How Educational Institutions are Preparing Students for Medical Handoffs
TimeFriday, April 161:00pm - 1:30pm EDT
LocationEducation and Simulation
Handoffs are characterized as transitions in patient care between providers, and miscommunication during this process is one of the leading causes of medical error in the United States (Joint Commission, 2012). The World Health Organization (WHO) and Joint Commission have released guidelines aimed at increasing handoff education practices (WHO Collaborating Centre for Patient Safety Solutions, 2007; Joint Commission, 2017). Although training has been identified as important for improving handoffs, systematic reviews by Gordon and colleagues (Gordon et al., 2018; Gordon & Findley, 2011) have repeatedly reported that research in this domain remains poor. They found few studies that utilized rigorous designs that allowed effects to be attributed to the intervention (i.e. few pre/post-tests or adequately controlled, between-subject designs). Furthermore, most primary outcomes in these studies focused on self-reported knowledge, skills, and attitudes (corresponding to Kirkpatrick’s levels 1 and 2 as assessed in Gordon et al., 2018) after training, and few assessed outcomes more indicative of training effectiveness through behavioral change or patient level changes indicating positive end results (i.e. Kirkpatrick’s levels 3 and 4; Gordon et al., 2018). These points have been reiterated for literature specific to pre-graduate training programs in structured communication (Buckley et al, 2016).
The pre-graduate population is one worthy of independent study, as they are a unique population where there is substantial variability in when (relative to education levels) and how they can be trained, and what options are available for assessing outcomes may vary according to additional institutional and timing constraints. Professionals managing education programs and healthcare institutions would benefit from a greater understanding of how these programs are developing, to help guide future training programs. To accomplish this, a further review of the literature is needed. The purpose of this review is to characterize the state of newly published literature in this domain relative to study designs, training tools, assessment methods and outcomes data. This will be used to inform best practices for the further development and study of handoff education programs.
Articles are included in the present analysis if they were 1) topically related to implementation of standardized handoff protocols in the pre-graduate medical setting (this was not restricted to any specific subset of professionals to ensure high generalizability), and 2) conducted since 2016 (after Buckley et al, 2016’s search was completed) through the end of December 2020. Articles are excluded if they are not in English or not a full manuscript (or full manuscript not accessible to authors); did not include details regarding training methods/mechanisms used (examples include, but are not limited to, didactic sessions, simulation, role play, individual or group feedback, etc.); or did not include either a pre-post intervention within-subjects design, or a between-subjects design that allows analysis of levels or types of handoff training. Articles designated as a patent document are also excluded, given that they are not intended to contribute to scientific knowledge. A search was completed through Google Scholar, using the Boolean search string “(training OR simulation OR feedback OR curriculum) AND (protocol OR standardized OR standardised OR structured) AND (handoff or hand-off or hand over or handover)” with the date restriction described in the inclusion criteria. This produced 3,002 total search results, from which 512 duplicates and 1353 patents were removed. The remaining 1137 article titles were reviewed for potential inclusion. Forty-three articles were identified as topically related and thus their abstracts/full texts were retrieved to evaluate final inclusion. Fifteen articles met criteria to be included in the present analysis. The reasons for exclusion included non-interventional articles (n=12), learners were not students (n=6), study was not specific to handoffs (n=3), abstract only/full text not in English (n=3), study did not utilize a pre-post or between- subjects design (n=3), and the article corresponding to the citation could not be located (n=1).
Article coding and assessment:
Included articles are being reviewed and coded on elements of note, including study characteristics (study location, participant roles), study design, components of training (training methods, time spent in training sessions, concepts addressed/emphasized, mnemonics/tools used), control conditions, outcome variables, and direction of effects relative to control comparison conditions. Outcome variables are being further assessed related to six distinct thematic categories: clinical variables (e.g. patient length of stay, mortality), workflow variables (e.g. handover duration, time to complete tasks, provider referrals), perception variables (e.g. provider ratings of communication/ handoff quality), indirect performance-based rating (e.g. survey/questionnaires evaluating knowledge, skills, and/or attitudes), direct performance-based rating (e.g. checklist omissions/percentage of checklist included, observer-based standardized quality ratings), and dichotomous tool use (i.e. was the checklist, EMR, or other tool utilized, regardless of completeness or accuracy of use). These outcomes will be further evaluated based on Kirkpatrick’s hierarchy, and specific outcomes in need of more detailed investigation will be discussed.
Complete results and implications of these findings will be discussed in the presentation to inform best practices for the design of future handoff education interventions and assessments.