The December 2014 Publication “Improving Transitions of Care: Hand-off Communications,” published by the Joint Commission Center for Transforming Healthcare, aims to address consistent and widespread failures in Hand-Off Communications. A lack of standardization for hand-off processes, ineffective communication methods, inadequate time committed to the hand-off, among many other failures were highlighted as the root cause for ineffective hand-offs.

This Joint Commission publication defines hand-offs as “a transfer and acceptance of patient care responsibility achieved through effective communication…a real-time process of passing patient specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient’s care.” But what are the unique features of a hospitalist hand-off, and how do hospitalist staffing models impact the necessary content and approach to hand-offs?

Given the realities of hospitalist service staffing, there are really four types of “Hand-Offs” to consider:

1) Morning Hand-Offs: Hospitalists who admit patients in the evening and overnight period need to transition the care of these newly admitted patients in the morning. This transition to daytime hospitalists is typically focused, given the fact that a long hospital course has not yet occurred. Therefore, the central goal for communication for the Morning Hand-Off is to communicate why the patient presented, why they required admission, and what key issues were identified pertinent to the admission history, exam, and data. The fact that the patient was only just recently in the emergency department, coupled to the fact that a full history and physical was likely dictated, means that this hand-off needs to be targeted to the central issues on admission. An overly lengthy Morning Hand-Off often suggests that the admitting hospitalist is being unnecessarily redundant, as the H&P is essentially a reference document with the patient’s narrative and detailed impression and plan. That said, an H&P may not be available when a morning hospitalist assumes care for a patient, so some form of a hand-off is clearly critically important. When considering these factors, therefore, the Morning Hand-Off should really focus on encapsulating the presenting complaint, key diagnostics, big-picture impression, and plan.  Equally important to the clinical content contained within the Morning Hand-Off is a clearly identified hospitalist who will assume the care of the patient in the morning.  Distribution to a morning hospitalist often involves many factors, such as patient severity of illness, location, observation/inpatient status, anticipated length of stay, among other factors.  Therefore, any system which helps to standardize the morning hand-off process ideally would incorporate all of these factors and guide the team in patient assignment, or even automatically assign patients to the most appropriate team based on service-specific rules.

2) Hospitalist Evening Hand-Offs (or “Signout”): Hand-offs from a daytime hospitalist to a temporarily covering evening and overnight hospitalist(s) have been covered fairly extensively in the literature, particularly in reference to housestaff and intern signouts.  Perhaps the format and approach which gained substantial ground since 2011 is the I-PASS model, perhaps given the fact that the bundled intervention in the study decreased medical errors and preventable adverse events (Starmer et al, JAMA 2013).  In this model, I-PASS is a mnemonic which refers to Illness Severity, Patient summary; Action items; Situation awareness and contingency planning; Synthesis by receiver.  While the I-PASS model includes components which are clearly important to medical graduate trainees, who have encountered few cross-cover issues and who have limited clinical experience, the relevance to busy hospitalist groups who in some cases may have one doctor covering four to five times as many patients as a typical intern during an overnight period is unknown.  Nevertheless, hospitalist groups must become engaged in the Evening Hand-Off, or Signout, and cannot solely rely on the clinical documentation of their daytime colleagues in the medical record to guide critical clinical decision-making during off hours.  As hospital medicine considers the standard of care for this type of handoff, realities of staffing also do need to be considered, such as the fact that daytime staff may not even be present when overnight covering staff arrive.  Therefore, while a full I-PASS hand-off model may be unnecessarily comprehensive as well as unrealistic for hospitalist groups to implement, clearly some type of Evening Signout is necessary.  Likewise, hospitalist overnight coverage, given the number of patients for whom they may cross-cover, needs to have a standardized method of determining what covered patients require overnight actions, such as lab checks or follow-up on urgently ordered radiologic studies.  In all, while not well-defined, hospitalist programs clearly need some form of signout and an action-tracking list.  Speaking with colleagues, it is apparent that this is not yet the standard and requires further discussion and, likely, investigation.

3) Off-Service Hospitalist Hand-Offs: The final type of hand-off is the Off-Service Hand-Off.  Unlike Morning Hand-Offs, Off-Service Hand-Offs need to encapsulate a hospital course, secondary clinical issues, disposition planning, and other components specific to this type of hand-off.  The “sending” hospitalist needs to enable the “receiving” hospitalist to pick up where they left off, ideally without having to perform an extensive review of the full inpatient medical record, at least initially when the receiver assumes care of the patient.  The receiving hospitalist, based on the Off-Service Hand-Off, should understand how a patient’s active problems developed and evolved, and what problems may have been present which have since resolved.  Secondary issues, such as newly noted but stable iron deficiency anemia, also need to be included so that these important issues, which are not necessarily pertinent to the patient’s currently active medical issues, ultimately are brought to the attention of a primary care provider.

4) Discharge Hand-Offs: While a patient discharge is not necessarily always considered as one of the types of hand-offs that hospitalists encounter, this is clearly a critically important transition of care which most certainly fulfills the spirit of the Joint Commission’s definition of hand-offs.  While these hand-offs frequently occur through formalized discharge summaries and discharge summary elements, discharge communication with a primary care provider or other, outpatient provider who is assuming the care of a patient, is equally important.  The content of this communication needs to be considered carefully in the context of the discharge paperwork that is already being produced.  Re-typed or copying and pasting an entire discharge summary in an e-mail, for example, to a primary care provider would not only be redundant, but would fail to fulfill the requirements of an effective hand-off.  Considering strategies to make discharge communication and effective strategy to enhance the Discharge Hand-Off, which complements but does not copy the discharge paperwork, will be important to hospitalist groups.

In summary, when it comes to hospitalists, the term “Hand-Offs” really applies to several, distinct types of transitions of care.  By clearly defining the necessary components of each of these types of hand-offs, a hospitalist group will position itself to be successful in all transitions of care.  Electronic hand-off solutions, which are recognized as important components of any hand-off solution (as noted by both the Joint Commission and the I-PASS investigators), should also be considered by hospitalist groups.  Choosing an electronic solution with recognizes the relationship of these different types of hand-offs will ultimately optimize the hand-off content while also streamlining workflow for otherwise busy hospitalists.