Insights (Essays)

Insights (Essays) November -0001

Handoffs and Fumbles

Neil Seeman

Out of the fog of high-school football, I'll always remember the intensity of hand-off drills. Proper technique requires the player to make a wide pocket snug against his chest for the ball to thud into, and to stay low. If you don't practice every day, you will fumble at game-time. Pros make it look easy, but it's among the hardest techniques to execute.
In healthcare, handoffs are more complex; the consequences of a fumble can be dangerous; and there's a lot less practice than in high-school football. New evidence suggests that more handoffs now take place due to the fact that hospital residents' daily hours have been curtailed. Whatever the benefits to patient safety in having doctors less sleepy may be offset by the increased opportunities for handoff miscommunication.

It's an important area of healthcare management and policy demanding further study. A new paper by Teryl Nuckols and colleagues in the New England Journal of Medicine highlights the greater cost implications (in the US system) of reduced resident work hours. An analysis by James Browne and colleagues concludes that US resident duty-hour reform (during 2002-2004) was associated with an accelerated rate of increased patient morbidity following treatment of hip fractures in teaching institutions.

Other recent and international analyses have confirmed that miscommunication risks arise from increased frequency of handoffs; that few internal medicine residency programs have comprehensive care transfer systems in place; and that most do not provide formal training in sign-out skills to all residents. Recommendations have been made for improvements in standardized, simplified physician sign-out procedures; and for greater rigour in the design, measurement and evaluation of processes that help to identify gaps in knowledge about handover practice.

What Patients Say about Handoffs

Just as recent academic literature identifies rising concerns about handoffs, so too do patients. Examining the physician rating site, RateMDs.com, patients show agitation over the stress of nursing and physician shifts. Interestingly, patients, especially women giving birth, spend time coordinating their hospital encounters to ensure that their physician of choice is on duty throughout the course of their stay.

Consider a sampling of Canadian postings on RateMDs.com:

  • "…the nurses were too busy worrying about shift change and getting home to be concerned about my very difficult breathing problem."
  • "A new MD took my case over (shift change) and instead of discharging me he ordered 1 week of IV antibiotic - AVOID ****!!!!!!"
  • "Unfortunately it was right at shift change, so Dr.*** ended up delivering my son."
  • "I would try my damndest to hold on til shift change! She has absolutely horrible bedside manner and is very very rough!"
  • "I guess the fact that I arrived in full pre-term labour at shift change really annoyed her."
Lest one think that RateMDs.com is just a wall of patient complaints, it is important to note that over 70 percent of patient postings about physicians are positive. Yet when it comes to patient commentary about shift change and physician handoffs, postings appear to be generally disgruntled.

Since online social rating sites like RateMDs.com are a recent phenomenon, it is difficult to assess whether patients are saying the problem is getting worse. But patient narratives about their experience of shift changes offer a new testing ground for evaluating whether quality interventions underway to improve the relay of information are, in fact, working.

What Healthcare can Learn from Football

A football fumble is easy to see and to quantify. Teams keep statistics on dropped balls; they compare them with other teams; and they count how many of their fumbles result in games lost. If the team's fumbles are on the rise, chances are their losses are mounting, too. Coaches know how to respond: more drills, more concentration on technique, more standardization, more film reels showing players how the best teams do it.

Coach Vince Lombardi famously said: "Winning isn't everything. It's the only thing." To Lombardi, the consequences of a loss were too profound. Machismo aside, this is a good lesson for healthcare on how not to drop the ball.

About the Author(s)

Neil Seeman is a writer, and Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College at the University of Toronto.

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