Efforts to improve patient safety and resident physician well-being resulted in an international push to limit resident work hours [1–2]. After the implementation of such restrictions in Canada, the United States, and Europe, the results are varied, with some studies showing worse patient outcomes, negative impacts on resident quality of life [1] with yet others showing a decrease in adverse events [3]. These changes emphasized the importance of “handoff”, a term used to describe the transfer of patient information from the outgoing physician of care to the incoming on-call physician [4].

At large institutions with high volumes of inpatients, handoff on all patients is not feasible, thereby requiring daytime physicians to prioritize a smaller subset of patients to convey potential issues on. From a survey of 26 physicians, it was noted that incomplete and omitted information in handoff was a significant issue and considered to lead to failure to anticipate and communicate problems to on-call physicians [5]. Previous work showed poor handoff specifically implicated in 20–24% of medical errors [4], while a more recent survey of Canadian residents showed that nearly half of respondents were directly involved in or witnessed an adverse event related to handoff [6]. Given this, the World Health Organization (WHO) and other regulatory bodies prioritized optimizing handoff as a top patient safety initiative [1,7–8].

A number of strategies for optimal handoff were suggested with standardization being noted most frequently [4]. Other suggested strategies include providing training or education and addressing environmental issues such as lighting, interruptions and noise [1,4,9]. Despite a call from the Accreditation Council for Graduate Medical Education (ACGME) to develop curricula [10], many residency programs do not educate trainees in the process of handoffs, with approximately 57% of Canadian residents learning this skill informally from other residents or staff [5]. Some of these strategies have recently been evaluated in a randomized trial of handoff methods in a surgical training program, demonstrating no clinically significant differences in patient outcomes [11]. We set out to evaluate implementation of standardized handoff among medical ward patients in a parallel controlled trial.

We conducted a cluster randomized controlled study to assess the effect of implementing a multi-faceted and standardized handoff intervention on the rates of handoff by residents. The intervention consisted of training and education on the type of patient to handoff, what information to handoff, and identifying a specific time and location for uninterrupted face-to-face handoff. We also assessed this intervention on resident satisfaction, and patient level outcomes including health resource utilization and clinical events. Clustering by ward teams was employed to minimize contamination of the structured handoff process between medical trainees within the same teams.

There were 48 residents and 1168 patients (8652 patient nights) during the study time (Fig 1). There was a similar number of residents and volumes of patients on the intervention and control teams (Table 1). Data on the total number of patients and their characteristics were provided by the hospital and were fairly balanced between groups. On the Clinical Teaching Units, most patients were elderly and the most common discharge diagnosis included pneumonia or influenza, sepsis, or gastrointestinal problems.

Over the study period, the CA’s recorded a total of 1,150 patient encounters over the study duration (8652 person-nights). There were 599 patient encounters recorded in the intervention group and 551 in the control group. Of the 1,150 there were 265 patient handoffs (patients formally handed off to the CA) in the intervention group and 208 in the control group. In the intervention group, 49% (130/265) of the handoffs occurred face-to-face and 41.5% occurred over the phone. For the control group, face-to-face handoff occurred 38.5% (80/208) of the time, while 51.9% was over the phone.

The implementation of a multi-faceted structured handoff program resulted in significantly more patients being handed off to the overnight physician and increased resource utilization compared with non-standardized handoff practices, but no significant differences in clinical outcomes or medical errors.

The bundled intervention demonstrated increased patient handoff and health resource utilization compared with usual handoff practices. These findings are consistent with other studies [13–15] and recommendations by the ACGME to improve handoff processes [16]. Our intervention may have led to increased health resource utilization because the CA does often receive specific instructions for investigations to be followed up overnight. Increased use of ECGs may reflect a common request to evaluate a complaint of chest pain. Increased use of blood products may reflect instructions to transfuse blood given a specific hemoglobin result. These findings suggest that a structured training program on handoff with feedback can lead to improved handoff practices. From the resident and CA surveys, satisfaction with handoff was modest and not different in both intervention and control group. However, response rates were low, limiting interpretation of these findings. Resident satisfaction with formalized handoffs has already been identified in a number of studies [14–15,17].

The research demonstrating a significant impact of formal and standardized handoff processes in terms of resident training and clinical outcomes is limited. Our negative results on patient outcomes are consistent with other studies [18–20]. Using a case-based computer simulation to provide opportunities to teach and practice handoffs, a study by Johnson et al. on pediatrics residents did not find any significant differences in patient outcomes such as rapid response calls or transfers to the ICU with implementation of the module [18]. Formalized handoff processes can result in increased confidence among medical providers and a perceived decrease in “near-miss” events [19], but no demonstration of an actual improvement in patient outcomes. Use of face-to-face handoff also did not show improved patient outcomes among hospitalized medical patients [20]. In a prospective pre-post test study by Starmer et al., handoff on all patients using a multifaceted handoff bundled intervention in 9 pediatric inpatients centers showed a 23% reduction in medical error rates with handoff practices [21]. However, this study design used a time series analysis that is at risk for bias for differing co-interventions at different time points and temporal changes in outcomes. Outcomes were assessed on all patients, not just those seen by on-call physicians. Further, this study’s intervention of handing off all in-patients is not easily applied to high patient volume settings. There may be other efforts required to show a handoff bundle is effective in reducing medical errors or improving patient outcomes. The strongest and most recent randomized trial of formalized patient handoff in a surgical residency program did not show any difference in mortality, medical errors or length of stay [11]. This may indicate a need for more tailored handoff strategies for different settings. Others have commented on the need for robust information systems that involve an effective electronic medical record along with a sustainable cultural change program [22].

The potential reasons for the negative findings in change in clinical outcomes between our two groups are likely multi-fold. Despite an increase in patients handed off, we did not identify any significant differences in patient outcomes. Handoff to the evening CA traditionally occurs for the seriously unwell patients on the ward as standard of care and thus the residents assigned to the control group may have also similarly identified and handed off patients at high risk for being seen by overnight physicians thus minimizing differences in ICU and CCOT transfers. Other patient clinical deterioration events may also be less or difficult to predict so handoff on a select subset of patients may miss a significant proportion of patients needing evaluation by the overnight physician. Furthermore, overnight CAs are, in general, experienced senior-level residents. One can postulate that whether they received a patient handoff or not, CA’s were able to stabilize and manage patients quickly and appropriately by reviewing the chart once notified by nurses. Also, our medical error rate was lower than expected. Safety measures built into our system such as physician alerts for abnormal laboratory values, modified assignment nursing staff allowing for closer monitoring of sicker patients and residents on-call in the emergency department overnight may have allowed for closer follow-up on patient issues identified during the daytime.

The strengths of the study include a parallel controlled trial design and multiple outcomes measured in a high volume patient setting. We also used a multi-faceted intervention that included not only mnemonics, but also observation and feedback during the education session and a specific time and location for uninterrupted face-to-face handoff. Our study focused on the internal medicine wards with a general census of over 100 patients, common in many general internal medicine residency programs. However, our study has limitations. Data were dependent on the accurate record keeping by the CA, however there is no evidence to suggest a difference in accuracy between the intervention and control arm. Although we employed clustering in our intervention, there may have been some contamination in the handoff process between intervention and control. Conducting the analysis at the cluster level did not enable us to take advantage of patient level analysis, such as variation in cluster size and allowing adjustment for patient level characteristics. The number of clinical events including serious medical errors was low in our study, thus limiting our ability to detect smaller changes in these events. Results from our survey were limited due to lower than expected participation in the survey. Our study was carried out in a high volume academic tertiary care center with a single experienced resident covering overnight shifts and as such, our findings may not be generalized to lower volume hospitals or hospitals without trainees. Finally, we did not explore the effect of having a single CA covering over 100 patients and whether having more physicians to share the workload along with improved handoff would improve patient outcomes.

While there is widespread recognition for the need in creating a handoff process in the inpatient hospital setting [23], an evidence-based approach for internal medicine residency programs remains to be determined. Our handoff bundle of resident training and education, standardization, mnemonics, and face-to-face handoff did not succeed in an improvement in general patient outcomes in a high volume in patient medical service. Novel methods to improve clinical outcomes associated with handoff need to be explored.