The increasing fragmentation of health care has resulted in more care transitions. This fragmentation includes by site (emergency rooms, ambulatory clinics, nursing facilities, rehabilitation) or physician specialty, which can be either organ-based (eg, cardiologists, nephrologists) or site-specific specialties (eg, emergency medicine physicians, critical care physicians). Hospitalists, of course, are the newest site-specific specialty to arrive on the health care scene. Increasingly, hospital care has become a field that focuses on the elderly, with over 50% of patients admitted to hospitals being older and often with several comorbidities.

This fragmentation has resulted in a greater need for care coordination and a focus on transitions, particularly for elderly patients. For example, the average primary care physician who sees 100 Medicare patients coordinates with 99 other doctors in 53 different practices. Moreover, 40% of hospitalized Medicare patients do not have a simple “hospital to home” transition, instead having brief stays at either a rehabilitation facility or a skilled nursing facility. Unfortunately, prior literature has illustrated that communication between hospital-based physicians and outpatient physicians is poor. While two-thirds of primary care physicians believe the use of hospitalists is a good idea, roughly half were satisfied with their experience communicating with hospitalists, and few received discharge summaries in a timely fashion to facilitate safe and effective management of their patient in the ambulatory setting.

In addition to care transitions in and out of the hospital, hospital care itself has become increasingly fragmented due to increased numbers of handoffs with the implementation of resident duty hour restrictions and the adoption of the familiar shift-work systems utilized by hospitalists. For example, for a typical patient, a member of the patient’s primary team is present in the hospital only 50% of the time. Hospitalized patients are passed between doctors an average of 15 times during a single 5-day hospitalization.

Despite the ubiquitous nature of handoffs and care transitions, numerous studies suggest that care transitions and handoffs are plagued by communication errors, which ultimately can lead to patient harm. As a result of these concerns, prevention of handoff errors has been the subject of numerous policy and patient safety initiatives. Namely, The Joint Commission made implementing a “standardized approach to handoffs” a national patient safety goal for acute care hospitals in 2006. That same year, the World Health Organization labeled prevention of “handover errors” as one of the top five patient safety solutions, giving it equal footing with such high-priority solutions as hand hygiene. Physician groups have also taken notice. In 2009, six medical societies representing four different specialties (emergency medicine, geriatrics, general internal medicine, Hospital Medicine) came together for an unprecedented collaboration to acknowledge the importance of care transitions through creation and approval of a Transitions of Care Consensus Policy Statement for care transitions. The general tenets of effective handoffs include such principles as accountability, communication, timely inter-change of information, and involvement of the patient and family members, among others.

Hospitalists have also played leading roles in advancing care transitions. The flagship organization for hospitalists, the Society of Hospital Medicine, has made handoffs part of its core competencies of Hospital Medicine. Going one step further, the Society of Hospital Medicine also convened a task force and released recommendations for hospitalist handoffs. The Society of Hospital Medicine, in partnership with the Hartford Foundation, has also created Project BOOST (Better Outcomes for Older Adults through Safe Transitions) to help delineate the components of effective discharge for hospitalized older patients.

Despite these initiatives, handoffs remain problematic and error prone. One of the biggest challenges to understanding handoffs is trying to delineate the many types of handoffs. To understand strategies for effective handoffs, it is first critical to understand the types of handoffs and the properties of handoffs that are associated with increased risk to patients.

The handoff is

• a fluid, dynamic exchange that is subject to distraction, interruptions, fluctuates on aptitude of and confidence in off-going and on-coming clinician and is contingent on the on-coming clinician’s confidence in the quality, completeness of the information.

Cook et al. (2000)

While the scope of Cook’s definition refers primarily to shift change, the term handoffs has taken on a life of its own, with the term being used synonymously with a broader set of care transitions, such as admission, discharge, and even communication between outpatient physicians. Using this approach, we have divided handoffs into those that are either entirely intrahospital or those that are extrahospital—that is, they involve some component outside of the index hospital.

Admission

Hospital admission is a complex process that could include triaging a patient to the inpatient ward of a hospital from the admission source, such as (1) a home, (2) an emergency room, (3) a clinic, or (4) a skilled nursing facility. The admission process itself includes multiple handoffs, such as from Emergency Medicine Services (EMS) personnel to the emergency medicine physician, and from emergency medicine staff to hospital staff. Because the emergency room is considered to be an ambulatory care site, the handoff from the emergency room to the hospital ward is considered extrahospital.

Discharge

Discharge is also a complex process by which a patient exits the hospital after the need for acute care is resolved or lessened. The patient could be discharged either to home for independent living, home with temporary or permanent home health services, or to another facility for ongoing care, which can either be temporary (eg, acute or subacute rehabilitation) or more permanent (eg, skilled nursing facility, hospice unit). Clinical responsibility and follow-up care for the patient can be transferred from a hospital based clinician (eg, hospitalist, ward attending) to a primary care physician, or one physician could assume care of both the inpatient and the outpatient setting. This type of handoff also necessitates that caregivers and patients assume a higher level of ongoing responsibility for a patient, and therefore often involves active preparation of caregivers and patients to assume the care of the patient. Several social factors, such as family or caregiver support, home health services, and patient ability to live independently may influence how and where a patient is eventually discharged.

Interhospital Transfer

Transfer from one hospital to another is typically due to either insurance reasons, patient preference; or the need for a higher level of care at a secondary or tertiary care hospital.

Intrahospital Handoffs

Shift Change

Shift change is the transfer of content and professional responsibility from one clinician to another at the end of the shift. One important distinction among shift changes is whether the outgoing clinician is assuming ongoing care of this patient or the handoff is just a temporary coverage for emergencies until the primary team returns. In the case of the latter, the covering physician is often accepting a handoff only to manage overnight emergencies, but planning and execution of care are largely on hold.

• Signout: A type of shift change that often preferentially refers to a primary team who is assuming care of the patient and transfers care temporarily to another clinician and that primary team member will return to assume care of patient. Can also refer to the written document used to transfer information.
  
• Cross-coverage: The care that a clinician provides when “covering” a patient whose daily responsibility is assumed by another clinician or team.

Service Change

A service change is a permanent transfer of content and professional responsibility at the end of one’s on-service time or rotation to a new physician or team of providers who will assume ongoing care of the patients. This service handoff is often more extensive and includes description of the initial reason for the patient’s need for hospitalization, hospital course to date, current status, and anticipated plan of care, including discharge.

Service Transfer

Service transfer is the change of service of a patient from care of one group of clinicians to an entirely different group of clinicians, usually from a different specialty or ward, to receive a different service that is unique to the receiver’s specialty or ward. This could include an “escalation of care” due to worsening patient illness (transfer to the intensive care unit) or transfer to a subspecialty service for a specific management issue (transfer from medicine team to surgical team for procedure and postoperative care).

Lastly, it is important to acknowledge that outside of the United States, in Europe and Australia, the most frequently used term to describe handoffs is actually handover.

In considering the various risks associated with these handoffs, a white paper from University HealthSystem Consortium suggests that the following three questions be used to triage risk to patients during handoffs: (1) Is the patient physically moving? (2) Is the handoff permanent (more than just a few hours or a night)? (3) Is the patient unstable? If the answer to any of these questions is a yes, then the risk is inherently higher. Therefore, the highest risk transitions may be admission—the patient is unstable, moving, and it is a “permanent handoff,” meaning more than just a few hours. Another example would be the interhospital transfer of a patient from a lesser acuity hospital to a hospital to receive intensive unit care.

In addition to these questions to stratify risk during handoffs, another philosophy that has emerged is the concept of “common ground”—or rather how much knowledge do the incoming and outgoing clinicians already share about the patient? When a receiver may not know a patient at all, the handoff may be at greater risk due to the high degree of uncertainty that can cloud the initial evaluation of a patient. Uncertainty is a definite risk for patients and has been demonstrated to lead to patient harm or near misses and inefficient work in both resident signouts and hospitalist service changes. Therefore, handoffs are inherently risky when the receiver does not have any a priori knowledge of the patient (Table 9-1).