reviewing all medications are also among the information required to be provided to the patient. The medication reconciliation is meant to clarify discrepancies between discharge medications and medications taken before admission. TJC National Patient Safety Goal (NPSG 03.06.01) states that the process should include medication name, dose, frequency, route of administration, and reason for starting or changing doses. Beyond these defined elements, this NPSG also provides for the inclusion of other information that may be required to safely administer medications in the future: “Organizations should identify the information that needs to be collected to reconcile current and newly ordered medications and to safely prescribe medications in the future.” This infers the inclusion of recent international normalized ratio (INR) values for patients on warfarin, or serum drug levels for patients on antiepileptics.
Although anticoagulation information is not explicitly required, NPSG 03.05.01 is to “reduce the likelihood of patient harm associated with the use of anticoagulant therapy.” Routine short-term prophylactic anticoagulation is excluded, but only when “the patient’s laboratory values for coagulation will remain within, or close to, normal values.” Although heparin 5000 units subcutaneously every 12 hours would be excluded, warfarin with a goal INR of 1.8 to 2.2 would not. There is, therefore, some embedded responsibility placed on the discharging service to ensure that the admitting service receives all the information necessary to safely continue anticoagulation.
The federal certification criteria for “meaningful use” of an EMR require that other relevant clinical data elements be documented and shared. To qualify for financial incentives, the hospital, via its EMR, must “provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies, discharge summary, procedures) on request.” An additional criterion states that when a facility “transitions their patient to another setting of care…[it] should provide summary of care record.”
Despite these requirements, discharge summaries were absent or incomplete in 42.0% of admissions to AR and 21.0% to 29.7% of admissions to SAR. Medication reconciliation was absent or incomplete in 39% of admissions to AR, and information was missing in up to 35% on admission to SAR. Follow-up instructions, which were absent in 2.0% to 43.0% of a larger review of discharge summaries, were missing in 60.0% of AR admissions, and 11.1% of SAR admissions.
Additional nonrequired data elements that have been screened for on admission to AR and SAR facilities include:
- •
Laboratory results
- •
Radiology results
- •
Test results pending at transfer
- •
Anticoagulation instructions/relevant data
- •
Weight-bearing status/therapy precautions
- •
Steroid instructions
- •
Seizure treatment/prophylaxis instructions
- •
Antibiotic instructions/duration
- •
Wound care instructions
- •
Dietary restrictions.
A review of discharge-to-home paperwork by Kriplani and colleagues found diagnostic test results, including laboratory and radiology results, absent in 33% to 65% of discharge summaries. Laboratory results were missing from only 12.0% of AR and 17.9% of SAR admissions. Similarly, radiology results were missing from 20.0% of AR and 10.7% of SAR admissions. Our AR study found that radiology results were most likely to be omitted for trauma cases, and were included less frequently for patients who later suffered adverse events (60% vs 81%, nonsignificant). Information about test results pending at transfer was absent in 65.0% of general discharges and 47.2% of SAR admissions.
Anticoagulation instructions and pertinent information was specifically studied on admission to SAR by Gandara and colleagues. For their study, the Anticoagulation Task Force at Massachusetts General Hospital determined that the following elements are essential for safely prescribing warfarin:
- •
Indication
- •
Target INR range
- •
Treatment duration
- •
Last 3 INR values with dates
- •
Last 3 warfarin doses
- •
Recommended dose until next INR
- •
Responsible follow-up provider.
The same panel determined that to safely prescribe unfractionated heparin (UH) or low-molecular-weight heparin (LMWH), the following elements are essential:
- •
Indication
- •
Agent
- •
Dose
- •
Treatment duration
- •
Required monitoring (if indicated).
They found that discharge summaries contained all of the required information for only 16.4% of patients on warfarin and 45.4% of patients on UH or LMWH. The most common missing elements for UH of LMWH were duration of therapy (50.6%) and monitoring parameters (90.3%). For warfarin, recent INR (59.9%) and prior warfarin doses (55.0%) were most often absent, followed by identification of the follow-up provider. Interestingly, community hospitals and surgical services were more likely to provide this required information. Our AR study found that DVT treatment/prophylaxis instructions were missing in 40% of admissions, most frequently among those with a brain or spine diagnosis.
Weight-bearing status and therapy precautions, including brace and immobilization instructions, were missing in 52% of AR admissions. Similarly, steroid, antiepileptic, and antibiotic recommendations were missing in 56% to 62% of AR admissions. Of patients admitted with a brain diagnosis, steroid instructions (when indicated) were provided for only 11%, and antiepileptic instructions for 42%.
Although this information is absolutely necessary to continue the patient’s care, empiric evidence that the inclusion of these data in admission handoff improves patient safety has yet to be produced (with the exception of test results pending at transfer). Our study found that medical reconciliation, therapy precautions, and imaging results were missing among patients with adverse events more often than among those without adverse events, but these results were not statistically significant. Evidence supporting the inclusion of additional rehabilitation-specific handoff elements, which presumably improve patient safety, will endorse the need for and better clarify the standardization of rehabilitation admission handoffs. Please see Appendix 1 for a list of rehabilitation-specific handoff elements.
Handoff elements
Although poor communication is prevalent and associated with negative outcomes, the delineation of handoff elements and types of handoff information that are most important remains unresolved. Other than the association between omitted pending test results and adverse events, we found no other study that linked the absence of a particular element to an adverse event. Our previously mentioned AR study failed to correlate the absence of any one piece of relevant information with adverse events, although there were very few adverse events overall.
The criteria for evaluating handoffs or discharge packets vary among studies. The core elements include TJC requirements with additional elements determined by the study authors. TJC requires a medical reconciliation and 6 discharge summary elements. Additional elements apply if the hospital uses an electronic medical records (EMR) system and wishes to qualify for federal benefits.
The discharge summary, according to TJC Standard RC.02.04.01, should state:
- •
Reason for hospitalization
- •
Procedures performed
- •
Care, treatment, and services provided
- •
Condition at discharge
- •
Information provided to patient and family
- •
Follow-up care.
Although not explicitly required, others have thought it reasonable to expect activity restrictions, weight-bearing status, and diet instructions to be included also.
Instructions reviewing all medications are also among the information required to be provided to the patient. The medication reconciliation is meant to clarify discrepancies between discharge medications and medications taken before admission. TJC National Patient Safety Goal (NPSG 03.06.01) states that the process should include medication name, dose, frequency, route of administration, and reason for starting or changing doses. Beyond these defined elements, this NPSG also provides for the inclusion of other information that may be required to safely administer medications in the future: “Organizations should identify the information that needs to be collected to reconcile current and newly ordered medications and to safely prescribe medications in the future.” This infers the inclusion of recent international normalized ratio (INR) values for patients on warfarin, or serum drug levels for patients on antiepileptics.
Although anticoagulation information is not explicitly required, NPSG 03.05.01 is to “reduce the likelihood of patient harm associated with the use of anticoagulant therapy.” Routine short-term prophylactic anticoagulation is excluded, but only when “the patient’s laboratory values for coagulation will remain within, or close to, normal values.” Although heparin 5000 units subcutaneously every 12 hours would be excluded, warfarin with a goal INR of 1.8 to 2.2 would not. There is, therefore, some embedded responsibility placed on the discharging service to ensure that the admitting service receives all the information necessary to safely continue anticoagulation.
The federal certification criteria for “meaningful use” of an EMR require that other relevant clinical data elements be documented and shared. To qualify for financial incentives, the hospital, via its EMR, must “provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies, discharge summary, procedures) on request.” An additional criterion states that when a facility “transitions their patient to another setting of care…[it] should provide summary of care record.”
Despite these requirements, discharge summaries were absent or incomplete in 42.0% of admissions to AR and 21.0% to 29.7% of admissions to SAR. Medication reconciliation was absent or incomplete in 39% of admissions to AR, and information was missing in up to 35% on admission to SAR. Follow-up instructions, which were absent in 2.0% to 43.0% of a larger review of discharge summaries, were missing in 60.0% of AR admissions, and 11.1% of SAR admissions.
Additional nonrequired data elements that have been screened for on admission to AR and SAR facilities include:
- •
Laboratory results
- •
Radiology results
- •
Test results pending at transfer
- •
Anticoagulation instructions/relevant data
- •
Weight-bearing status/therapy precautions
- •
Steroid instructions
- •
Seizure treatment/prophylaxis instructions
- •
Antibiotic instructions/duration
- •
Wound care instructions
- •
Dietary restrictions.
A review of discharge-to-home paperwork by Kriplani and colleagues found diagnostic test results, including laboratory and radiology results, absent in 33% to 65% of discharge summaries. Laboratory results were missing from only 12.0% of AR and 17.9% of SAR admissions. Similarly, radiology results were missing from 20.0% of AR and 10.7% of SAR admissions. Our AR study found that radiology results were most likely to be omitted for trauma cases, and were included less frequently for patients who later suffered adverse events (60% vs 81%, nonsignificant). Information about test results pending at transfer was absent in 65.0% of general discharges and 47.2% of SAR admissions.
Anticoagulation instructions and pertinent information was specifically studied on admission to SAR by Gandara and colleagues. For their study, the Anticoagulation Task Force at Massachusetts General Hospital determined that the following elements are essential for safely prescribing warfarin:
- •
Indication
- •
Target INR range
- •
Treatment duration
- •
Last 3 INR values with dates
- •
Last 3 warfarin doses
- •
Recommended dose until next INR
- •
Responsible follow-up provider.
The same panel determined that to safely prescribe unfractionated heparin (UH) or low-molecular-weight heparin (LMWH), the following elements are essential:
- •
Indication
- •
Agent
- •
Dose
- •
Treatment duration
- •
Required monitoring (if indicated).
They found that discharge summaries contained all of the required information for only 16.4% of patients on warfarin and 45.4% of patients on UH or LMWH. The most common missing elements for UH of LMWH were duration of therapy (50.6%) and monitoring parameters (90.3%). For warfarin, recent INR (59.9%) and prior warfarin doses (55.0%) were most often absent, followed by identification of the follow-up provider. Interestingly, community hospitals and surgical services were more likely to provide this required information. Our AR study found that DVT treatment/prophylaxis instructions were missing in 40% of admissions, most frequently among those with a brain or spine diagnosis.
Weight-bearing status and therapy precautions, including brace and immobilization instructions, were missing in 52% of AR admissions. Similarly, steroid, antiepileptic, and antibiotic recommendations were missing in 56% to 62% of AR admissions. Of patients admitted with a brain diagnosis, steroid instructions (when indicated) were provided for only 11%, and antiepileptic instructions for 42%.
Although this information is absolutely necessary to continue the patient’s care, empiric evidence that the inclusion of these data in admission handoff improves patient safety has yet to be produced (with the exception of test results pending at transfer). Our study found that medical reconciliation, therapy precautions, and imaging results were missing among patients with adverse events more often than among those without adverse events, but these results were not statistically significant. Evidence supporting the inclusion of additional rehabilitation-specific handoff elements, which presumably improve patient safety, will endorse the need for and better clarify the standardization of rehabilitation admission handoffs. Please see Appendix 1 for a list of rehabilitation-specific handoff elements.
Barriers to handoff
For patient handoff to be effective, “both the sender and the receiver achieve a shared understanding and perceive the content in the same way.” This includes the concrete data elements (ie, vitals, laboratory tests), as well as the emphasis placed on them and their role in the decision making process. Although communication tools and frameworks have been recently introduced, no standardized formula has been developed that consistently results in such a shared mental model. Many of the obstacles that prevent effective handoff have been identified, though, and these may be minimized or avoided.
Some of the more insidious barriers to effective communication arise from individual means of filtering and processing information. As autonomy and individual performance are rewarded by the health care system, these factors may play a larger role. Our individuality arises from the sum of our personal experiences, which is influenced by the following :
- •
Identity (race, ethnicity, gender, age, and so forth)
- •
Culture
- •
Personality
- •
Language
- ○
Regional vernacular
- ○
Health literacy
- ○
Verbal expression and comprehension education
- ○
- •
Fears/Insecurities.
Considering the potential disparity between caregiver demographics and the community they serve, these variables require particular attention when providing education and handoff to patients and their families.
Previous health care experiences also affect our delivery and interpretation of handoff, and may be shaped by the following :
- •
Institutional protocols
- •
Prior cases (similar patients)
- •
Specialty or subspecialty focus
- •
Goals of care
- •
Hierarchy within the care team.
Perhaps easier to address, though, are some of the systematic barriers to handoff. These include workflow, institutional, and educational barriers. Workflow barriers refer to the challenges of finding appropriate time and space for handoff. For example, nurses have ongoing patient care requirements, unpredictable staffing shortages, time constraints, and possibly even simultaneous administrative responsibilities that form unique daily barriers to handoff.
Anesthesiologists reported handoff occurring in the midst of other attention-demanding activities. Furthermore, they may have been only transiently involved in the patient’s care and are therefore unable to provide a comprehensive handoff. A study of ER physicians reported that high workloads prevented them from reassessing a patient between handoff and transfer, and so the admitting service was rarely notified of any interim changes. This potential for communication failure may be amplified if there are long boarding times combined with provider shift changes.
Workflow barriers to handoff on admission to AR or SAR might often include a combination of the barriers mentioned previously. Physician-to-physician handoff is uncommon, and handoff more likely follows a path of discharging provider to social worker to admissions coordinator to physician. This complexity presents many opportunities for communication breakdown:
- •
The discharging provider may not be the primary provider and may not know the pertinent elements for that patient’s handoff (ie, mobility restrictions or anticoagulation instructions).
- •
Discharge paperwork is often completed in advance, and updates are not made while the patient is awaiting a vacant rehabilitation bed.
- •
The discharging social worker and provider may be overworked, making coordination for discharge planning difficult.
- •
The discharging provider may not be aware of the handoff elements that are most important for a rehabilitation provider to know on admission.
- •
When the patient arrives, which may be later in the evening, the discharging service may be unavailable to answer questions.
Institutional support and intervention with the goal of improving handoff could potentially address many of the workflow barriers. Historically, there has been limited oversight, standardization, and training of staff regarding proper handoff. This is likely related to a combination of caregiver resistance to practice change, the cost of implementing new handoff procedures, and the lack of research demonstrating the economic benefit of improved handoff. Although TJC Leadership Standards require that leaders “provide for an infrastructure that enables effective communication,” they do not specify the methodology or means by which this should be accomplished. Similarly, discrete outcome measures and goals are not set.
Related posts:
Patient Safety and Quality Improvement in Rehabilitation Medicine
Patient Safety Considerations in the Rehabilitation of the Individual with Cognitive Impairment
Patient Safety in Rehabilitation Medicine: Traumatic Brain Injury
Falls in the Inpatient Rehabilitation Facility
Safety Considerations During Cardiac and Pulmonary Rehabilitation Program
Patient Safety in the Rehabilitation of Children with Spinal Cord Injuries, Spina Bifida, Neuromuscular Disorders, and Amputations
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