 Hello everybody, this is Steve Barker and we're going to talk for a few minutes about some recent developments and thoughts on the issue of hand-off communications within the hospital. Very important topic as I will hopefully show you. Let's start with the definition. What is a hand-off in the hospital? Well, a patient hand-off between caregivers is a transfer of care responsibility, hopefully achieved through effective communication of patient information to ensure continuity and safety of care. Every hand-off involves senders, the caregivers who are transferring the care of the patient to the next caregiver or team, and receivers, the caregivers who accept the patient care responsibility. And both the senders and the receivers may be teams or individuals. Is this a problem and what is the problem? Well, according to the Agency for Healthcare Research and Quality, recent report, half of hospital staff feels that patient information, significant information, is lost during the hand-off process. The Joint Commission identified breakdowns in communication, especially hand-offs, as the leading root cause of sentinel events reported in their reports between 1995 and 2006. So there are three reasons why I've chosen this topic for today. One, it's obviously very important. Secondly, it fits in with the strengths and interests of the patient safety movement. And third, my own background, which I haven't explained to you yet, but I've been an anesthesiologist for about 35 years, 23 of those as a department chair. Before that, I had a previous career. I was an aeronautical engineer and actually a tenured professor in that field. So in two more slides, you will see how that has influenced my approach to this problem. What are the ingredients of a proper hand-off from one individual or team to another? Well, it should include the chief complaint. Why is this patient in the hospital? A list of their medical problems, even if they are not relevant to the admission. Something about the history and physical, some degree of detail. Lab results and other test results, perhaps x-rays. What medications and treatments are the patient receiving? Current and planned. What has been the hospital course? Complications? What things have gone well? What things have not? And what has been the progress? What is the discharge plan? How do we get this patient home, the final hand-off and the final destination? And last but not least, recommendations. Here is what I think as the sender. Here is what I think should happen and here is what I suggest. So what else needs to be on this list? And it's a list that we check frequently. Gee, what does that sound like? It's a checklist. Yes, indeed. And that's what takes us to my previous life of aviation. Because the aviation industry came up with the idea of checklists a long time ago as a necessary ingredient. This is the start-up checklist of a Boeing 747. This doesn't take you into the air. It takes you from the time the pilot and co-pilot sit down in the cockpit until the last thing at the end of the checklist is they release the brakes and start their taxi. And it takes two to go through this list. One, the pilot or co-pilot is reading the ingredients and the other is checking the proper instrument or function of the airplane. Nobody could remember all of this every day and they shouldn't even try. And the same is true with hand-off communications for us. So part of our solution is indeed a checklist for several reasons. One, we are human and just like pilots we can forget stuff, crucial stuff. And there are two other reasons why that's likely. One is our world where we are doing these hand-offs is increasingly complex and complicated and technical. There is stress involved and the third ingredient which is very important in many of these events is distractors. The presence of unrelated minor events that may change or distract your train of thought. Somebody else calls you during the hand-off. Somebody drops something, anything that distracts your attention. This has been shown to be a key to hand-off problems in the cockpit. And it's equally true in the operating room or in the hospital. And I'm not the only one who believes in the use of checklists for hand-offs and other parts of medical care. You've all heard of this book by now by Atul Gawande who is a general and endocrine surgeon at the Brigham hospital. He came up with this book called The Checklist Manifesto published in 2010. It is a bestseller. By the way it is available on Kindle so I have it with me at all times. And this checklist that he has pushed and basically sold is for surgeons. That is a tough audience to convince to change their ways and he has successfully convinced them. In fact he has published a newer study showing that the use of his checklists have actually improved patient care outcome. So we need checklists for each type of hand-off communication. What would those include? Well our starter list included these four senders, the emergency department, emergency room, the hospital unit or ward, the operating room and the paramedics. From those four senders you can have any of these receivers like for example the emergency room can transfer patients to the ward directly to the operating room to a critical care unit or to a testing unit and so on. You can read the rest of this. There are a total of 17 checklists there and the list has actually grown since we formulated this original version. What else? As I said the list is up to about 21 or 22 today. Here are two examples. Here is one example from the emergency room to the operating room. And as I might have mentioned this is a hand-off where time is a major factor. Time is limited. In fact this is one that I have participated in many times and you might be running beside a rolling gurney rapidly moving the patient from the emergency room to emergency surgery in the operating room. You literally may have about one minute to do this hand-off while you are running beside a gurney. So you need a short and concise checklist and here it is. Chief complaint, surgical plan, what are we going to do to the patient, special needs, etc. And you can read all of this. It's short and it contains all of the vital information. Now you can compare that with the other type of hand-off. This is a good example of one where time is quite flexible and you can take longer if you need it. This is a shift change. That is for example the change from the day shift to the evening shift on a hospital ward. And in this one we use the algorithm called S-bar which stands for situation, background, assessment, and recommendation. It's a good best practice for standardizing communication. And by the way, interesting sidelight, the S-bar technique was developed by the U.S. Navy for use on nuclear submarines. So here is the hand-off, the S-bar hand-off for shift change, situation, why was the patient admitted, what is their contact information, etc. And you can read this, all of the vital information. And last but not least, your recommendations to the receiving team. At least as I said 17 of these hand-off checklists I showed you the list of 17. The list is today more like 21 or 22. What can we do to simplify this list? Are there any of these hand-offs that can be combined, food for thought? What do these checklists actually look like? Are they cards or pieces of paper that you carry around? Well that depends on the exact hand-off that you're talking about because as I said there are many varieties and they have different time scales. Are they paper or perhaps they're electronic? Perhaps they're on your iPhone or your iPad. How are they used? Are you actually reading the checklist between the sender and the receiver? Or perhaps you're talking to your device. Hey Alexa, hand-off communication from emergency room to operating room. Go. And Alexa walks you through the hand-off as you are, as I said, running beside the gurney. So some of these are time limited, some are not. Above all, and this was a temptation that we had to resist, they are not forms to be filled out. They do not represent an increase in workload. Remember, they are there to prevent us from forgetting stuff, not to increase our workload. What really happens in a hand-off? As I said, it's defined as a coordinated, carefully timed transfer of patient care from one provider to the other. So is this the patient, a stick of wood? In other words, is the patient a passive participant in this hand-off process? Well, let's think about that for a second. Let's look at the hand-off anatomy again as we have originally described it. It's a transfer of information from the sender to the receiver. But wait a minute, there's something vital missing here already and that is that this is two-way communication between sender and receiver. The receiver has to indicate that he or she understands the hand-off, has received and understands the hand-off information, and they might have new questions or suggestions, things that have not occurred to the sender. This is a vital example where two heads are better than one and the receiver offers a new perspective on this patient which may discover things that we're not thought of. And then furthermore, why not involve the patient if the patient is conscious and alert and capable of participating? So if you count all of the arrows here, this is now a six-way communication between sender, receiver and patient, when possible. And I'm not the only one who thinks this. The Joint Commission has published this beautiful eight-step algorithm tips for high-quality hand-offs. I don't expect you to read the fine print. So let's blow up this one here. And it says when conducting a hand-off include all team members and, if appropriate, the patient and family. For example, in the shift change hand-off, if the patient is sitting there, again, they're not a stick of wood, involve them in the process, and the patient may bring in new perspectives that neither the sender nor the receiver had thought of previously. The Joint Commission has been very active in this process. Since before even 2017, they identified inadequate hand-off communication as a major problem. And as I said, a common problem regarding hand-offs or hand-overs centers on communication. Expectations can be out of balance between the sender and the receiver. A key problem. It's all about communication. Another group that I work closely with is the Anesthesia Patient Safety Foundation. They actually dedicated their entire 2017 annual meeting to hand-off communications. And their approach was, of course, peri-operative hand-offs where either the sender or the receiver is actually the operating room team and the anesthesiologist. They came up with this flowchart algorithm design involving these different locations where the operating room can transfer patients to or from. And if you count the number of arrows there, most of them being two-way, the hand-off can go in either direction. There's about 16 arrows just involving the operating room. So our work is cut out for us. Each of these hand-offs has things in common, but they also have their own individual differences. So to conclude, hand-off communications occur in a very stressful environment where it is easy to forget stuff, just like flying an airplane through a storm. And there are many distractors, other events happening that may or may not be related to this patient. Patient hand-off communication and flying an airplane, you both need to use checklists. There are at least 17, in fact, greater than 17 different types of inpatient hand-offs. We're up to about 21 or 22 now. There is some institutional variability. Different hospitals with different patient populations and procedures and treatments may have some variations in these hand-offs, but the basic structure will be the same. Remember that hand-off communication is not a one-way process. It is at least a two-way process between sender and receiver, and it may involve the patient too. The patient should be part of the process whenever possible. Patient safety movement is in a unique position to help with this problem, and we are actively working on it and look forward to continuing this work in the future. That ends my talk. We are limited only by our imagination, just as the Apollo 11 mission that landed on the moon, and I'm happy to see that the U.S. is back in space, by the way. And thank you very much for your attention, and I look forward to discussing this with you.