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Post-call handoffs less than stellar, but why?

Miscommunication

Miscommunication

Vineet Arora, whom I mentioned in a post a few days ago, is a co-author on a new study showing that when post-call interns hand off their patients, important information often fails to be communicated to the receiving resident team.  In other words, the post-call handoff isn’t very good.


Vivian Y. Chang, Vineet M. Arora, Shiri Lev-Ari, Michael D’Arcy, and Boaz Keysar
Pediatrics 2010; 125: 491-496  [PubMed citation]

OBJECTIVE Theories from the psychology of communication may be applicable in understanding why hand-off communication is inherently problematic. The purpose of this study was to assess whether postcall pediatric interns can correctly estimate the patient care information and rationale received by on-call interns during hand-off communication.

METHODS Pediatric interns at the University of Chicago were interviewed about the hand-off. Postcall interns were asked to predict what on-call interns would report as the important pieces of information communicated during the hand-off about each patient, with accompanying rationale. Postcall interns also guessed on-call interns’ rating of how well the hand-offs went. Then, on-call interns were asked to list the most important pieces of information for each patient that postcall interns communicated during the hand-off, with accompanying rationale. On-call interns also rated how well the hand-offs went. Interns had access to written hand-offs during the interviews.

RESULTS We conducted 52 interviews, which constituted 59% of eligible interviews. Seventy-two patients were discussed. The most important piece of information about a patient was not successfully communicated 60% of the time, despite the postcall intern’s believing that it was communicated. Postcall and on-call interns did not agree on the rationales provided for 60% of items. In addition, an item was more likely to be effectively communicated when it was a to-do item (65%) or an item related to anticipatory guidance (69%) compared with a knowledge item (38%). Despite the lack of agreement on content and rationale of information communicated during hand-offs, peer ratings of hand-off quality were high.

CONCLUSIONS Pediatric interns overestimated the effectiveness of their hand-off communication. Theories from communication psychology suggest that miscommunication is caused by egocentric thought processes and a tendency for the speaker to overestimate the receiver’s understanding. This study demonstrates that systematic causes of miscommunication may play a role in hand-off quality.

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This study suggests that the post-call handoff is potentially a dangerous one.  The authors write “… the inability of the postcall intern to gauge accurately the on-call intern’s understanding of patient information may greatly affect hand-off quality; not only are on-call interns failing to receive important patient information, but also the postcall interns are systematically failing to realize that breakdown of communication.”  The authors suggest a few possible reasons for these failures (“egocentric thought processes and a tendency for the speaker to overestimate the receiver’s understanding”), but ignore what seems to me the most obvious one — the postcall interns have been working without sleep for 30 hours.  Whatever quirks of human personality prevent clear communication, it seems likely that these obstacles would be harder to overcome after you’ve been significantly sleep deprived.

Given these results, I’d like to see a study that compares the quality of the handoffs performed by a post-call team to those performed by a team that’s not on call and has only been on duty for a normal working day.  Does the oncoming team get better handoffs from a team that’s not post-call?  I’m disappointed that the authors did not mention this possibility in their paper, given the controversy surrounding duty hours.

The authors don’t suggest that the results of this study support either side in the debate between those who want to make patients safer by decreasing resident work hours, and those who want to improve safety by reducing the number of dangerous handoffs.  I hope that no one else will argue that it does, either.


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