Danger Zone: Signout

by Stephen Strasberg, MD

Handoff = Signout = Dangerous

It is well known that patient handoffs are a dangerous time for patients.  Information is exchanged and whenever this happens, inevitably something gets lost in the mix.

What can you do to help your patients?  Have a system.  Any system really, but just having a system in place to signout or handoff patients in a systematic way will reduce medical errors and keep your patients safer.  There are numerous systems out there.  JCAHO and WHO use SBAR.  Our friends and UNM (University New Mexico) use PLAN ED.  Here is their policy.

  • “Run the List” (go over next steps for all patients so that a clear plan is presented at handoff) within the hour leading up to the shift change with the attending.
  • Reevaluate high-risk patients (patients who have already been handed off once and/or who do not have a clear diagnosis or disposition plan) within the hour leading up to handoff.
  • Write down key lab values for acutely ill and complicated patients within thirty minutes of handoff. Time permitting, radiology findings and current vital signs should also be included.

 

Handoff Presentation

All providers should use the same structured format for handoff presentations in order to facilitate the consistency and completeness of communication among providers and nursing staff.

 

PLAN ED
Patient (age, sex, name, room number and chief complaint)
Label with working diagnosis or differential diagnosis
Assessment (key elements of history, physical exam, labs, diagnostic imaging)
Next steps and nursing assessment (pending labs, diagnostic imaging, consultants)
Everything else (social issues, handed off before, systems issues)
Disposition

 

General Handoff Guidelines:

  • Plan to spend 1 to 3 minutes on each patient, depending on complexity
  • Spend approximately 5 minutes on clinical teaching
  • Be on time and prepare for handoff early so that handoffs can start when scheduled
  • Organize handoffs by doing selected “bedside waking rounds”

 

Proven Techniques for Effective Handoffs

  • Incorporate the use of written notes and/or electronic medical records (EMR) in handoff (has been proven to reduce physical exam and lab result memory errors, especially for patients who have been in the ED for prolonged periods of time)
  • “Repeat back”: accepting provider repeats plan of care to outgoing provider to create closed-loop verification of critical information
  • Engage in interactive questioning
  • Reduce interruptions
  • Reduce signal-to-noise ratio (background noise)

 

Other General Recommendations

  • Officially admitted patients (have bed request and orders) should have a very brief handoff by the outgoing resident to the accepting attending; if the patient had admitting orders at the time of the previous handoff the outgoing attending provides the handoff to the accepting attending.
  • Within 15 minutes of the end of handoff, the accepting resident should assign himself or herself as the resident provider in the FirstNet tracking system.
  • Within the first 2 hours of the shift, patients that were handed off should have had their chart, laboratory and other findings reviewed and the resident should have physically introduced himself or herself.
  • Handoff communication guidelines (based on Grice’s Maxims)
  1. Include only relevant information.
  2. Be brief.
  3. Be orderly by using the PLAN ED framework.
  4. Be honest. If someone asks a question that you are not 100% sure about (i.e. lab value or result of a scan), find out the answer after the handoff and follow up with the most accurate answer.

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