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Abstract

  1. Top of page
  2. Abstract
  3. Overview of Communication Modes in Hand-Offs
  4. Critical Elements of Effective Transition
  5. Conclusions
  6. References

ACADEMIC EMERGENCY MEDICINE 2012; 19:1188–1195 © 2012 by the Society for Academic Emergency Medicine

Abstract

Patient care transitions across specialties involve more complexity than those within the same specialty, yet the unique social and technical features remain underexplored. Further, little consensus exists among researchers and practitioners about strategies to improve interspecialty communication. This concept article addresses these gaps by focusing on the hand-off process between emergency and hospital medicine physicians. Sensitivity to cultural and operational differences and a common set of expectations pertaining to hand-off content will more effectively prepare the next provider to act safely and efficiently when caring for the patient. Through a consensus decision-making process of experienced and published authorities in health care transitions, including physicians in both specialties as well as in communication studies, the authors propose content and style principles clinicians may use to improve transition communication. With representation from both community and academic settings, similarities and differences between emergency medicine and internal medicine are highlighted to heighten appreciation of the values, attitudes, and goals of each specialty, particularly pertaining to communication. The authors also examine different communication media, social and cultural behaviors, and tools that practitioners use to share patient care information. Quality measures are proposed within the structure, process, and outcome framework for institutions seeking to evaluate and monitor improvement strategies in hand-off performance. Validation studies to determine if these suggested improvements in transition communication will result in improved patient outcomes will be necessary. By exploring the dynamics of transition communication between specialties and suggesting best practices, the authors hope to strengthen hand-off skills and contribute to improved continuity of care.

Resumen

Las transiciones en la atención del paciente entre distintas especialidades son más complejas que entre la misma especialidad, pero las características técnicas y sociales permanecen sin explorar. Todavía existe poco consenso entre los investigadores y los médicos sobre las estrategias para mejorar la comunicación entre especialidades. Este artículo conceptual aborda este vacío y focaliza en el proceso del pase entre los urgenciólogos y los médicos de medicina del hospital. La sensibilidad a las diferencias culturales y operativas y una serie común de ideas concernientes al contenido del pase preparará de forma más efectiva al próximo médico para actuar de forma segura y eficiente en la atención del paciente. A través de un consenso en el proceso de toma de decisiones entre autoridades reconocidas y experimentadas en transiciones sanitarias, que incluye médicos de ambas especialidades y expertos en estudios de comunicación, se proponen unos principios de contenido y de estilo que los clínicos pueden usar para mejorar la comunicación de la transición. Con representación de los escenarios universitario y comunitario, las similitudes y diferencias entre la medicina de urgencias y emergencias y la medicina interna se destacan para realzar la apreciación de valores, actitudes y objetivos de cada especialidad, particularmente en lo perteneciente a la comunicación. También se evalúan los diferentes medios de comunicación, los comportamientos sociales y culturales, y las herramientas que los médicos utilizan para compartir la información sobre la atención del paciente. Se proponen medidas de calidad en la estructura, el proceso y los resultados para las instituciones que buscan evaluar y monitorizar estrategias de mejora en la realización del pase de pacientes. Serán necesarios futuros estudios de validación para determinar si estas mejoras sugeridas en la comunicación del pase resultan en la mejora de los resultados del paciente. Mediante la exploración de las dinámicas de la comunicación de la transición entre especialidades y sugiriendo prácticas mejores se espera reforzarlas tareas del pase y contribuir a mejorar la continuidad de los cuidados.

Emergency physicians (EPs) and hospital-based internists share an intimate working relationship due to similarities in professional responsibilities and increasing quantity of interactions. Integral to this relationship is the communication associated with interunit patient care transition from the emergency department (ED) to the inpatient service. In 2006, EPs admitted over 17 million patients to hospitals in the United States, approximately half of all nonobstetrical admissions.1 A majority of these patients were admitted to an internal medicine service, often under the care of an internist or hospital medicine physician (HMP).2

The effectiveness of hand-off communication has been a matter of concern in health care for over a decade.3–10 Communication failures during hand-off can lead to preventable adverse events.11 Most efforts to facilitate hand-offs in health care have been specific to local facilities and intended for physicians of like specialties.12–15 Interunit hand-offs (i.e., occurring between different specialties) is likely to present additional challenges because each specialty has a different set of needs and expectations regarding health care-related communication, which has been culturally imparted over years of training and experience. The complex, dynamic task of hand-off, often viewed as a moment of vulnerability (or potential rescue) for the patient, may benefit from jointly understood expectations on process and content.16–21 Attempts to use all-inclusive lists of patient care information have been proposed by some to improve transition communication, but these efforts may simply deluge the recipient physician and be less effective than a more thoughtful and economical approach. Although consensus statements exist for transitions between settings, and specifically for ED–ED transition, to which authors in this article have contributed,15,18 there is little research on interventions that work effectively for EM–HMP transition. In light of the challenges, specifically noted by Snow et al.,18 that the “variety of variables precludes a single approach to ED transition of care coordination” the authors (four EPs, three hospitalists, a general internist, and two communication researchers) propose suggestions for improving transition communication through a review of existing literature and a consensus-oriented decision-making process.

We propose “best practice” principles for communication in the transition of care from EP to HMP, address challenges to adopting these recommended practices, describe difficult clinical scenarios frequently encountered, and offer suggestions for research and quality measurement. We balance the discussion of the realities of performing the “task” of transition with a discussion of achieving proficiency. Transition communication is a task because it is a component of the care process that is not optional. Little is known about EM-HMP hand-offs, and as such, these recommendations are based on reported literature as well as expert opinion. Unlike other intended safety improvements, some of which add to task complexity and result in less safe conditions, this organized approach to transition communication does not require a checklist, substantial additions to work process, or changes to current cognitive work flow.22–24 It is designed to maximize the value of the EP’s clinical evaluation, to encourage transactional conversation, and to match typical workflow. We emphasize the importance of sense-making and understanding between individuals, rather than a one-way dialogue of data dumping, as a vital component of performing this task to assure the next party is prepared to act safely and effectively in caring for the patient.

Recommendations were arrived at through a systematic, interactive, consensus-oriented decision-making process.25 We began with a structured outline and shared literature review and convened bimonthly discussions over a 10-month period. Consensus was achieved independently and as a group. This was a participatory, egalitarian, and collaborative approach. Validation of these recommendations through empirical observations or modification by experience will be necessary. Formative evaluation of the proposed suggestions, sensitive to variations in local context, may provide substantive knowledge toward understanding patient care transition communication further. We anticipate that this collaborative effort will provide useful and practical information to both clinicians who perform this task routinely and researchers who study health care transitions. Most importantly, patients may benefit from improvements in communication between EPs and HMPs.

Overview of Communication Modes in Hand-Offs

  1. Top of page
  2. Abstract
  3. Overview of Communication Modes in Hand-Offs
  4. Critical Elements of Effective Transition
  5. Conclusions
  6. References

The overarching objective of a hand-off is to prepare the next party to be able to act safely and effectively in caring for the patient with maximum efficiency and minimal delay. Specific objectives for an EP-HMP hand-off include the EP conveying uniquely held information about the patient’s presentation, workup, working diagnosis and level of certainty, treatment, and responses. Both parties create a mutual understanding about the care plan and relay the status of negotiations to stakeholders such as the primary physician, the family, and any consultants about important decisions.26

The transition communication from EP to HMP can be accomplished via synchronous media such as direct verbal communication (e.g., telephone call), asynchronous media such as indirect written communication (e.g., fax or voicemail), mutual access to formal documentation (e.g., electronic chart), shared access to informal artifacts (e.g., whiteboard, crib sheets), and indirectly through communication events with patients and other caregivers. In actual practice, a combination of methods is often used to attain the full breadth of available data and assure accuracy. In situations where prior hand-off encounters have produced trusting relationships, less use of media tools to assure accuracy is common. The balance of redundancy and efficiency is a paradox in many industries, including health care.27 Where prudent and necessary, practitioners choose to make care processes less complex and opaque through developing trusting relationships. Efficiency is one of the many benefits of earning and maintaining a strong professional relationship, which requires thoughtfulness, reliability, and clinical accuracy.21,28

Hand-offs occur mainly through verbal exchange. Narratives increase recall, provide opportunities to enhance trust and respect, and allow both parties to convey sensitive information not suitable for official documentation.29,30 The narrative mode of communicating is useful when embedding decision-making within the discussion, particularly when the known data points are used to justify these decisions. Written documentation is used to support the EP’s care plan and expectations for the future and is a useful media for the HMP to reference if important details are not retained.31 The use of narratives, either written or verbal, creates a shared awareness and understanding of each unique patient’s condition. Sense-making is a cognitive activity that provides meaning from the experiences or interactions with the patient.32 Conveying these thoughts in a coherent and logical manner to the next physician caring for the patient and assuring, to the extent possible, that the EP’s thoughts are accurately understood are the tasks of transition communication. An ideal hand-off will portray the right quantity and quality of information in a timely manner—no more, no less. Brief exchanges may leave gaps, and excessive detail may be equally hazardous and inefficient. As Nobel Prize–winning psychologist Herbert Simon wrote, “An abundance of information creates a poverty of attention.”33

Understanding Our Professional Worlds

Mutual appreciation of respective viewpoints is critical in establishing and maintaining positive rapport, collegial trust, openness, and shared decision-making. Understanding each specialty’s natural proclivities, external pressures, and perspectives may also lead to better transitions. Without understanding and trust, a collaborative relationship can quickly degenerate into an adversarial one.

Capacity and workload issues exert an insidious influence. Competition for limited attention and resources can lead to behaviors that value self-preservation over teamwork. EPs have little control over the rate, timing, severity, and volume of incoming patients. HMPs encounter similar capacity issues, often in direct correlation with ED volume. In addition, both specialties bear a large burden of hospital quality and financial pressures, including the need to improve throughput, coordinate the discharge process, and reduce preventable readmissions. The goals of decreasing ED visits, ED length of stay, diversion, and boarding are not necessarily antithetical to those of reducing length of hospital stays and readmissions, but these have all been difficult to achieve.34,35

The decision to admit a patient is a predictable point of friction. Admitting a patient without clear, objective reasons may result in conflict between EPs and HMPs. The EP may not have a definitive diagnosis at the time of admission, and this lack of diagnostic certainty can trouble the HMP, especially if the EP portrays overconfidence in the working diagnosis and plan of care.20,36 This may lead to “diagnostic momentum” or “anchoring,” in which the diagnostic interpretation of the EP unduly influences the HMP’s reasoning.37 Such clinical overconfidence threatens patient safety and, importantly, fosters mistrust.38

The EP and HMP also fundamentally differ in their need for detail, clarity, completeness, and closure. It is just such reasons that make interunit transitions more complex than, for instance, a shift-change transition between EPs. EPs, by training and experience, develop a level of comfort with limited data and an evolving clinical course. Internal medicine training leads HMPs to seek diagnostic certainty. EPs tend to focus on disposition. HMPs are more sensitive to the ensuing course and value of a hospital admission. EPs focus on “what is the best next step” and sometimes feel that HMPs desire a level of detail that seems unnecessary to make proximate decisions. EPs favor expedient workups and have limited tolerance for additional evaluation or treatment that may lengthen time in the ED. They must make disposition decisions quickly, because of the continuous flow and unpredictable acuity of patients seeking emergency care. HMPs also value efficiency but through a different lens. They aim to determine the definitive diagnosis as efficiently as possible to address disposition planning. They fear that truncated ED workups may lead to downstream inefficiencies, prolonging hospital length of stay, or may increase the short-term risk of patient decompensation.

Each successful transition from EP to HMP will require negotiating a trade-off between near- and long-term goals. These negotiations can determine the right place, time, and personnel to carry out patient care activities and decrease the expectation gap between both parties. An approach tailored to fit local characteristics and culture may result in more effective and efficient patient care, while satisfying both specialists’ clinical needs and strengthening professional relationships. This type of negotiation, termed integrative bargaining, addresses the needs and concerns of both sets of clinicians and hopefully results in better patient management because it involves identifying problems, clarifying faulty assumptions, discussing needs and interests, and sharing understanding of hand-off events.39

System, Unit, and Individual Challenges

Many of the challenges to effectively transition a patient from the ED to an inpatient medical unit relate to the systems of care delivery and the variation in preferences for communication among the individuals. Although we tend to focus on physician-to-physician hand-offs, the reality is that patients are transferred from one entire clinical microsystem to another. Clinical microsystems include not only the team of health care professionals but also the equipment, information systems, support staff, and work environment.40,41 Notably, although care is delivered by an interdisciplinary team, hand-offs typically occur within disciplines. Specifically, EPs provide hand-offs to HMPs, while ED nurses give hand-offs to nurses on the medical unit. The lack of an interdisciplinary approach may perpetuate and reinforce known deficiencies in collaboration between each system.42 In this regard, a human factors approach, taking into account teamwork and coordination, individual cognition, technology, the surrounding organization, culture, and all other aspects of the system, has been invaluable to understanding and initiating improvement of care transitions as described below.27

Technologic advances can affect transition communication. A growing number of hospitals are implementing electronic health records (EHRs) and clinical decision support structures such as computerized physician order entry.43 These technologies, often custom built to the local context, enable providers to populate data in a variety of ways (e.g., free-text fields, structured or discrete data entry) within the patient record into an EHR-based hand-off tool.44 The receiving provider reviews pertinent, concise pieces of information that conform to mutually agreed expectations.45 Subsequent interactions may occur between clinicians in other media (e.g., face-to-face, telephone) if follow-up communication is warranted.46

Scholarship regarding EHRs or EHR-based hand-off tools is an emerging research area, with available studies showing a range of pros and cons. Although there lacks a definitive line of research in the ED context, extant findings can be usefully extrapolated to EP-HMP hand-off communication. For instance, an EHR allows remote access to review medical records of patients awaiting admission from the ED, thereby reducing the need for lengthy verbal exchanges. Structured data entry can reduce the problem of variable terminology between EP and HMP, heighten more complete gathering and entry of information, and reduce omission of necessary steps.44 Another benefit is that by reviewing the EHR simultaneously while discussing the patient hand-off, EPs and HMPs can fill in any narrative gaps and provide opportunities for real-time questions and answers. Assuring sense-making through organized and transactional narratives may assist providers in improving safety.27,28

However, the literature also indicates that EHR use may present barriers to effective transition communication.19,47 For example, the EP, knowing the HMP has reviewed the EHR, may overestimate his or her understanding of the patient’s clinical status and leave out key details, with the potential for inefficiency or patient harm.45 Conversely, the HMP may not ask clarifying questions, believing that information can be located in the EHR at a later time. In addition, structured data entry may exacerbate pertinent omissions as well as fail to convey subtle patient variables.44 Such problems may adversely affect understanding by both EP and HMP.

Fluctuations in patient volume and capacity within the ED and the medical units present further challenges. The ED may have the greatest need to transition patients during periods of limited capacity on the medical units (e.g., afternoon before discharges occur). Excessive workload may prompt an EP to include less detail in his or her hand-off. Similarly, excessive workload on the medical unit may prompt a HMP to prefer less information or to delay the hand-off. Additionally, hand-offs occur throughout the day within each microsystem, and physicians make decisions about tradeoffs involved in hand-off timing. For example, an EP may decide to transition a patient to the admitting physician prior to shift change. While the ED workup may not be entirely complete, the accepting physician may benefit from speaking with the EP who has followed the patient’s trajectory since arrival. Similarly, an HMP ending a shift may wish to postpone receipt of a hand-off so that an incoming colleague, who will perform the admission, can take report firsthand. Collaboration between departments to establish transition process guidelines around respective shift changes is one of many ways to mitigate risk during this task.

Another barrier is the wide range of personal preferences for communication among clinicians. Physician preferences and expectations during a hand-off are influenced by cultural dynamics, training, and personal style.20,21

Preferences may vary within each specialty and, more commonly, among individual physicians. The mode of communication between the EP and HMP can also influence the interaction between clinicians. The media richness theory of Daft and Lengel48 can be usefully applied to describe and understand hand-off media usage. The theory suggests that people choose one medium over another according to the ambiguity of the task and the ability of the chosen medium to convey information. Rather than advocate for one best way, the media richness framework postulates that each mode has potential advantages and disadvantages that should be considered when making communication choices (Table 1). Less rich media (e.g., clinical notes, medical record) may be more convenient in certain situations, but lack many key elements found in face-to-face communication, such as tone of voice, expression, gesture, and eye contact that can promote give-and-take between EPs and HMPs49 (Figure 1).

Table 1.    Hand-off Media Advantages and Disadvantages
Media: Most Rich to Most LeanAdvantagesDisadvantages
  1. EHR = electronic health record.

Face-to-face or videoconferenceMultiple cuesDistraction, time constraints
InteractiveDifficult to connect
TelephonePotential for documentationProne to misinterpretation
Potential for standardization
E-mail or text messageImmediate feedbackDifficult to connect
EHR or paper chartConvenientLack of dialogue
Less time waiting to connect
image

Figure 1.  Types of hand-off media.

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Experienced clinicians tend to choose richer media when uncertain, conflicting, or multiple interpretations of an issue exist. For instance, a stable patient with an uncomplicated presentation and clear diagnosis may require a brief telephone conversation supplemented by paper or electronic records. A more complex patient, such as a critically ill patient, may require face-to-face discussions and continuous updates between the EP and HMP. An ideal transition may involve several, complementary modes of communication, tailored to the patient’s clinical situation. Performing the task of transition communication within a framework of value-added content and style expectations may assure the task is completed effectively while meeting the majority of personal and specialty preferences. The following section, developed through consensus by practitioners in both specialties, elaborates on these.

Critical Elements of Effective Transition

  1. Top of page
  2. Abstract
  3. Overview of Communication Modes in Hand-Offs
  4. Critical Elements of Effective Transition
  5. Conclusions
  6. References

An effective transition from the EP to the HMP ensures that the patient’s care is seamless across two dynamic settings. An organized approach can help align expectations, prompt consistency of information, facilitate recall, and guide training. However, no “silver bullet” exists for averting communication failures, particularly if they focus on narrow content details (i.e., “always include the creatinine”) rather than key principles. We propose a set of conceptual standards for EP–HMP communication designed to be sufficiently flexible to meet the needs of a diverse set of patients and clinicians, but reliable enough to ensure improved transition quality.

Effective communication skills and a mutual understanding of each other’s professional worlds are the foundation of successful handovers. Aspects of effective transition include synthesis and judgment, interactive conversation rather than unidirectional information transfer, a focus on sense-making, and delivery tailored to the level and perspective of the participants (Figure 2). Given the wide range in types of patients presenting to the ED and severity of illness, a “criterion standard” of critical content should be principle- and category-based. In addition, the content of the hand-off should be focused on increasing the value of data that may already be available to the receiving clinician by other means (e.g., EHR), rather than merely repeating it. Last, local work processes or institutional cultural norms may result in variations of how and what is communicated and, most importantly, understood. With these requirements in mind, we have identified seven best practice elements of hand-off content (Table 2).

image

Figure 2.  Best practice recommendations for style and form.

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Table 2.    Best Practice Recommendations for Content
1. Clinical condition of the patient
   • Severity of illness
   • Stability of condition
2. Working diagnosis with degree of certainty and rationale
3. Highlights of history and physical
4. Summary of ED course
   • Diagnostic tests and therapeutic intervention
   • Patient response to intervention
5. Results and analysis of key tests
6. Pending data and tasks with unambiguous assignment  for follow-up
7. Unusual circumstances (do-not-attempt-resuscitation,  isolation, language barrier, etc.)

First, the hand-off should convey the current clinical condition of the patient, including the severity of illness level and the stability of the patient’s condition. While formal tools (e.g., PERC rule—Pulmonary Embolism Rule-out Criteria50) may be used to generate these assessments when appropriate, the EP’s judgment as to severity and stability will be more commonly used.51

Second, all hand-off communication should include a working problem statement with degree of certainty and rationale. For example, the EP might say, “Given the history and exam findings I’m leaning towards a diagnosis of pneumonia, but the x-ray is equivocal,” rather than simply, “I’m admitting him with a diagnosis of pneumonia.” Premature closure and anchoring bias are important sources of cognitive error that can be precipitated by stating a diagnosis prior to a complete evaluation.37 Pressure from the HMP to “tell me what the patient has” should be addressed cautiously.

Third, essential aspects of the history and physical should be included, focused chiefly on abnormal findings or pertinent normal findings. A litany of normal or contextually irrelevant results or review of systems is not only unnecessary but may actually obscure relevant data.

Fourth, a brief summary of the ED course—with particular attention to any unexpected or atypical features—should be provided to understand both what was done for the patient and how the patient responded. ED records detail when and what treatments were administered. However, it is difficult to determine the patient’s response and timeliness of response to treatment through written record review.

Fifth, results and/or analysis of key tests should be provided, again, in a synthesized manner. For instance, “She has an anion gap acidosis,” not “the sodium was x, the chloride was y, the bicarbonate was z.” Sixth, a specific comment about data still pending or tests not yet done is included in every hand-off and should be accompanied by unambiguous assignment of who is responsible for follow-up. And seventh, if there are any unusual circumstances—language barriers, isolation requirements, do-not-attempt-resuscitation status, or fall risk—these should be explicitly addressed as well.

Overall, the key content elements listed in Table 2 are designed to apply to all patients, to maximize the value of the EP’s clinical evaluation of the patient, to encourage conversation, and to ensure the next provider can effectively and efficiently assume care of the patient. These elements may be organized in a logical and coherent order that matches typical local workflow, yet does not rigidly prohibit discussion.

Special Scenarios

Critical care, psychiatric, and “boarded” patients present particular challenges. Critical care patients are often medically complex, resulting in “staggered” hand-offs, characterized by initial notification, one or more question/answer periods, updates on stability, response to treatments and evolving data elements, and final negotiations prior to transfer. A staggered hand-off may offer the HMP a greater understanding of the patient’s clinical needs when the focus of discussion remains on the patient and not on service-related work or convenience issues.

A detailed medical history for psychiatric patients is often less important when transferring care than addressing social, behavioral, and legal concerns. A synthesis of the visit is still necessary. However, content such as risk of harm to self or others, flight assessment, security needs, access to weapons, social supports, previous psychiatric interventions, and contribution of medical issues to mental health problems is essential.

Hospital crowding results in ED “boarding” of patients admitted to the hospital, and these patients are at higher risk of harm.52–54 Geography often dictates who is responsible for a patient, whether or not transition communication has occurred. However, local variations exist. Admitted patients in the ED often receive less attention from both services—the EP has moved on to new ED patients, and the HMP’s focus is on patients already on his or her floor. Local policies may be designed to address the assignment of responsibility. In their absence, this may be an important component of transition negotiations.

Quality Measurement and Research

Despite the lack of validated measures, institutions and clinicians will seek measures of success as they attempt to improve hand-offs. In Table 3 we propose measures divided into the Institute of Medicine domains of quality and categorized as structural, process, or outcome measures.55 Structural measures include organizational characteristics such as staffing ratios. For example, an institutional policy requiring synchronous hand-offs for admissions is a structural measure. Process measures evaluate performance of such a task, but do not necessarily assure sense-making between parties. These include timeliness or content components and serve as a tool to assure the task was attempted. Data such as these may lay the groundwork for more detailed analysis of process contribution to outcomes. Outcome measures, such as unexpected upgrades in care within 12 hours of admission, are events directly affecting patients. Other measures specific to clinical care, for example, those pertaining to fall risk communication, delayed medication effects, or Primary Care Physician communication, are beyond the aims of this current article. The challenges of measuring hand-offs have been specifically addressed by Patterson and Wears.26 Current metrics, including those mentioned here, are imperfect measures of transition quality, as intervening influences between the hand-off and the outcome exist.

Table 3.    Potential Measures of Transitions
  1. ICU = intensive care unit; IM = internal medicine; O = outcome measure; S = structural measure; P = process measure.

I. Timely and efficient
 1. Time from ED admission order to IM acceptance (P)
 2. Time from ED admission order to IM admission orders (P)
II. Effective
 1. Use of shared electronic or written transition record (P)
 2. Frequency of 1-day admissions not identified at time of ED admission—a measure of potentially unnecessary admissions (O)
III. Safe
 1. Frequency of unexpected transfer to ICU within   12 hours of admission to the floor (O)
 2. Adverse events within first 12 hours of admission (O)
 3. Synchronous hand-offs for all patient admissions (S)

Given the increasing focus on delivering value in health care, research in transitions should extend beyond process measures to identify meaningful improvement in patient outcomes or reduced cost.56 To date, reliable measurement tools are lacking.26 The 2011 Accreditation Council for Graduate Medical Education duty hour recommendations mandate hand-off education and monitoring within residency programs, including interunit hand-offs between specialties.57 Although logical, such recommendations will be more effective when they are more content- and style-specific and supported by well-designed studies. As transition communication is essentially a social function, it may be a ripe area for alternative research methodologies such as “realistic evaluation,” a methodology more commonly found in sociology research.58 Realistic evaluation can be used to identify local context mechanisms (such as content principles) and applied to better understand how these affect the desired patient-oriented outcome.

Conclusions

  1. Top of page
  2. Abstract
  3. Overview of Communication Modes in Hand-Offs
  4. Critical Elements of Effective Transition
  5. Conclusions
  6. References

Hand-offs between specialties are particularly complex because of differing culture, expectations, and pressures. We analyzed the transition from the EP to hospital medicine physician, providing practical suggestions. A joint expectation on general content, delivery, and style can reduce misinformation, delays, and unexpected events affecting patient outcomes. It is designed to maximize the value of the initial clinical evaluation, encourage transactional conversation, and match typical workflow. We emphasize the importance of sense-making between individuals, rather than a one-way dialogue, as a vital component of performing this task to assure that the next party is prepared to act safely and effectively in providing care. These recommendations describe insights, challenges, and standards for patient care transitions. There will be need for validation studies to determine if these suggested improvements in transition communication will result in improved patient outcomes.

References

  1. Top of page
  2. Abstract
  3. Overview of Communication Modes in Hand-Offs
  4. Critical Elements of Effective Transition
  5. Conclusions
  6. References
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