Wednesday, May 7, 2014

Improving patient handoffs and transitions of care

- Kenny Lin, MD, MPH

As a long distance runner on my high school track team, I won few accolades in individual events, but shone in relays. My teammates and I spent hours perfecting our baton exchanges, which must occur within a limited area of the track, until these handoffs felt smooth and effortless. In contrast, world class athletes focused on individual performances are often assigned to relay teams at the last minute, a practice that led to stunning disqualifications for dropped batons of both the U.S. men's and women's 4 X 100 meter relay teams at the Beijing Summer Olympics.

Dropped handoffs in medicine can expose patients to harm, too, even if individual clinicians are exceptionally skilled. An editorial in the May 1st issue of AFP reviewed studies of programs designed to improve care transitions from hospital to home and found mixed evidence that such programs improve health outcomes:

Although some programs reduced 30-day rehospitalization rates, a systematic review found that no single intervention is reliably helpful, and successful readmission reduction programs generally occur only in single institutions.However, it seems that programs that focus on the whole patient rather than a specific diagnosis are more successful in reducing readmissions. This concept is in keeping with the focus of primary care physicians. To solve the challenge of care transitions, the primary care physician should have a prominent role at three times: at admission, immediately after discharge, and at the postdischarge follow-up visit.

Research on improving inpatient handoffs has evaluated the varying effectiveness of electronic handoff tools, standardized communication training, verbal mnemonics, structural changes, and "handoff bundles" that include one or more interventions. Several residency programs at my institution recently found that an electronic template for graduating residents to hand off their "high risk" outpatients to other clinicians did not improve handoff quality or clinician satisfaction compared with free-text handoff notes.

What tools have you or your colleagues found useful to assure uninterrupted transitions of patient care from hospital to home, between clinicians in inpatient and outpatient settings, or between primary care physicians and subspecialists?