1. Handoff Communication
Katie Gielissen, MD
IM Associate Clerkship Director

2. What is a handoff (sign out)?
Transfer of:
Information
Authority
Responsibility
Occurs during transitions in care:
Shift changes
End of service block
Unit transfers
Discharges
Handoffs include the transfer of knowledge and information about the degree of uncertainty or certainty (about diagnoses, etc), response to treatment, recent changes in condition and circumstances, and the plan, to include contingency plans. In addition, both authority and responsibility are transferred. Lack of clarity about who is responsible for care and for decision-making has often been a major contributor to medical errors.

3. Have you had the chance to perform a handoff?
How many of you have seen a handoff performed in real clinical settings?
How many of you have performed a handoff in real clinical settings?
How many of you have gotten feedback on the handoff you performed?

4. Objectives
Discuss the importance of high-quality handoff communication as part of patient care (and why you should learn it as a medical student).
Learn about and practice a technique for performing handoffs while on your internal medicine rotation(s).
Introduce a method to get feedback on your handoffs.

5. Objectives
Discuss the importance of high-quality handoff communication as part of patient care (and why you should learn it as a medical student).
Learn about and practice a technique for performing handoffs while on your internal medicine rotation(s).
Introduce a method to get feedback on your handoffs.

6. Why is communication important in healthcare?
Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type.
The reason that improving caregiver communication has been so heavily emphasized within the patient safety movement becomes apparent when one looks at the underlying causes of medical error. Using root cause analysis to determine contributing factors shows that of sentinel events that were voluntarily reported to JCAHO over a ten year period, the top contributing factor representing nearly 2/3 of all cases was found to be inadequate communication amongst providers.

7. Communication events by trainees
Landmark study of IM Residents in 1994
3146 patients admitted over 4 months
124 adverse events, 44% preventable
Patients with adverse events were more likely than controls to be covered by a physician from another team at the time of event (Odds Ratio 6.1!)
Multiple studies have demonstrated transitions of care are the most unsafe time for patients!
Petersen LA. Annals of Internal Medicine. 1994; 121(11):

8. Handoff Curricula in Med Schools
121/143 members of Clerkship Directors in Internal Medicine were surveyed in 2014
15% reported structured handoff curriculum during the IM clerkship
37% reported handoff curriculum during IM Sub-I’s
66% stated 3rd year med student did not perform handoffs
93% stated 4th year Sub-I’s did perform handoffs
Liston, BW. HJ Gen Intern Med May; 29(5):

9. Interns’ Perceptions on Their Preparedness
Provide an oral presentation
Ryan MS. Medical Science Educator (3),
Give or receive a patient handover
Ryan 2016
44 first year residents (29 medical schools) rated their overall preparedness for the Core EPAs and describe their training leading into residency
64% of respondents reported a capstone/bootcamp course!
91% had a H&P course
98% had a sub-internship of some kind

10. When are Trainees Exposed to Handoffs?
T T T T T T T
E E E EEEEE EE EEEEEEEEEEEEEEEEEEEEE
EPA 6: Oral Presentation A A A
Ryan MS. Medical Science Educator, (3), T
E EE EEEEEEEEEEEEEEEEEEEEE
EPA 8: Give a Handover
T = Teaching
E = Experience
A = Assessment
MS MS MS MS PGY1 PGY2 PGY3 

11. Key Points Effective handoffs are essential to safe patient care
Medical students are asked to perform handoffs during their Sub-Is without sufficient training
Many recent graduates feel unprepared to perform handoffs as they transition to internship

12. Objectives continued
Discuss the importance of high-quality handoff communication as part of patient care (and why you should learn it as a medical student).
Learn about and practice a technique for performing handoffs while on your internal medicine rotation(s).
Introduce a method to get feedback on your handoffs.

13. I-PASS Technique

14. Video Reflection As you watch the video, jot down what you observe.
How could the handoff been performed more safely and effectively?

15. Key Components of Handoffs
Effective Handoffs:
Ensure transfer of accurate information
Facilitate transfer of responsibility
Two components to effective handoffs:
Verbal Handoffs:
Are structured
Employ close-loop communication
Printed Handoffs
Provide more detail
Integrate with verbal handoffs

16. I-PASS Handoff Technique

17. The I-PASS Mnemonic I  Illness Severity P  Patient Summary
Stable, “Watcher,” Unstable
P  Patient Summary
Summary statement; events leading to admission; hospital course; ongoing assessment; plan
A  Action List
To-do list; timeline and ownership
S  Situation Awareness & Contingency Planning
Know what’s going on; plan for what might happen
S  Synthesis by Receiver
Receiver summarizes what s/he heard; asks questions; restates key action items
Starmer, A.J. Pediatrics (2012):

18. The I-PASS Mnemonic
I Illness Severity P Patient Summary A Action List S Situation Awareness S Synthesis by Receiver
Starmer, A.J. Pediatrics (2012):

19. The I-PASS Mnemonic
I Illness Severity P Patient Summary A Action List S Situation Awareness S Synthesis by Receiver
Starmer, A.J. Pediatrics (2012):

20. Why should we flag illness severity?
Focuses attention appropriately to sickest patients first
Helps develop a shared understanding of pt status
Clearly stating code status with illness severity can also help to frame the patient

21. Illness severity: a continuum
Stable
Watcher
Unstable
Watcher: any clinical “gut feeling” that a patient is at risk of deterioration or “close to the edge”
On the medicine units you might hear the term “sick” or “not sick”

22. Sample Dialogue I P A S Illness Severity Patient Summary Action List
“Okay, this is our sickest patient, and he’s full code” P
Patient Summary
“Mr. S is a 73yo M with PMHx of HFpEF and COPD who presented with hypoxia thought to be due to RLL community-acquired pneumonia, currently on CTX/Doxy. Today we had to uptitrate his oxygen from 2L to 4L. He was noted to have worsening LE edema and crackles so we thought he may have a CHF exacerbation and started aggressive diuresis. Given the RLL involvement we are also worried about possible aspiration. I just checked on him at 5pm and his RR was 20, but he was not in distress and he’s maintaining sats in the 90s. His BP has been soft at 110/60s with baseline 140/80s.
Of note, we have had ongoing discussions with the family regarding code status. We had a family meeting today. He is currently full code but they are thinking about DNR/DNI. His daughter, Donna, is the POA.” A
Action List
[ ] follow up BMP at 6pm – replete K and Mg if needed
[ ] check his respiratory status at 7pm; if no improvement consider CXR
[ ] check UOP at 7pm – goal net negative 1L over 24h by tomorrow 7am S
Situation Awareness
IF worsening respiratory status, check CXR/ABG and consider transfer to the ICU
IF febrile or septic, consider broadening to Unasyn/Doxy to cover for aspiration
FYI daughter Donna wishes to be called with any significant change in his status
Synthesis by Receiver
“Okay, Mr. S is a 73yo M with COPD and HFpEF here for RLL pneumonia. Today he had worsening hypoxia thought to be due to pulmonary edema, though you guys are also suspicious of aspiration. I need to follow up his BMP at 5pm, and check his UOP and respiratory status at 7pm. Thanks. I just had one clarifying question…”

23. The I-PASS Mnemonic
I Illness Severity P Patient Summary A Action List S Situation Awareness S Synthesis by Receiver
Starmer, A.J. Pediatrics (2012):

24. Patient Summary – Why is this important?
Succinct description of the ‘big picture’
Reason(s) for admission
Events leading to admission
Hospital course
Overarching plan(s)
Communicates concerns and nuances
Anticipates expected course
Patient summary is one of the most important elements in the handoff process.
We feel that the skill of providing a succinct, yet rich and descriptive, patient summary is a very high level cognitive skill.
Therefore, we feel that this needs to be learned and modeled.

25. Sections of Patient Summary
Summary Statement
Events leading up to admission
Hospital course
Ongoing assessment
Plan

26. Summary Statement “One-liner”
Events leading up to admission
Hospital course
Ongoing assessment
Plan
Summary Statement
“One-liner”
Contains only critical identifying information
Name
Age
Gender
Pertinent PMHx
Reason for admission
“Mr. S is a 73yo M with PMHx of HFpEF and COPD who presented with hypoxia thought to be due to RLL community-acquired pneumonia.”

27. Events Leading to Admission
Summary Statement
Events leading up to admission
Hospital course
Ongoing assessment
Plan
Events Leading to Admission
Describes the way the patient presented
Includes ONLY essential history and exam findings
Can be truncated when high level of diagnostic certainty is attained
Should be revised every day as new information comes in
“Mr. Smith is a 74yo man with PMHx of COPD who presented with fever, SOB, and cough for 3 days, found to have hypoxia and RLL crackles.”
“Mr. Smith is a 74yo man with PMHx of COPD who presented with RLL community acquired pneumonia.”

28. Hospital Course List key events and updates
Summary Statement
Events leading up to admission
Hospital course
Ongoing assessment
Plan
Hospital Course
List key events and updates
Highlights special considerations
Family/social issues
Nursing concerns
Relevant chronic medical conditions

29. Ongoing Assessment Provides diagnostic reasoning
Summary Statement
Events leading up to admission
Hospital course
Ongoing assessment
Plan
Ongoing Assessment
Provides diagnostic reasoning
Ex: “We chose do diurese today because…”
Offers differential diagnosis and assessment
Ex: for a patient with presumed CAP who is not improving, you may mention a concern for antibiotic resistance or developing empyema with an overnight plan to consider imaging or changing antibiotics

30. Summary Statement
Events leading up to admission
Hospital course
Ongoing assessment
Plan
Plan
Mention specific plans for certain problems ONLY if relevant to overnight work
AVOID to-do lists from the day shift
If no specific plan required for a problem, it is likely you don’t need to mention or include it

31. Sample Dialogue I P A S Illness Severity Patient Summary Action List
“Okay, this is our sickest patient, and he’s full code” P
Patient Summary
“Mr. S is a 73yo M with PMHx of HFpEF and COPD who presented with hypoxia thought to be due to RLL community-acquired pneumonia, currently on CTX/Doxy. Today we had to uptitrate his oxygen from 2L to 4L. He was noted to have worsening LE edema and crackles so we thought he may have a CHF exacerbation and started aggressive diuresis. Given the RLL involvement we are also worried about possible aspiration. I just checked on him at 5pm and his RR was 20, but he was not in distress and he’s maintaining sats in the 90s. His BP has been soft at 110/60s with baseline 140/80s.
Of note, we have had ongoing discussions with the family regarding code status. We had a family meeting today. He is currently full code but they are thinking about DNR/DNI. His daughter, Donna, is the POA.” A
Action List
[ ] follow up BMP at 6pm – replete K and Mg if needed
[ ] check his respiratory status at 7pm; if no improvement consider CXR
[ ] check UOP at 7pm – goal net negative 1L over 24h by tomorrow 7am S
Situation Awareness
IF worsening respiratory status, check CXR/ABG and consider transfer to the ICU
IF febrile or septic, consider broadening to Unasyn/Doxy to cover for aspiration
FYI daughter Donna wishes to be called with any significant change in his status
Synthesis by Receiver
“Okay, Mr. S is a 73yo M with COPD and HFpEF here for RLL pneumonia. Today he had worsening hypoxia thought to be due to pulmonary edema, though you guys are also suspicious of aspiration. I need to follow up his BMP at 5pm, and check his UOP and respiratory status at 7pm. Thanks. I just had one clarifying question…”

32. The I-PASS Mnemonic
I Illness Severity P Patient Summary A Action List S Situation Awareness S Synthesis by Receiver
Starmer, A.J. Pediatrics (2012):

33. Action List To-do list Includes specific elements:
Timeline
Clearly assigned responsibility
Indication of what ‘completion’ means
Actions to be taken
If no action items anticipated, clearly state “nothing to do”

34. Example Action List To Do: [ ] check respiratory status
[ ] check pain scores Q4h
[ ] check I/Os at midnight
[ ] follow up 6PM electrolytes
[ ] follow up blood cultures

35. Sample Dialogue I P A S Illness Severity Patient Summary Action List
“Okay, this is our sickest patient, and he’s full code” P
Patient Summary
“Mr. S is a 73yo M with PMHx of HFpEF and COPD who presented with hypoxia thought to be due to RLL community-acquired pneumonia, currently on CTX/Doxy. Today we had to uptitrate his oxygen from 2L to 4L. He was noted to have worsening LE edema and crackles so we thought he may have a CHF exacerbation and started aggressive diuresis. Given the RLL involvement we are also worried about possible aspiration. I just checked on him at 5pm and his RR was 20, but he was not in distress and he’s maintaining sats in the 90s. His BP has been soft at 110/60s with baseline 140/80s.
Of note, we have had ongoing discussions with the family regarding code status. We had a family meeting today. He is currently full code but they are thinking about DNR/DNI. His daughter, Donna, is the POA.” A
Action List
[ ] follow up BMP at 6pm – goal K > 4.0
[ ] check his respiratory status at 7pm; if no improvement consider CXR
[ ] check UOP at 7pm – goal net negative 1L (responds to 40mg IV Lasix) S
Situation Awareness
IF worsening respiratory status, check CXR/ABG and consider transfer to the ICU
IF febrile or septic, consider broadening to Unasyn/Doxy to cover for aspiration
FYI daughter Donna wishes to be called with any significant change in his status
Synthesis by Receiver
“Okay, Mr. S is a 73yo M with COPD and HFpEF here for RLL pneumonia. Today he had worsening hypoxia thought to be due to pulmonary edema, though you guys are also suspicious of aspiration. I need to follow up his BMP at 5pm, and check his UOP and respiratory status at 7pm. Thanks. I just had one clarifying question…”

36. The I-PASS Mnemonic
I Illness Severity P Patient Summary A Action List S Situation Awareness & Contingency Planning S Synthesis by Receiver
Starmer, A.J. Pediatrics (2012):

37. Situation Awareness “Know what’s going on with your patient”
Status of patient’s disease process (improving, worsening, etc)
Team member’s role in this patient’s care
Environmental factors
ADDITIONAL INFORMATION AND REFERENCE MATERIAL:
Status of patient – patient history, vital signs, medications, physical exam, plan of care, psychosocial
Team members – fatigue, workload, task performance, stress
Environment – facility information, administrative information, human resources, triage acuity, equipment
Progress toward goal – status of team’s patient, established goals of team, tasks/actions of team, plan still appropriate

38. Contingency Planning Critical for patient safety
Problem solving before things go wrong
IF/THEN statements
Provides the receiver with specific instructions for what might go wrong

39. Effective Contingency Planning
Articulate what might go wrong
Define the plan
List interventions that have/have not worked
Ex: “If he desats, we found repositioning him in the bed is really helpful”
Identify resources and chain of command
Ex: “Here is Dr. Richards’ phone number.”

40. Sample Dialogue I P A S Illness Severity Patient Summary Action List
“Okay, this is our sickest patient, and he’s full code” P
Patient Summary
“Mr. S is a 73yo M with PMHx of HFpEF and COPD who presented with hypoxia thought to be due to RLL community-acquired pneumonia, currently on CTX/Doxy. Today we had to uptitrate his oxygen from 2L to 4L. He was noted to have worsening LE edema and crackles so we thought he may have a CHF exacerbation and started aggressive diuresis. Given the RLL involvement we are also worried about possible aspiration. I just checked on him at 5pm and his RR was 20, but he was not in distress and he’s maintaining sats in the 90s. His BP has been soft at 110/60s with baseline 140/80s.
Of note, we have had ongoing discussions with the family regarding code status. We had a family meeting today. He is currently full code but they are thinking about DNR/DNI. His daughter, Donna, is the POA.” A
Action List
[ ] follow up BMP at 6pm – goal K > 4.0
[ ] check his respiratory status at 7pm; if no improvement consider CXR
[ ] check UOP at 7pm – goal net negative 1L (responds to 40mg IV Lasix) S
Situation Awareness
IF worsening respiratory status, check CXR/ABG and consider transfer to the ICU
IF febrile or septic, consider broadening to Unasyn/Doxy to cover for aspiration
FYI daughter Donna wishes to be called with any significant change in his status
Synthesis by Receiver
“Okay, Mr. S is a 73yo M with COPD and HFpEF here for RLL pneumonia. Today he had worsening hypoxia thought to be due to pulmonary edema, though you guys are also suspicious of aspiration. I need to follow up his BMP at 5pm, and check his UOP and respiratory status at 7pm. Thanks. I just had one clarifying question…”

41. The I-PASS Mnemonic
I Illness Severity P Patient Summary A Action List S Situation Awareness & Contingency Planning S Synthesis by Receiver
Starmer, A.J. Pediatrics (2012):

42. It is NOT a restating of the entire verbal handoff!
Synthesis by Receiver
Provides brief re-statement of essential information in a cogent summary
Demonstrates information is received and how it was understood
Opportunity for receiver to:
Clarify elements of handoff
Ensure there is a clear understanding
Have an active role in the handoff process
It is NOT a restating of the entire verbal handoff!

43. Sample Dialogue I P A S Illness Severity Patient Summary Action List
“Okay, this is our sickest patient, and he’s full code” P
Patient Summary
“Mr. S is a 73yo M with PMHx of HFpEF and COPD who presented with hypoxia thought to be due to RLL community-acquired pneumonia, currently on CTX/Doxy. Today we had to uptitrate his oxygen from 2L to 4L. He was noted to have worsening LE edema and crackles so we thought he may have a CHF exacerbation and started aggressive diuresis. Given the RLL involvement we are also worried about possible aspiration. I just checked on him at 5pm and his RR was 20, but he was not in distress and he’s maintaining sats in the 90s. His BP has been soft at 110/60s with baseline 140/80s.
Of note, we have had ongoing discussions with the family regarding code status. We had a family meeting today. He is currently full code but they are thinking about DNR/DNI. His daughter, Donna, is the POA.” A
Action List
[ ] follow up BMP at 6pm – goal K > 4.0
[ ] check his respiratory status at 7pm; if no improvement consider CXR
[ ] check UOP at 7pm – goal net negative 1L (responds to 40mg IV Lasix) S
Situation Awareness
IF worsening respiratory status, check CXR/ABG and consider transfer to the ICU
IF febrile or septic, consider broadening to Unasyn/Doxy to cover for aspiration
FYI daughter Donna wishes to be called with any significant change in his status
Synthesis by Receiver
“Okay, Mr. S is a 73yo M with COPD and HFpEF here for RLL pneumonia. Today he had worsening hypoxia thought to be due to pulmonary edema, though you guys are also suspicious of aspiration. I need to follow up his BMP at 5pm, and check his UOP and respiratory status at 7pm. Thanks. I just had one clarifying question…”

44. The I-PASS Mnemonic
I Illness Severity P Patient Summary A Action List S Situation Awareness & Contingency Planning S Synthesis by Receiver
Starmer, A.J. Pediatrics (2012):

45. Use IPASS technique to perform a verbal handoff with a partner
Handoff Exercise
Use IPASS technique to perform a verbal handoff with a partner

46. Handoff Exercise Break into groups of two
Practice the I-PASS technique, each taking a turn as the handoff giver and receiver
One person acts as Participant A, one person as Participant B
Follow directions on your handout
Debrief and give one another feedback using the QR code on the back of your card

47. Getting evaluations while on rotation
Ask and intern or resident if you can perform handoff(s) on your patient(s), then ask if they can directly observe you and provide feedback.
Have your resident fill out the feedback form using the QR code on your card
These assessments are NOT required and will NOT be counted towards your grade!
Let us know if this method works for you… we want to find ways for you to get meaningful practice!