Challenge 6

Hand-off Communications

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Executive Summary Checklist

Hand-off communications (HOC) must occur whenever care of a patient is transferred from one individual or care team to another. Accurate, effective and complete HOC are vital for patient safety. When HOC information is absent, incomplete, erroneous or delayed, serious patient harm can occur.

  • Establish a HOC core team that includes a strong sponsor (senior clinical and administrative leadership is strongly encouraged for this role), physician champion, nursing champion and project leader. Other members include practicing physicians, nurses, therapists, technicians and information technology experts.
  • Define the exact roles of the sender and receiver in each category of HOC in order to make them effective, complete and reliable.
  • Educate all hospital staff on the following principles and requirements for effective HOC:
  • Recognize that each HOC involves a “sender” and “receiver.”
    • HOC failures occur when (1) the “sender” omits vital patient information from his/her report, (2) the “receiver” fails to understand or properly record vital information given by the sender, or (3) the sender and/or receiver fails to manage the subject information in a complete, accurate, or timely manner.
  • Measure the effectiveness of current HOC processes and build into performance goals
  • Develop and implement multiple HOC checklists that occur commonly in hospitals or other care units.

Emergency Department to Operating Room Checklist

1. Chief Complaints

▢  Why is patient coming to OR?

▢  What made it an emergency?

▢  If a chronic disease, what are its history, treatments, complications, prognosis?

2. Surgical Plan

▢  Exactly what surgery will occur?

▢  Major known surgical risks?

3. Special Anesthesia Needs

▢  Patient position, paralysis or lack thereof, anticipated blood loss, etc.

4. Cervical Spine Status

▢  “Cleared”? If so, how?

▢  History of neck disease or injury?

5. Other Acute Disease or Injury

▢  Other known acute disease, other than the reason for emergency surgery

▢  If trauma, other injuries not related to surgery?

5. Medical/Surgical History

▢  To extent known, and as time allows. Review of systems if available.

6. Physical Exam Findings: Positive findings only. Include ABC’s

▢  Airway: Patent? Assistance required?

▢  Breathing: Status of ventilation and oxygenation

▢  Circulation: Vital signs, including BP and other findings re circulation

7. Blood Loss & Fluid Status

▢  Estimated blood loss from current injury or disease

▢  IV fluids given: type, amount route

▢  Other I and O: recent oral intake, urine output, vomiting, drainage

8. Patient Lines & Access

▢  All intravenous lines – size and location.

▢  All other patient cannulas, including central line, chest tube, Foley catheter, arterial cannula, etc.

9. Labs and Studies

▢  Current lab results and relevant older lab results

▢  Results of X-rays, CT, MRI, other studies

10. Drugs

▢  Analgesia given by any route, past 24 h. Opiates?

▢  All other meds usually taken by patient

▢  Any other meds given since current problem began. Dose, frequency, response?

11. Special Instructions or Findings

▢  Anything unusual or remarkable, not covered by above?

▢  Any special instructions or restrictions? (For example: patient refuses blood products for religious reasons)

Hospital Unit to Home (Discharge) Checklist (Bloink, 2013)

Initial Transitional Care Contact

Patient name:_______________

Date of contact: _____/_____/_____
Sources of information:

  • Patient, family member, or caregiver


  • Hospital discharge summary
  • Hospital fax
  • List of recent hospitalizations or ED visits
  • Other_______________
  •  Discharged from:_______________
    on _____/_____/_____Diagnosis/problem: _______________
    Medication changes: ▢ Yes ▢ No
    Medication list updated: ▢ Yes ▢ No
    Needs referral: ▢ Yes ▢ No
    Needs lab: ▢ Yes ▢ No
    Needs follow-up appointment:

    • Within seven days of discharge (highly complex visit).
    • Within 14 days of discharge (moderately complex visit).
    • Appointment made for _____/_____/_____

Additional information needed and requested:

    • No
    • Yes:_______________

Face-to-Face Transitional Care Visit Documentation

For use in plan section of visit note.

Medication reconciliation:

▢  Medication list updated

▢  New medication list given to patient


▢  None needed

▢  Referrals made to: _______________

Community resources identified for patient/family:

▢  None needed

▢  Home health agency

▢  Assisted living

▢  Hospice

▢  Support Group

▢  Education Program: _______________

Durable medical equipment ordered:

▢  None needed

▢  DME ordered:_______________

Additional communication delivered or planned:

▢  Family/caregiver: _______________

▢  Specialists: _______________

▢  Other: _______________

Patient education:

Topics discussed: _______________

Handouts given:_______________

Initial transitional care contact was made on _____/_____/_____

Shift Change Checklist

The following technique called the Situation, Background, Assessment and Recommendation (SBAR) is the industry’s best practice for standardized communication between caregivers.5 The SBAR technique was developed by the United States Navy for use on nuclear submarines. SBAR was introduced into healthcare in the late-1990’s. It is recognized as a simple and effective way to standardize communication between caregivers in hospitals across the world.

S (Situation)

▢ Reason for admission

▢ Contact information

▢ Allergies

▢ Current attending/resident

B (Background)

▢ Status of advanced directives/code status

▢ Pertinent medical history

▢ Labs: abnormals this shift and pending or to do next shift

▢ Tests/Procedures: current shift and anticipated for next shift

▢ Current Problems: medical and nursing

A (Assessment)

▢ VS/pain past 24 hours/shift

▢ Neuro

▢ CV

▢ Respiratory

▢ GI/GU (include I and O)

▢ Skin

▢ Mobility

▢ Patient safety issues: current and anticipated

▢ Medication concerns and updates

R (Recommendation)

▢ Pending/anticipated tests and procedures

▢ Other concerns

▢ Current and anticipated family issues

▢ Status of current shift goals/problems

▢ Anticipated Goals/problems for next shift

▢ Other TO Dos/Do you have any questions?

▢ Patient/Nurse introduction

▢ Joint review of lines/drips, neuro check, etc.

Operating Room to Hospital Unit Checklist


▢  Patient Name, Sex & MRN

▢  Attending Anesthesiologist

▢  Anesthesia Resident/Fellow/CRNA

▢  Surgeon


▢  Age: ____ ASA: ____ Weight: ____ kg Height: ______

▢  Guardianship, Surrogate, Advance Directives, DNR Status

▢  Allergies:_______________

▢  Pre-Op Vital Signs: BP: _____ HR: _____ SpO2: _____ Temp: _____ RR: ______

▢  Current Medications

▢  Past Medical History

▢  Past Surgical History

▢  Past Anesthesia History

▢  Pertinent Pre-op labs and studies

▢  Pre-op Mental Status and Primary Language

▢  NPO Status

▢  Blood/Bloodless status

Intra-Op Events:

▢  Surgical Procedure Performed

▢  Anesthetic Technique & Airway Management

▢  IV Sites – Fluid / Location / Difficult Access

▢  Fluid Status – Intake / Output / EBL / Blood Products

▢  Medications Given (Including Antibiotics)

▢  Complications / Interventions


▢  Surgical Procedure Performed

▢  Anesthetic Technique & Airway Management

▢  Vital Signs

▢  Assessment: Respiratory / CV / Neuro / GU / Skin

▢  Post-Op Pain Management Plan

▢  Recent/Pending Labs / Medications

▢  Special Instructions & Concerns

▢  Questions from Receiving Provider

Operating Room to Home Checklist (Bloink, 2013)

▢  Responsible Adult to stay with you for 24 hours

▢  Understanding of no driving or major decisions for 24 hours

▢  Understanding of precautions after anesthesia

▢  Drowsiness, impaired judgment and slower reaction time, sore throat, muscle aches

▢  Sensory block understanding

▢  May not be able to feel sharp pain, hot or cold at the involved site

▢  Understanding to begin pain medication before block wears off

▢  Activity

▢  Rest the remainder of the day

▢  Move slowly when changing positions (dizziness is normal)

▢  Gradually do a little more each day

▢  Follow the surgeon’s instructions for return to normal activities

▢  Do not DRIVE if taking medications for pain like Percocet® or Vicodin®

▢  Best outcomes

▢  It is important to walk often, change positions and move legs if resting in a lying or sitting position.

▢  Take 10 deep breaths and cough every hour or two while awake.

▢  Remember to hold a small pillow or towel over your abdominal incision while doing your deep breathing and coughing exercises

▢  Medication

▢  Medications will be reviewed and when to resume and take them

▢  Follow directions on the label

▢  Pain medication should be taken before the pain is severe during the initial 2 – 3 days after surgery.

▢  Medications like Percocet and Vicodin contain acetaminophen (Tylenol®); do not take plain Tylenol when using these medications.

▢  Pain medication cause constipation and nausea

▢  Remember to follow instructions for laxative, if needed

▢  Post-op nausea information sheet can be used for suggestion for this side effect

▢  Diet and Elimination

▢  Progress to regular diet as tolerated

▢  Begin with comfort foods: soup, crackers, jello, juices

▢  Stay away from food that may increase the chance of nausea and vomiting (spicy or greasy foods)

▢  If you have trouble voiding (burning or urgency) call your surgeon

▢  If you are unable to urinate when you get home have someone bring you to the emergency room.

▢  No alcoholic beverages, marijuana, or other drugs for 24 hours or while taking pain medications

▢  Importance of handwashing to prevent infection

▢  Keep dressing dry and protect dressing, incisions and casts

▢  When you can take a shower or bath depending on the procedure

▢  Special Equipment (based on the procedure)

▢  Incision care and when to remove dressing

▢  Drain instructions

▢  Foley care instruction

▢  Crutch walking

▢  Incentive spirometer

▢  Reasons to call your surgeon

▢  Pain is not relieved with the pain medication

▢  Bleeding

▢  Fever over 101⁰F – Call your surgeon

▢  Continuous nausea and unable to keep fluids down

▢  Redness and swelling around the surgical wound or drainage that changes to yellow or green

▢  Intravenous site with signs of redness or drainage

▢  If unable to get physician come to the emergency department

▢  Call 911 if you have breathing problems or chest pain

Hospital Unit to Outside Care Unit Checklist

1. Chief Complaint

▢  Why was patient admitted to hospital?

▢  If the result of a chronic disease, what are its history, treatments, complications, prognosis?

2. Hospital Course

▢  Duration of stay in each hospital unit.

▢  Therapeutic procedures done: indications and results.

▢  Medications while in hospital. Effectiveness? Complications?

▢  General condition at discharge.

3. Diet

▢  Current diet as well as any restrictions and preferences.

4. Allergies

▢  To medications as well as anything else. Include specific type of reaction (skin, pulmonary, anaphylaxis, etc.), severity, type of exposure for trigger (enteric, topical, inhaled).

5. Activity

▢  Amount, type, frequency of exercise.

▢  Activity restrictions?

▢  Bathroom privileges.

6. Hygiene

▢  Bathing and any other: frequency and assistance/supervision required.

7. Mental status

▢  Ability to communicate and understand instructions. Languages? Sleep habits.

8. Other Known Diseases or Injuries

▢  All diseases requiring continuing treatment or precautions.

▢  Current status of each: chronic, recurrent, cured?

9. Hospital/Surgical History

▢  Hospitalizations: reasons, treatments, outcomes.

▢  Surgeries: procedures, dates, indications, outcomes.

10. Physical Exam Findings

▢  Positive findings only.

11. I’s & O’s (Intakes and Outputs)

▢  Patient lines & access: intravenous lines – size and location. All other patient cannulas, including any drains, Foley catheter.

▢  Daily intake/output of each site, including oral, wound drainage, etc.

12. Labs and Studies

▢  Current lab results, note all abnormal values.

▢  Relevant older lab results.

▢  Results of recent X-rays, CT, MRI, other studies.

13. Drugs

▢  Daily analgesia required? Opiates? If so, how is respiration being monitored?

▢  All other meds taken by patient: dose, route (oral or other?), frequency.

▢  Any other meds given since current problem began. Dose, frequency, response?

14. Social

▢  Family and/or friends contact information. Visiting needs.

15. Special Instructions or Findings

▢  Anything unusual or remarkable, not covered by above? Any special instructions or restrictions?

Emergency Department to MedSurge Units

S (Situation)

⃞  Introduction of person- name, age, and baseline physiology
⃞  Chief complaint on arrival
⃞  Advanced Directives
⃞  Allergies
⃞  Admitting Diagnosis and Provider

B (Background)

⃞  Past Medical History- chronic and relevant acute conditions, home medications
⃞  Diagnostics- abnormal and relevant lab and imaging information
⃞  Diagnostics awaiting results
⃞  Current Condition/Problems: self-management goal, medical and nursing

A (Assessment)

⃞ Current Status- any change from presenting condition
⃞ Neurological status
⃞ Vital Signs
⃞ Assessment of condition related to admitting diagnosis
⃞ Any abnormal findings- skin, wound
⃞ Health Literacy initiation

R (Recommendation)

⃞  Interventions needed within next 2 hours
⃞  Current and anticipated person and family concerns and needs
⃞  Review of problems and plan of care
⃞  Review of self-management goal
⃞  My-Story®

Face to Face

⃞  Person, family, RN actively participate in transitions to Med/Surg location

I-PASS Hand-off Mnemonic

I-PASS Handoff Mnemonic Components
I Illness Severity
  • Stable, “watcher,” unstable
P Patient Summary
  • Summary statement
  • Events leading up to admission
  • Hospital course
  • Ongoing assessment
  • Plan
A Action List
  • To do list
  • Timeline and ownership
S Situation Awareness & Contingency Planning
  • Know what’s going on
  • Plan for what might happen
S Synthesis by Receiver
  • Receiver summarizes what was heard
  • Asks questions
  • Restates key action/to do items

Emergency Department to Critical Care Unit

Illness Severity:   

  ⃞     Unstable/Watch/Stable/Discharging (structured)   
Primary Information       


  1. Chief Complaint:     
  2. Vitals  
    1. ⃞     HR (Beats/min)   
    2. ⃞     BP (Sys/Dias; mL Mercury)   
    3. ⃞     PulseOx (O2Sat)   
    4. ⃞     Temperature (C/F)   
    5. ⃞     Respiratory Rate (breaths/min)   
    6. ⃞     Current Pain Threshold (Universal Pain Scale, 1-10)   
  3. Pertinent Findings  
    1. ⃞     Is systolic BP <110?   
    2. ⃞     RALES or evidence of CHF   
    3. ⃞     Any evidence ischemia on electrocardiogram (ECG/EKG)?    
    4. ⃞     Significant toxin of infectious agent exposure   
    5. ⃞     MDRO to consider  
  4. What did you find?   
  5. Key results?
  6. Pending Results and timing?        

Action List   

  1. What diagnoses, confirmed or in the differential, need follow up investigations in the next 12 hours? 
    1. Action items:   
  2. Has all neuroimaging been reviewed by a radiologist as accurate?       
  3. Are there any services this patient may require in the next 48 hours that are both life threatening and cannot be arranged quickly for inpatients?       
  4. What procedures need to be done in the next 48 hours to optimally care for this patient? 
    1. Additional Action Items (List)

Situational Awareness/Contingency Planning (Questions to consider, things to be aware of…) 

  1. Has there been or could I expect any hemodynamics instability (pulse <55 or >110, MAP<70, SBP>150)?
        a. If so what is plan to manage?
  2. What cardioactive substances were administered in the ED? What is the continuation plan for each of them?
  3. In what as yet unmanifested way is this patient most likely to decompensate in the next 48 hours?
  4. What IV’s, central lines, other access ports and indwelling devices (foley, implants) has this patient had in the last 2 weeks?

Synthesis (Teachback): (Check a box upon completion)

⃞     Teachback

Paramedics to Emergency Department

  1. Is patient awake and alert now?  Was there any loss of consciousness?       
  2. Presumed diagnosis?  (very short version — less than 50 words)       
  3. Establish A-B-C-D:      
    1. = Airway: Is the airway open and patent, or obstructed?   
    2. = Breathing:  Is patient breathing?  Breath sounds heard both lungs?    
    3. = Circulation:  Blood pressure; peripheral pulses; skin color; mental status? End-tidal CO2 if intubated.
    4. = Drugs:    
              What drugs given by paramedics?
              What recreational drugs has patient taken?
              What medications is patient taking?
  4. History       
    1. Chief Complaint:  Why is the patient in an ambulance?  What led to a 911 call?   
    2. What is the history of this illness?  Details of diagnosis; differential diagnosis.
    3. What other illnesses or medical problems in past?
  5. Physical exam.
    1. Abnormal findings on general exam.
    2. Specific findings related to present illness.
  6. Treatment Plan.  (Two-way discussion!)
    1.  What treatments and interventions have been done?  (Include IV catheters.)
    2. What immediate treatments are needed?  Risks/benefits?
    3.  What additional diagnostics or studies needed?
    4.  Family members or others who should be contacted for information and consent?
    5. Known patient preferences or restrictions?  (e.g., living will.)

The Performance Gap

A successful patient hand-off between caregivers is defined as a transfer and acceptance of responsibility for care that is achieved through effective communication. It is a real-time process of transmitting patient-specific information from one caregiver or team to another, to ensure the continuity and safety of care. The hand-off process
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