Use of recommended strategies to improve resident shift handoffs in internal medicine residency programs

Survey responses from internal medicine residency program directors reported large variation in implementation of recommended handoff techniques and educational strategies to teach handoffs in internal medicine training programs, according to a study appearing in the December 6 issue of JAMA, a medical education theme issue.

National organizations have recommended specific strategies to improve resident handoffs, such as dedicated time and space to perform handoffs, standardized templates, and supervision by senior physicians. How these best-practice recommendations are implemented across programs is unknown. Charlie M. Wray, D.O., M.S., of the San Francisco Veterans Affairs Medical Center, and colleagues examined internal medicine residency program directors' responses to the 2014 Association of Program Directors in Internal Medicine electronic survey, in which they were asked to report implementation of handoff strategies within 3 domains: properties of verbal handoffs (i.e., dedicated time), properties of written handoffs (i.e., use of electronic health records [EHRs]), and educational resources (i.e., didactic lectures).

Among all programs, 234 of 361 (65 percent) responded to the survey. Most program directors (61 percent) were very or somewhat satisfied with the handoff strategies used at their institutions. Implementation of handoff strategies ranged from 6 percent to 67 percent, with the most frequent strategies being dedicated time (67 percent), didactic lectures (64 percent), overlapping shifts (61 percent), ward-based teaching by residents (61 percent), and allowing the receiver access to patient records (60 percent).

Statistically significant differences in the proportion of program directors who were satisfied were observed for those implementing vs not implementing 4 strategies: having a dedicated room, supervision by a senior resident, EHR-enabled handoff, and receiver given written copy of sign out. Implementation ranged between 47 percent (EHR-enabled handoff) and 59 percent (receiver given written copy of sign out), with 12 percent implementing all 4 strategies.

"Discordance between low implementation and high program director satisfaction may indicate confusion regarding which practices are best for their setting because of the lack of strong or consistent evidence," the authors write. "Also, program directors may want to implement these handoff strategies but face significant barriers, such as an EHR unable to facilitate shift handoffs or lack of local expertise to lead interactive workshops."

"Future work to disseminate and implement recommended handoff strategies is warranted."