In-hospital care has suffered as a result of the increased fragmentation in the delivery of care, specifically secondary to new clinical models such as the rise of hospitalist care in the United States, and the move toward cutting hours for residency trainees in teaching hospitals. This fragmentation has resulted in a greater need for care coordination and a focus on transitions, particularly for the hospitalized elderly population. For example, for a typical patient, a member of the patient’s primary team is present in the hospital only 50% of the time. Hospitalized patients are passed between doctors an average of 15 times during a single 5-day hospitalization.
In addition to the focus on end-of-shift changes that are germane to hospital medicine, there is increasing recognition that the focus on handoff behaviors needs to extend to cover the vulnerable “service change,” which represents a more permanent change in primary hospital care provider. While the current literature has focused on strategies for to effectively “give” information during the handoff, recent literature has also highlighted the need to examine the critical role of the receiver.
a fluid, dynamic exchange that is subject to distraction, interruptions, fluctuates on aptitude of and confidence in off-going and on-coming clinician and is contingent on the on-coming clinician’s confidence in the quality, completeness of the information. Cook et al (2000)
While the scope of Cook’s definition refers primarily to shift change, the term handoffs has taken on a life of its own, with the term being used synonymously with a broader set of care transitions, such as admission, discharge, and even communication between outpatient physicians. In this chapter, we will focus on the skills that are essentially to those handoffs which permeate the in-hospital setting for hospitalists, with a special focus on shift and service change, as well as introduce assessment strategies to ensure the safety and efficacy of these handoffs.
TYPES OF INTRAHOSPITAL HANDOFFS
Shift change is the transfer of content and professional responsibility from one clinician to another at the end of the shift. One important distinction among shift changes is whether the outgoing clinician is returning to assume ongoing care of this patient or the handoff is just a temporary coverage for emergencies until the primary team returns. In the case of the latter, the covering physician is often accepting a handoff only to manage overnight emergencies, but planning and execution of care are largely on hold.