Handoff information should cover past, future
Meghan Dierks, MD, MS, a faculty member at Harvard Medical School and a member of the Clinical Decision Making Group at the Massachusetts Institute of Technology, both in Cambridge, offers an outline of what information should be exchanged in an ideal patient handoff.
The degree to which this information is discussed will depend on the individual patient and situation, but she says certain broad areas should be covered.
This outline uses a surgical scenario as an example but can be adapted for any situation:
- Baseline metrics/benchmarks
What was the patient’s behavioral/emotional/mental status, level of alertness, level of anxiety, ability to follow directions, communication abilities/disabilities, during the pre-op period? What are their standard medications, diagnoses, needs? What was received, administered today? Any prior perioperative experiences? Prior admission experiences for this same diagnosis? - Most recent phase of care (e.g., intraoperative course)
What was the procedure, (or diagnosis, chief complaint, etc.), and what are the implications for immediate next phase of care (e.g., femoral-distal bypass pulse status and visual inspection of wound at sites of anastomosis)?
What was the duration of the procedure — or labor/delivery, or emergency department (ED) course? Was it longer, shorter, or as expected, and what are the implications for immediate next phase of care (e.g., hypothermia, fatigue, agitation, pain)?
Was the scope or complexity of the procedure (or ED intervention) greater, less than or as expected, and what are the implications for immediate next phase of care?
Unexpected events? Deviations from expected course?
What are your (transferring provider) uncertainties regarding specific aspects of the patient and what are the implications for immediate next phase of care (e.g., arterial line waveform is unreliable, estimated blood loss may have been underestimated, precise urine output may be difficult to monitor because of vesico-vaginal fistula/incontinence, surgeon was concerned with quality of vascular anastomosis, doctor was concerned about uterine atony, and possibility of ongoing bleeding)?
- Current status
What is the current status of vital signs, pain control, hemostasis, airway/breathing, and mental status?
Is this within your expectations, given the intraoperative course and recent interventions?
What are the emerging trends?
What is the current trajectory of vital signs, mental status, pain control, hemostasis, airway/ breathing? Improving, deteriorating, remaining the same?
If it is changing, what is the rate of change in status — rapid, slow? - Expectations (for the next phase of care)
What are your expectations for the patient’s status, progress or occurrence of specific events over the next several epochs: 10 min., 30 min., 60 min., readiness for discharge?
What are your expectations regarding rate of change in vital signs, mental status, pain control, hemostasis, airway/breathing, electrolyte or hematocrit, wound/dressing status, output from drains?
What are your expectations regarding specific, unambiguous thresholds, parameters and goals to achieve, time frame in which to achieve these, interventions to take and whom to contact if thresholds, parameters are exceeded or goals not met? - Housekeeping issues
Scheduled medications, interventions, procedures — when?
Where did the patient come from?
Where is the patient going?
Where is their family, what does the family know, what do they need to be told?
Whom to contact for specific issues — first tier, second tier (if unable to reach first tier), consultants for specific subsystems.
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