Reducing the handoff errors after hospital discharge

As a long distance runner on my high school track team, I won few accolades in individual events, but shone in relays. My teammates and I spent hours perfecting our baton exchanges, which must occur within a limited area of the track, until these handoffs felt smooth and effortless. In contrast, world class athletes focused on individual performances are often assigned to relay teams at the last minute, a practice that led to stunning disqualifications for dropped batons of both the U.S. men’s and women’s 4 x 100 meter relay teams at the Beijing Olympics.

Dropped handoffs in medicine can expose patients to harm, too, even if individual clinicians are exceptionally skilled. An editorial in American Family Physician reviewed studies of programs designed to improve care transitions from hospital to home and found mixed evidence that such programs improve health outcomes:

Although some programs reduced 30-day rehospitalization rates, a systematic review found that no single intervention is reliably helpful, and successful readmission reduction programs generally occur only in single institutions. However, it seems that programs that focus on the whole patient rather than a specific diagnosis are more successful in reducing readmissions. This concept is in keeping with the focus of primary care physicians. To solve the challenge of care transitions, the primary care physician should have a prominent role at three times: at admission, immediately after discharge, and at the post-discharge follow-up visit.

Research on improving inpatient handoffs has evaluated the varying effectiveness of electronic handoff toolsstandardized communication training, verbal mnemonics, structural changes, and “handoff bundles” that include one or more interventions. Several residency programs at my institution recently found that an electronic template for graduating residents to hand off their “high risk” outpatients to other clinicians did not improve handoff quality or clinician satisfaction compared with free text handoff notes.

What other kinds of tools can be used to assure uninterrupted transitions of patient care from hospital to home, between clinicians in inpatient and outpatient settings, or between primary care physicians and subspecialists?

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor

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  • guest

    Here’s what it takes for us to have flawless discharge planning and a low readmission rate at our county hospital, where we treat a high volume of patients with complex illnesses and limited social supports.

    1. Each inpatient doctor is capped at ten patients.
    2. Each doctor’s team has a full-time social worker assigned whose responsibilities include communicating with families, coordinating outpatient appointments, and coordinating benefits as well as handling initial utilization reviews.
    3. Our hospital requires us to communicate telephonically with the patient’s outpatient physician, upon admission and again at the time of discharge, to provide a verbal hand-off.
    4. At some point prior to discharge, there is a team meeting involving the patient, their family, their outpatient case manager, the inpatient doctor and the inpatient social worker to review the discharge plan.
    5. We are required to generate a very detailed discharge summary before the patient walks out the door, which includes a current med list, results of lab work and diagnostic studies and a narrative explaining the course of the patient’s hospital treatment. This discharge summary is faxed to the patient’s PCP and outpatient mental health clinic.

    6. And most critically, in my opinion, no patient leaves our facility without scheduled follow up appointments, made by the social worker, and listed in detail on his or her AVS.

    This is what it takes, in our system, to ensure a seamless transition between inpatient and outpatient care. It’s really not rocket science, it’s all just common sense. The main problem with care transitions in our healthcare system is not that we don’t know what to do. It’s that we don’t want to dedicate the resources to make sure it actually happens.

  • Steven Reznick

    If they compensated the primary care physicians appropriately they would be able to care for their patients in the hospital AND as outpatients eliminating handoff problems.
    We might try to start decreasing handoff issues by first fixing them in the hospital and within different areas of the hospital. When the patient goes from a critical care area to the floor some departmental orders carry over ( imaging) and others do not ( lab, physical and speech therapy). Nurses, the emergency department and physicians ordering are on separate
    Software programs as the facility lumbers towards computerizing. Nurses no longer make bedside rounds with health care providers , the medication lists and orders so communication within the facility suffers. The level of coordination within my local hospital has become a safety issue.