Most academic healthcare systems have been welcoming their new incoming residents and fellows in that past 2 weeks. Fortunately, most programs are now incorporating patient safety training into their orientation programs for those new members of the healthcare team. And many have begun to incorporate specific sessions on the importance of handoffs and introduced them to the structured formats that we have been using at our individual organizations.
So it is timely that the June 1, 2009 issue of the Medical Journal of Australia contains an entire supplement dedicated to clinical handoffs. It covers handoffs from offices, from long-term care units to emergency rooms, using TeamSTEPPS training to improve communication in a mental health unit, use of video recordings of handoffs in emergency departments to improve communication, use of whiteboards, use of a standardized communication tool for maternity settings, a framework for communication in a post-anesthetic care situation, plus your more common in-hospital and inter-hospital handoffs.
They have articles on two modifications of the well-known SBAR format. One is the SHARED (situation, history, assessment, risk, expectation, documentation) format. The second is the iSoBAR (identify–situation–observations–background–agreed plan–read back) format, which they have used as a clinical handover checklist.
If you don’t have subscription access to the Medical Journal of Australia (it is not included in most of our academic electronic journal collections but you can purchase 1-week online access to it for about $25), you can still read about the iSoBAR program at the Australian Commission on Safety and Quality in Health Care website and download for free some really great materials about the tools developed and how to use them.
Communication problems underlie at least 75% of sentinel events and can be found as an important contributing factor in almost every root cause analysis (RCA) that we do. It is well-recognized that handoffs are a high-risk activity from a patient safety perspective. Development of structured handoff formats has been an important milestone in patient safety. The SBAR (Situation-Background-Assessment-Recommendation) format was originally developed in the Kaiser-Permanente health system and has been widely adopted as a handoff tool.
Perhaps the biggest problem with handoffs is that they all too often tend to be one-way in practice. On the other hand, good handoffs are clearly two-way communication sessions. They should be conducted in an environment that is conducive to interaction and not subject to interruptions. The most important things are allowing adequate time for the “recipient” to ask questions and seek clarification and for both parties to clearly understand and agree on what needs to be done. Therefore, a regional and national collaborative in Australia modified certain elements of the SBAR format to better recognize these needs (Porteous et al 2009). Involving teams with clinicians, nurses and others, they analyzed data from multiple sources and developed both standardized operating protocols (SOP’s) and minimum datasets (MDS’s) that could be integrated into checklists and/or forms to be used for handoffs and transfers of care. However, one concept they emphasized was that, even though they ultimately want a structured and standardized format, flexibility and the ability to adapt the process to meet needs at the local level were essential. That flexibility plus engagement of clinicians to apply the concept within the context of their local healthcare environment is important in influencing both ownership and adoption of the processes and tools. So they both added to and made some subtle, but important, changes to the SBAR format. The additions are the “i” for “identify” (identify yourself and the patient) and the “o” for “observations” (factual information about the patient’s condition, diagnostic studies, etc.). But it is the changes that are the most important features. The “a” has been changed from assessment to “agreed plan” and the “r” has been changed from recommendation to “read back”. The latter is important to clarify for all parties a shared understanding of the plans and who is responsible for what. The resulting acronym iSoBAR thus stands for:
A Agreed Plan, Accountability
R Read Back
While one of the tools first developed using iSoBAR was an inter-hospital transfer form, the concept and checklist can be readily adapted to multiple other types of handoff, including the typical change-of-shift handoffs that nurses and physicians do daily in hospitals. One group (Yee et al 2009) refined the process even more. Their team conducted extensive interview and observation sessions, and analysis of not only verbal and written handoff content but also factors such as body language and frequency of interruptions. Through an interative process they arrived at a new SOP and MDS with the catchy acronym “HAND ME AN iSoBAR”. The “iSoBAR” part is unchanged from above but the additions are helpful in operationalizing and preparing for your handoffs.
The HAND part stands for:
H Hey, it’s handover time!
A Allocate staff for continuity of care
N Nominate participants, time and venue
D Document on written sheets and patient notes
This ensures that all the pertinent parties are available for an effective handoff and that sufficient arrangements have been made for others to provide patient care so that minimal interruptions occur during the handoff.
The ME part stands for:
M Make sure all participants have arrived
E Elect a leader
This means ensuring protected time for all parties, that sessions will be prompt, and that one person ensures the agenda items are covered in a timely fashion.
The AN part stands for:
A Alerts, attention, and safety
This part is really about prioritizing and anticipating. The alert and attention part is to make clear to everyone the items that need to be addressed first (eg. patients who are deteriorating, test results that need to be checked soon, etc.) and other items that may be important for patient safety and safety of staff and others. The “notice” part deals with anticipating all potential patient movements so that arrangements can be made for changes in workflow.
In hospital pilot projects, the Yee group was able to adapt the “HAND ME AN ISOBAR” approach to shift-to-shift handoffs for both medical and nursing staffs on general medicine, general surgery, and emergency medicine. The concept has been well accepted in those settings. They are now in the process of testing the concept in multiple other clinical settings and collecting data about the effects on clinical outcomes.
They stress the importance of a culture change in recognizing the importance of the clinical handoff and making it a priority.
Those of you who are regular readers of our columns know we are proponents of using videotapes with feedback to help improve communications in multiple venues (see the discussions on the sterile cockpit in our Patient Safety Tips of the Week for October 2, 2007 “Learning from Tragedies. Part II”). One of the articles in the MJA supplement (Iedema et al 2009) used such videotaping in improving the handoff process. They used a “video-reflexive” tool called HELiCS (Handover-Enabling Learning in Communication for Safety) to redesign handoff processes in emergency department and ICU settings. They began with discussing handover processes, observing some actual handovers, and then watching videotapes of themselves during actual handoffs. This led to the clinicians improving both their intra- and inter-disciplinary communications and redesigning multiple facets of their handoffs. Videotapes are powerful tools for promoting change. Just like we use “story telling” and “personalization” as powerful tools to effect change in multiple aspects of patient safety, use of videotapes personalizes whatever process is being reviewed and makes one both aware of his/her interactions and remember them.” and May 26, 2009 “
There are multiple other great lessons in this MJA supplement. They are well worth your time. Also, take some time to play with the downloadable educational toolkit on iSoBar from the Australian Commission on Safety and Quality in Health Care website.
Kudos to our Australian colleagues who have taken the lead in developing, validating and piloting a number of tools to improve the handoff process. It should be emphasized that measuring the impact of implementing these tools is not yet complete but it is expected that publication of that data will be forthcoming in the near future.
Clinical handover: critical communications
Med J Aust 2009; 190 (11 supplement): S108-S160
Western Australia Country Health Service and Royal Perth Hospital. iSoBAR for Inter-hospital Patient Transfers. Austrailian Commission on Safety and Quality in Health Care website.
Porteous JM, Stewart-Wynne EG, Connolly M, Crommelin PF. iSoBAR — a concept and handover checklist: the National Clinical Handover Initiative . Med J Aust 2009; 190 (11): S152-S156.
Inter-Hospital Patient Transfer Form (from the WACHS Clinical Handover Initiative)
Yee KC, Wong MC, Turner P. “HAND ME AN ISOBAR”: a pilot study of an evidence-based approach to improving shift-to-shift clinical handover. Med J Aust 2009; 190 (11): S121-S124.
Iedema R, Merrick ET, Kerridge R, Herkes R, Lee B, Anscombe M, Rajbhandari D, Lucey M, White L. Handover — Enabling Learning in Communication for Safety (HELiCS): a report on achievements at two hospital sites. Med J Aust 2009; 190 (11): S133-S136.
See also some of our prior columns on handoffs:
February 26, 2008 “”
September 30, 2008 “Hot Topic: Handoffs”
December 2008 “Another Good Paper on Handoffs”
April 13, 2010 “Update on Handoffs”