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Measurement of Information Transfer During Simulated Sequential Complete Shift-to-Shift Intraoperative Handoffs

Open AccessPublished:December 12, 2022DOI:https://doi.org/10.1016/j.mayocpiqo.2022.11.001

      Abstract

      Objective

      To determine information transfer during simulated shift-to-shift intraoperative anesthesia handoffs and the benefits of using a handoff tool.

      Patients and Methods

      Anesthesiology residents and faculty participating in simulation-based education in a simulation center on April 6 and 20, 2017, and April 11 and 25, 2019. We used a fixed clinical scenario to compare information transfer in multiple sequential simulated handoff chains conducted from memory or guided by an electronic medical record generated tool. For each handoff, 25 informational elements were assessed on a discrete 0–2 scale generating a possible information retention score of 50. Time to handoff completion and number of clarifications requested by the receiver were also determined.

      Results

      We assessed 32 handoff chains with up to 4 handoffs per chain. When both groups were combined, the mean information retention score was 31 of 50 (P<.001) for the first clinician and declined by an average of 4 points per handoff (P<.001). The handoff tool improved information retention by almost 7 points (P=.002), but did not affect the rate of information degradation (P=.38). Handoff time remained constant for the intervention group (P=.67), but declined by 2 minutes/handoff (P<.001) in the control group, which required 7 more clarifications/handoff (P=.003). In the control group, 7 of 16 (44%) handoff chains contained one or more information retention scores below the lowest score of the entire intervention group (P=.007).

      Conclusion

      Clinical handoffs are accompanied by degradation of information that is only partially reduced by use of a handoff tool, which appears to prevent extremes of information degradation.

      Abbreviations and Acronyms:

      EMR (electronic medical record), MCQ (multiple-choice question)
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      and may increase the risk of all-cause death and major complications. Some estimates attribute 600,000 potentially preventable serious adverse events each year worldwide to deficiencies of anesthesia handoffs.
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      The Joint Commission established a National Patient Safety Goal in 2006 and a Provision of Care in 2010 to address patient handoffs.

      Commission TJ. The Joint Commission 2009 Requirements Related to the Provision of Culturally Competent Patient-Centered Care Hospital Accreditation Program (HAP). Published 2009. Accessed April 18, 2019.

      These documents advocate implementation of a standardized handoff system that is easily accessed in the workflow, enhanced by electronic medical record (EMR) technology, and monitored for quality improvement.
      Commission TJ
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      In 2012, only 8% of medical schools in the United States had a standardized handoff curriculum, and no U.S. residency program used a comprehensive approach to teaching or assessing handoff competency.

      Wagner R, Koh N, Bagian J, Weiss K. CLER 2016 National Report of Findings, Issue Brief #5: Care Transitions. Chicago, IL: Accreditation Council for Graduate Medical Education; 2016. 13: 978-1-945365-10-2.

      Accreditation Council for Graduate Medical Education visits in 2016

      Wagner R, Koh N, Bagian J, Weiss K. CLER 2016 National Report of Findings, Issue Brief #5: Care Transitions. Chicago, IL: Accreditation Council for Graduate Medical Education; 2016. 13: 978-1-945365-10-2.

      and 2018
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      indicated a continued lack of standardization for change-of-duty handoffs and limited supervision of trainees performing handoffs.

      Wagner R, Koh N, Bagian J, Weiss K. CLER 2016 National Report of Findings, Issue Brief #5: Care Transitions. Chicago, IL: Accreditation Council for Graduate Medical Education; 2016. 13: 978-1-945365-10-2.

      In the Agency for Health Care Research and Quality survey in 2021, 53% of respondents endorsed the statement “important patient care information is often lost during shift changes,”
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      essentially unchanged from the 2011 survey.
      • Riesenberg L.A.
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      Although pre–post observational studies indicate a reduction in preventable clinical errors when a handoff program is used,
      • Starmer A.J.
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      the form and potential benefit of such a program remains unresolved. There is a growing body of literature concerning handoffs with a trend toward conceptual models of team dynamics and systems engineering.
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      However, there is a paucity of research that addresses communication skill and accuracy of information transfer in a controlled environment as most studies are from convenience samples in the clinical environment. Overviews of the field have called for studies that document accuracy of information transfer provided during handoffs, measure the extent that handoffs contain all essential information, and assess recall accuracy of the information provided.
      • Riesenberg L.A.
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      ,
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      Consequently, we adopted the simulation environment to perform repeatable and controlled assessment of clinical information loss and the extent loss is mitigated by use of an EMR—enhanced handoff tool.

      Materials and Methods

      Study Design

      This study was approved by the Johns Hopkins institutional review board (IRB00110777), which waived the need for written consent. Our institution is a large academic tertiary care hospital in the mid-Atlantic region that uses Epic (Epic Systems Corporation, Verona, Wisconsin) to generate the EMR. We developed a handoff tool in conjunction with Epic that extracts data automatically according to predetermined parameters from EMR documentation entered by clinicians. The tool uses a structured format on the basis of mnemonic “HANDOFF”: (H: How sick is patient? A: Airways, Access, N: New, iNtraop, D: Drugs, Disposition, O: Opioids/Pain Plan, F: Fluids, F: Fears, Future Plans, “Follow Me” [read back]). We introduced the electronic handoff tool into clinical practice in 2017. In 2017 (after 6 months of use) and again in 2019, we prospectively evaluated the tool by creating a simulated perioperative record from which the EMR generated a handoff report. For these studies, we randomized participants to perform a sequence of simulated complete intraoperative transfers of care using either the handoff tool (intervention) or only their memory (control).

      Simulation

      We created the simulated clinical case of a patient with complex medical history undergoing spine surgery. In each cohort, 16 post-graduate year (PGY)-2, PGY-3, and PGY-4 residents (Clinical Anesthesia first-, second-, and third-year residents, respectively) were randomized (Random.org) to serve as the first link of 16 individual handoff chains. These participants received materials for the case by e-mail 1 day before the simulation and were asked to learn the information “as if they had been taking care of the patient in the operating room all day.” This arrangement provided them with the flexibility to learn the case details at their own pace and did not consume time set aside for performing the handoffs. The materials included the Epic-based anesthesia preoperative evaluation with history, physical, laboratory, and other test results; the anesthetic plan; the intraoperative record of the case in progress; and a written narrative of the case (Supplemental Appendix 1, available online at http://www.mcpiqojournal.org/). This narrative and the handoff tool both included the same 25 clinically relevant elements highlighted in bold that had the potential to lead to patient harm if conveyed incompletely or incorrectly (Supplemental Appendix 2, available online at http://www.mcpiqojournal.org/). These elements were the basis for the 25 retention questions from which the information retention score, the study’s primary outcome, was generated.
      The 16 first-link participants were randomized to the intervention or control group (8 participants each). Additional participants were randomly assigned to subsequent second and third positions, etc. in each chain (Figure 1A). Simulations were held over 8 hours on 2 days with 1 control and 1 intervention chain running simultaneously each hour in separate rooms. Participants were aware that the study was evaluating 2 different handoff methods and that they were not being evaluated personally. A schematic of the event sequence in each chain is shown in Figure 1B. The first participant in each chain answered multiple-choice questions (MCQs) on unrelated anesthesia topics for 5 minutes, simulating the burden of balancing multiple cognitive processes in the clinical environment. The answers to these questions were not analyzed. The first participant handed off the patient to the second participant to simulate a complete shift-to-shift handoff between the 2. The participant receiving the handoff could ask as many questions as needed for clarification until both parties were satisfied that the transfer was complete. There was no time limit for the handoff. A hidden faculty proctor recorded time spent completing the handoff and the number of clarification questions asked by the receiver, and ensured that unpermitted cognitive aids were not used.
      Figure thumbnail gr1
      Figure 1A, Schematic of years 2017 and 2019 and the makeup of each handoff chain. The letters indicate the individual chains (A, B, C, etc.), and numbers indicate individual residents within each chain. “P” at the end of each chain indicates the proctor for that chain who received the final handoff and answered the retention questions on the basis of the information they received in the final handoff. B, Schematic of the sequence of events that occurred in each chain. The first resident in each chain received the information contained in the simulated case the day before the simulation. All others received the information during the handoff from the previous resident in the chain. After answering “distraction” MCQs for 5 minutes, the handoff between residents was performed from memory (control group) or with the aid of the EMR handoff tool (intervention group). Retention questions were answered on the basis of what the resident could remember about the case. Neither group could use additional cognitive aids while answering the retention questions. MCQ, multiple-choice question.
      After the handoff was complete, the first participant in the chain went to a separate quiet examination room to answer 25 retention questions. The second participant, after receiving the handoff, answered MCQs for 5 minutes. This process (receive handoff, MCQs, give handoff, retention questions) was repeated with the second participant handing off to the third, etc. until the final participant handed off to the faculty proctor. Faculty proctors also answered the retention questions with information received from the final participant. The length of the chain ranged from 2 to 4 individuals, reflecting several studies that have evaluated the impact of up to 4 or more handoffs,
      • Saager L.
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      • You J.
      • et al.
      Intraoperative transitions of anesthesia care and postoperative adverse outcomes.
      ,
      • Terekhov M.A.
      • Ehrenfeld J.M.
      • Dutton R.P.
      • Guillamondegui O.D.
      • Martin B.J.
      • Wanderer J.P.
      Intraoperative care transitions are not associated with postoperative adverse outcomes.
      in addition to the faculty proctor who was the last recipient in each chain. The number of handoffs that could be completed within 1 hour limited chain length. Aside from the EMR handoff tool used by the intervention group during the handoff process, all conditions in the intervention and control groups were identical. In an effort to control for variability, neither group was permitted to use notes or outside cognitive aids. Neither group had access to the handoff tool while answering the retention questions.
      Two blinded reviewers (B.H.M., C.R.M.) graded the retention questions as 0 (incorrect), 1 (partially correct), or 2 (correct) using a set of predetermined criteria (Supplemental Appendix 2, available online at http://www.mcpiqojournal.org/). Whenever grading discrepancies were present, the reviewers refined scoring criteria until consensus was reached. The scores from the 25 questions were summed to generate an information retention score.

      Statistical Analyses

      For this initial study, a power analysis was not performed. Data are expressed as number (%) for frequency of a given score for each retention question. Significance of differences between groups for individual questions was determined by using ordered logistic regression, and satisfaction of the proportional odds assumption confirmed. Longitudinal count and continuous data were analyzed with multilevel marginal models with and without random intercepts and where linear and quadratic changes over time were considered. The Akaike information criterion was used to facilitate model selection. Differences were considered significant at P<.05, and all reported significance levels are from two-sided tests. Data analyses were performed with Stata 16.0 (StataCorp, College Station, TX, USA).

      Results

      In 2017 (cohort 1), 52 residents participated in 16 separate handoff chains. Each concluded with a handoff to a faculty proctor, leading to 68 assessments of information retention. In 2019 (cohort 2), 50 residents participated in 16 chains resulting in 66 assessments of information retention. When the cohorts were combined, first-, second-, third-, fourth-, and fifth-order participants numbered 32, 32, 31, 30, and 9, respectively. Longitudinal analysis of the data led to a marginal model with a single autoregressive lag and separate covariance for the control and intervention groups. For parsimony, position along the handoff chain was treated linearly although a quadratic term improved the model slightly but without affecting any of the conclusions. The model revealed no differences between the 2 cohorts (P=.46) and subsequently, all data were treated as a single combined cohort. Resident level of training was not significantly different between the groups and had no influence on retention scores (P=.19).
      Retention scores for each handoff chain and their mean are given in Figure 2A (intervention group) and Figure 2B (control group). A comparison between the groups is shown in Figure 2C. Overall, for the first-order participant the mean information retention score was 26.7 in the control group and 35.5 in the intervention group compared with the maximal potential score of 50 (P<.001) and declined by 4 points with each handoff (P<.001). When handoff methods were considered separately, the handoff tool improved information retention by almost 7 points (P=.002), but the methods did not differ in the rate of information decline per handoff (P=.38). The variance in the retention scores from the control group was 2.1-fold greater than that in the intervention group (P=.002). The lowest retention score in the intervention group was 12, whereas 19 of 69 (28%) scores in the control group were below 12 (including 3 scores of 1 and two scores of 2), resulting in 7 of 16 (44%) handoff chains in the control group experiencing at least 1 retention score below the lowest retention score of any in the intervention group (P=.007). In several handoff chains of the intervention group, but in none of the control group, the retention score increased (Figure 2A). In Figure 3, the percentage of correct answers is given for each of the 25 two-point questions from which the retention score is generated. Thirteen of the 25 retention questions exhibited a clear advantage in information retention (P<.01), and 5 additional questions saw a probable advantage with tool use (P<.05 and P≥.01).
      Figure thumbnail gr2
      Figure 2Retention scores for each participant in the handoff chain with and without the use of the handoff tool. Retention scores are the sum of 25 responses graded on a scale of 0, 1, or 2 for a potential score of 50. A, Retention scores for each individual handoff chain and mean retention score (solid line) for the group that used the handoff tool. B, Retention scores for each individual handoff chain and mean retention score (dashed line) for the control group. C, The corresponding means with standard errors. Longitudinal marginal modeling revealed differences between the 2 groups (P<.001) and found that the variance of retention scores without handoff tool use was approximately double that when the handoff tool was used (P=.002). As detailed in the text, 44% of the handoff chains in the control group experience at least 1 retention score below the lowest score of any in the intervention group (P=.007) Note that in several examples, the retention score actually increased in the handoff tool group (A).
      Figure thumbnail gr3
      Figure 3Distribution of all scores for each of the 25 individual questions whose sum is the retention score depicted in . For each question, the percent of all participants in each group who scored 1 (light gray) or 2 (medium gray) is shown. The concept associated with each potential response is given to the right of each bar. The significance of differences between those who used the handoff tool and those who did not was determined for each question by ordered logistic regression, with the corresponding P values are given at the right of each concept. CAD, coronary artery disease; Hb, hemoglobin; Cr, creatinine.
      The number of clarification questions asked by the receiver during the handoff (Figure 4A, B) and the duration of each handoff (Figure 4C, D) were also determined. Fewer clarification questions were asked when the tool was used (mean, 12; 95% CI, 10–15) than when the tool was not used (mean, 19; 95% CI, 15–23; P=.003). Initially, time spent handing off was approximately 10 minutes and did not differ between the intervention and control groups (P=.18). It declined in the control group by approximately 2 minutes per handoff (P<.001) but remained relatively constant in the intervention group (P=.67).
      Figure thumbnail gr4
      Figure 4The number of clarifications requested and duration of the handoff process for each handoff. (A, B) Fewer clarification questions were asked in handoffs that used the tool (A) than in handoffs with no tool (B, P=.003), as revealed by longitudinal multilevel analysis appropriate for counts. (C, D) The time expended by participants in the handoff process was greater for those using the handoff tool (C) than for those who did not use the tool (D, P<.001) as revealed by longitudinal multilevel analysis. In contrast to participants using the handoff tool, the duration of the handoff process declined with successive handoffs for participants who did not have the handoff tool (P=.002).

      Discussion

      Using a simulation methodology to control for environmental and case heterogeneity, this study reported the extent that clinical information is continuously degraded during sequential handoffs. It also found that a case-specific handoff tool derived from the EMR limits but does not prevent this information loss. Although unable to prevent information loss, the handoff tool averted its most severe and potentially harmful occurrences. Without the handoff tool, almost half of the handoff chains in the control group had an information retention score lower than the lowest value attained with the aid of the handoff tool. Revealing this aspect of the variability of the handoff process was facilitated by simulating handoffs using a fixed complex scenario with multiple handoff chains. Consistent with the amount of information conveyed along each handoff chain, handoff times in the control group grew shorter and required an increasing number of clarification questions. In some isolated instances, the handoff tool appeared to have facilitated large increases in information retention along the handoff chain.
      Ultimately, the goal of any handoff tool is to improve patient safety. Agarwala et al
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      ,
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      they do not account for the correspondence between the number of handoffs and longer surgical time, which are typically associated with more complex procedures and patients. By using simulation to evaluate handoffs for a fixed complex clinical scenario, we reported an increase in the transfer of relevant clinical information and a reduction in the variability of information transferred. Thus, potentially catastrophic losses of clinical information in complex cases could be prevented with a handoff tool.
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      We observed an even greater deterioration in information retention than reported in those studies, possibly because our clinical scenario was more complex. Clinical trials have shown that use of checklists for transitions between operating room and intensive care unit
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      result in a greater number of items transferred that are deemed “must” and “should” be handed over, further reporting that essential clinical information may not be adequately conveyed without a formalized tool or process. By simulating multiple handoff chains for a standardized complex clinical scenario, we were able to quantify the amount of clinical information lost during handoffs, and the extent that a handoff tool could limit this loss. Moreover, this methodology provides the means to test and refine newer handoff tools, and may be valuable to medical educators in the training and evaluating the handoff process.

      Wagner R, Koh N, Bagian J, Weiss K. CLER 2016 National Report of Findings, Issue Brief #5: Care Transitions. Chicago, IL: Accreditation Council for Graduate Medical Education; 2016. 13: 978-1-945365-10-2.

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      Nonetheless, working hours may also have an inflection point, before which handoffs are likely harmful, and after which handoffs are likely beneficial by introducing rested clinicians.
      • Jones P.M.
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      Regardless, handoffs should intend to minimize potentially catastrophic information loss.
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      Our results highlight the advantage of using a cognitive aid for a complex case although the handoff tool included a great deal of data, which may have masked critical information. Conversely, the oral tradition likely included less extraneous data because the clinician extracted relevant details from memory. The oral tradition however, as shown in the current study, almost certainly led to the loss of critical information in many of the handoff chains.
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      • Shannon C.E.
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      posits that the self-information of an event, clinical or otherwise, is inversely related to the probability of that event occurring. Therefore, it is unlikely that the true information value of each question was perfectly reflected in our scoring system. More broadly, such considerations emphasize the need for some formalized handoff process as well as the difficulties in devising one. The choice of what to convey about a given case and how that is received will depend highly on the particulars of the case as well as the individual knowledge and experience of both participants, because what is rare and unexpected to one participant may be familiar and foreseen to another. A practical handoff tool would seek a necessarily imperfect balance.
      Apart from the quantification of information, this study has several additional limitations. Although we addressed intraoperative complete transfers of anesthesia care by resident trainees, we did not study other types of handoffs in health care, or those by other clinicians. However, no aspect of the methodology reported here would preclude its adaptation to other handoff scenarios that are pervasive in health care. Participants had varying experience levels, and we did not provide handoff training with or without the tool. We also did not independently quantify participant’s proficiency in performing handoffs overall or their familiarity with specific handoff tools. Certainly, the utility of cognitive aids may be limited if introduced without adequate familiarization and training.
      • Goldhaber-Fiebert S.N.
      • Howard S.K.
      Implementing emergency manuals: Can cognitive aids help translate best practices for patient care during acute events?.
      Moreover, the simulation was performed in a controlled environment that did not reflect distractions that typically complicate clinical care, and may have removed time pressure that typically accompanies shift endings. Similarly, the sequential handoffs occurred without intervening clinical care or progression of the case for the purpose of using a standard set of retention questions. Although these features of simulation are not reflective of clinical practice, they would likely bias the actual results toward more complete transfers of clinical information. Participant awareness that we were evaluating 2 different handoff methods may have introduced bias toward greater effort with a method they perceived to be better. Although all first participants in the chain were given identical materials in advance, the time and effort they spent absorbing that information was not controlled for, perhaps reflecting variation in individual practice in the clinical environment. Our control group handed off solely on the basis of memory, without benefit of notes or outside cognitive aids, possibly biasing their results in a negative direction. Although national regulatory bodies have advocated using a standardized handoff system enhanced by the EMR for over a decade, recent evidence indicates that implementation and adherence is inconsistent,

      Wagner R, Koh N, Bagian J, Weiss K. CLER 2016 National Report of Findings, Issue Brief #5: Care Transitions. Chicago, IL: Accreditation Council for Graduate Medical Education; 2016. 13: 978-1-945365-10-2.

      ,
      • Co J.
      • Wieiss K.
      • Koh N.
      • Wagner R.
      CLER National Report of Findings 2018: Executive Summary.
      and experience indicates that many clinicians still handoff from memory. Faculty proctors were involved in the study design or familiar with the case before the study date, which may have introduced bias in their recording of responses in the final handoff. Finally, because we embedded information elements within a large data set of a simulated case, we can only speculate whether successful conveyance of these elements would be essential to prevent patient harm.
      In conclusion, sequential handoffs lead to substantial, perhaps inevitable, degradation of clinical information that is somewhat ameliorated by use of a handoff tool. However, the major clinical benefit of such a tool may be to reduce variability in information transfer and limit the most deleterious losses of clinical information. We anticipate the methods described here will be of value to those wishing to evaluate and compare various handoff methods in a controlled environment and to educators involved in the training and evaluation of learners in a variety of clinical fields.

      Potential Competing Interests

      The authors report no competing interests.

      Supplemental Online Material

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