The perils of the hand-off

One of the more vulnerable places on the health care continuum is the point at which patients make the transition from one provider to another – switching from the daytime staff to the night shift at the hospital, for instance, or leaving the hospital to go home or to a skilled nursing facility.

It’s known as The Hand-Off, and it’s a time when things can frequently go wrong. Sometimes important information isn’t communicated, or incorrect assumptions are made. Sometimes there’s simply a failure to think far enough ahead to anticipate potential problems.

One of the latest case studies posted on the Agency for Healthcare Research and Quality’s online morbidity and mortality rounds illustrates how easy it can be for a transition in patient care to go awry.

An anesthesiologist has trouble removing a spinal drain from a patient who has undergone surgery. After consulting with a neurosurgeon, it’s agreed to remove the catheter under general anesthesia in the operating room. But this information isn’t passed on to the anesthesiologist who is on call for the night, nor does the anesthesiologist look at the patient’s chart. Instead, she attempts to remove the spinal drain in the preoperative area while the patient is awake. The catheter breaks, leaving a portion inside the patient and necessitating surgery to remove it.

Could this have been prevented? There were probably several steps that could have been taken to ensure better communication, the case reviewers concluded:

Fundamentally, handoffs should become a sacred ritual, as common as the checklist in a cockpit, in which the incoming provider also asks questions to elicit potentially undocumented or unusual circumstances. The basic question should be: “Is there anything unusual I need to know about this patient or procedure or what’s going on currently that might impact what I do or how I do it?” This sounds so simple. But when things generally go well, and when production pressure is routine, providers can become complacent about risks.

Achieving a smooth hand-off is harder than it looks. A couple of years ago the Harvard Risk Management Foundation devoted an entire issue of its quarterly patient safety publication to the pitfalls of the handover and strategies to help make it safer.

One particular form of the handover – discharge from the hospital – is getting a lot of attention these days. Hospital readmissions have become a big deal, not only for their cost but also for their impact on patients. Increasingly, readmission rates are being viewed as a key indicator of quality of care. Just last week, the New Jersey Hospital Association announced a year-long, statewide initiative to reduce the number of patients with congestive heart failure who are readmitted to the hospital within 30 days.

Obviously there are multiple reasons why someone might end up back in the hospital, and a certain number of readmissions are probably inevitable. There could likely be fewer of them, however, if there were a better hand-off process at the time of discharge.

Patients and families might think they have little influence over the handover but they’d be wrong. There are a lot of things they can do, starting with being more assertive and involved. An article last week in the New York Times lays out some of the tactics, including the need to take charge:

In the hospital, multiple people may have been involved in supervising a patient’s care: a surgeon, a nurse, an attending fellow and a discharge planner.

That means it’s up to patients and their advocates to make sure discharge plans are sound and to challenge any information that doesn’t add up.

(I’d add that while most of the discussion about discharge planning and handovers centers on elderly patients, you don’t have to be old to fall through the cracks during a hospital hand-off; young patients can get into trouble too with a hand-off that’s perfunctory or incomplete.)

Unfortunately, many people are unaware of the perils of the hand-off – unaware, that is, until they or someone in their family is hospitalized and things deteriorate because of a badly managed transition. It’s a tough lesson that perhaps hasn’t been emphasized for consumers as much as it should be. When people know transitions in care are an important and vulnerable time, they can be better prepared to help make the handover go more smoothly.

One thought on “The perils of the hand-off

  1. Excellent Article.
    I was speaking with the CMO of a large Boston-area hospital. He said that “everyone knows ACO’s are coming. Everyone knows that in the future providers’ compensation will be tied to outcomes. But the sad fact is that TODAY we are still be paid for services rendered. So today no hospital is going to pay for anything that will improve handoff communications.”

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