Reviewing the Literature NURS6125, section 23, Integrating Theory and Research for Evidence-Based Practice February 12, 2011 Reviewing the Literature Patient handoffs are an integral part of taking care of people in all patient care settings. Patient handoffs occur at many different times throughout a facility including shift changes, provider break times, inter-departmental transfers, when a patient may travel for testing. Patient handoff definitions vary widely, but the most simplified version found was anytime responsibility for the patient shifts from one provider to another (Dorsey & Litzenburg, 2010).
Although essential for care, these necessary information exchanges are extremely high-risk for patients. Communication errors were found to be a factor in two-thirds of sentinel events over a ten year period (Riesenberg, Leitzsch, & Cunningham, 2010). Since that has been shown, it is believed amongst the health community that standardizing handoffs would result in safer care (Patterson & Wears, 2010). After a thorough review of the literature, it seems that there is much opinion about the subject of patient handoff, but not as much actual evidence. Riesenberg, et. , al. 2010) conducted a systematic review of the literature on patient handoffs from 1987 through August 2008, using recognized, peer-reviewed , databases such as Ovid and CINAHL. Of the original 2,649 articles identified 469 were reviewed further. Of those studies only 95 met criteria to be assessed further (Riesenberg, et. al. , 2010). The purpose of the research was to seek common themes in both barriers and effective strategies in quantitative and qualitative studies on patient handoffs (Riesenberg, et. al. , 2010). 75 qualitative studies were identified and analyzed using content analysis (Riesenberg, et. l. , 2010). 20 quantitative studies were identified and analyzed using a modified Downs and Black scale called The Quality Scoring System (Riesenberg, et. al. , 2010). Using the modified scale of possible 1-16 rating 85% of articles rated < or equal to 8 (Riesenberg, et. al. , 2010). Eight common barrier themes emerged. These included communication barriers, problems with standardization, equipment issues, environmental issues, lack or misuse of time, difficulties related to complex or high patient caseload, lack of training or education, and human factors (Riesenberg, et. l. , 2010). Interestingly, of all studies reviewed the barrier categorization of Riesenberg, et. al. (2010) covers each and every barrier identified. For example, Anderson, et. al. (2010) point to lack of standardization as a barrier to safe handoff practices. Patterson and Wears (2010) pointed out noisy, high-pressure environments as one example of a barrier to implementation of safe practice. Riesenberg, et. al. (2010) also identified seven common themes for strategies leading to effective patient handoffs.
These were communication skills, standardization strategies, technologic solutions, environmental strategies, training and education, staff involvement, and leadership (Riesenberg, et. al. , 2010). Again, these are common themes throughout all of the given research. Although, the findings suggest a firm handle on what makes an effective and efficient patient handoff, the research authors state more investigation is needed to understand the process (Riesenberg, et. al. , 2010).
Risks for not conducting further research are cited as wasting resources on interventions that are not effective and provider burnout and future reluctance to implement change (Riesenberg, et. al. , 2010). Dufault, et. al. (2010) used Roger’s diffusion of innovation theory to complete the first three steps in implementing a practice protocol and patient handoffs. The protocol was associated with Sigma Theta Tau International and conducted in a Magnet designated facility Dufault, et. al. (2010). Perhaps that is why the content was geared much more toward theory, and also made connections other authors did not (Dufault, et. l. 2010). For example, the researchers linked handoffs to patient satisfaction and Press Ganey survey scoring, as well as staff satisfaction (Dufault, et. al. 2010). Another interesting, and previously unread link, was that handoff communication may affect a negative attitude upon oncoming staff, therefore effecting patient care negatively (Dufault, et. al. 2010). Other barriers identified by the research team were uncovered by the other teams as well. Research by Matic, Davidson, & Salamonson (2010) as well as Anderson et. al. (2010) looked at implementation of electronic standardization of handoff tools. Matic et. l. (2010) conducted a literature review to discover what ways handoff was occurring, and how that information was being communicated from one caregiver to another. Electronic tools for handoff are one way to standardize information transfer among caregivers. 126 articles were analyzed from 1997-2008. The review found that team morale and cohesiveness is built at patient handoffs, it is not simply an exchange of information (Matic, et. al. , 2010). The team also found time spent at handoff may be excessive, the information given may be subjective, and there was limited research on specific methods of handoff (i. . verbal versus written, or a combination of the two), from any available sources searched (Matic, et. al. , 2010). The researchers point out any report method will have positive and negative attributes, staff must understand and commit to the underlying safety change (Matic, et. al. , 2010). Anderson et. al. (2010) was a mixed method single intervention type study. Although conducted with physicians at Veterans Affairs hospitals, the lessons can be applied to handoffs in other areas as well.
Researchers looked at what the residents were using for patient handoff, and found haphazard, scraps of paper or sometimes an incomplete verbal reporting off (Anderson, et. al. , 2010). They then designed a tool with a minimum set of data such as demographics, code status, medications, allergies, etc. that auto-populated from the medical record system, as well as areas that had to be filled in such as condition, vitals, etc. (Matic, et. al. , 2010). The researchers then tracked the use of the new report sheet, and compliance with the minimum dataset (Matic, et. al. , 2010).
The new system had increased data accuracy and content, was legible, standardized, and always had the physicians current patient. Inadvertently, researchers discovered that some of the auto-population software was not working as intended. The issue was quickly resolved (Matic, et. al. , 2010). Finally, Patterson & Wears (2009) conducted a literature review on patient handoffs and found 400 articles pertaining to the subject. They organized handoffs into themes or “framings” for the purpose of the handoff. Their research states that there are essentially seven purposes for patient handoffs in healthcare today (Patterson & Wears, 2009).
Those reasons are: Information processing, stereotypical narratives, resilience, accountability, social interaction, distributed cognition, & cultural norms (Patterson & Wears, 2009). The researchers contend that to effectively change the risk for patients during handoffs, providers must keep the reasons for the handoff in mind (Patterson & Wears, 2009). They also warn against oversimplifying handoffs, and explicitly state that a single, standardized, tool cannot be recommended at the time of the study being published (Patterson & Wears, 2009).
Limitations for all studies seem to be that none of them measure how accurate the data given from one caregiver to another during handoff procedures. Also, no one knows how many safety events occur as a direct result of handoffs or secondly how many near-misses occur. This data with root cause analysis would be extremely helpful in fixing things at an individual system level at the very least. Lastly, some researchers seem to be affiliated with certain groups. For example, Patterson is a member of the Editorial Advisory Board for The Joint Commission Journal on Quality and Patient Safety.
Although the preliminary literature review agrees upon strategies for success such as standardization and two way communication, more research needs to be done on the actual process of patient handoff between caregivers. It is essential to the safety of our patients. References Anderson, J. , Shroff, D. , Curtis, A. , Eldridge, N. , Cannon, K. , Karnani, R. , & … Kaboli, P. (2010). The veterans affairs shift change physician to physician handoff project. The Joint Commission Journal on Quality and Patient Safety, 36(2), 62-71. Retrieved from