Hand-Off

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EPIC

  1. At the top of the inpatient patient list interface click “Write Handoff”.
    Handoff01.png
  2. DO NOT click the the “sign out rpt” button. That is a NURSING tool at our hospital.
  3. Four boxes will open to the right of the list.
    Handoff02.png
  4. Summary box should include an assessment of stability, e.g. STABLE, SICK, significant problems, brief hospital course, significant treatments. You can use the smart phrase ".RRSUMMARY"
  5. Events box should include recent events and major events not in the summary such as procedures, surgery, transfusions, new fever, rapid/code etc.
  6. If a cross-cover page or event occurs, it should be recorded in the Events box.
  7. "To-Do" box includes items that should be completed in the next shift by the person receiving sign-out. This includes follow-up on labs, phone calls, consents, procedures, new orders, etc.
  8. Anticipatory guidance is direction for your team member regarding problematic events that might reasonably arise. You can use the smart phrase ".RRANTICIPATE"
    1. This direction should preferably be written in the form of IF/THEN statements.
    2. For example in an bleeding patient, you can write, “IF Hb < 7, THEN give blood.”
  9. Not every patient will require filling out each box
  10. Clicking "Close" will save the handoff and automatically log you as the last editor.
  11. On the patient list interface, the patient lists can be configured with 4 columns with each box or one column with 4 boxes.
    Handoff03.png
  12. Handoff can be printed by clicking "Print Handoff." It can similarly be printed using "Print Patient Lists."

Policy & Procedure

General Expectations

  • Hand-Off is expected to follow the "SIGNOUT?" format described below.
  • The designated location for hand-off is the Resident's Lounge/Workroom.
  • Hand-off takes priority over other work or activity in the room during the designated time.
  • The room should be free of distraction or interruption.
  • Be on time. It is not fair to your colleagues to make them work longer or lose sleep because you are late. They should not give YOUR hand-off to someone else because you were not there to receive it.
  • Hand-Off should be efficient and concise. Avoid information overload.
  • Information should be entered into the designated boxes. How that information is displayed or printed in patient lists is left to individual preference.
  • If preferred, it is recommended to use the dot-phrases ".RRSUMMARY" and ".RRANTICAPATE"
  • See Cross Cover for guidance on how cross cover events should be recorded.

Morning Hand-Off

  1. The designated time for morning hand-off is 7:00 AM to 7:30 AM.
  2. Day team residents are expected at 7:00 AM, ready to assume care and return calls on their patients.
  3. On days where there are meetings or conferences that conflict with hand-off time, the expectation is that hand-off and transfer of care are completed before 7:00 AM
  4. The night float team reports new admits and cross-cover events they will have already recorded.
  5. The night float resident presents new admits to the assigned teams. This should roughly follow the "SIGNOUT?" format, but includes more information.
  6. The upper level assigns patients to the team members, including interns or medical students.

Afternoon Hand-Off

  1. The designated time for afternoon hand-off is 4:30 PM to 5:00 PM.
  2. The on-call team will take hand-off from the other resident teams.
  3. Hand-off can occur any time before 4:30 if the on-call team is agreeable. This does not excuse the resident from clinical duties early, unless agreed to by both the ATTENDING and the ON-CALL TEAM.
  4. Ideally, the intern will hand-off to the on-call intern, and the upper level will hand-off to the on-call upper level.
  5. On clinic days, the resident should make every effort to hand-off to the on-call resident.
  6. If this is not possible, the resident should hand-off to his or her remaining team member.
  7. EPIC Hand-Off is expected to be updated before hand-off.
  8. If the on-call team is occupied or unavailable during the designated time, every effort should be made to contact the team and wait.
  9. It is not acceptable for the resident to update Epic and hand-off via text message.
  10. Hand-off via phone should be avoided if possible.

Evening Hand-Off

  1. The designated time for evening hand-off is 7:30 PM to 8:00 PM
  2. The on-call team will hand-off to the night float team.
  3. The on-call team reports new admits and cross-cover events they will have already recorded.
  4. Ideally, the intern will hand-off to the on-call intern, and the upper level will hand-off to the on-call upper level.
  5. If the on-call team is occupied or unavailable during the designated time, the night float team should contact the team and wait.

Format Guidelines

SIGNOUT?

A complete verbal handoff should include the following elements:

S Sick? Stable? Code status? Includes one word statement on stability and statement on code status. Should be "FULL", "DNR", or "LIMITED"
I Identifying data Name/Age/Sex. Automatically included in Epic, but should be rehearsed in verbal hand-off.
G General hospital course Include reason for admission and significant problems, major treatments and response to treatment. Comment on length of stay.
N New events Include procedures, significant labs, vitals, rapids, etc. This can include any pages received for cross cover.
O Overall status Snapshot description of the patient's current status.
U Upcoming possibilities. Anticipatory guidance for situations that may arise, preferably in form of "If/Then" statements.
T Tasks to complete Action items that must be completed in the next shift.
? Questions Allow the listener to ask any questions he or she may have.

Necessary Components from IM Program Director

  1. Dialogue
  2. Updated
  3. Includes relevant detail, but not too verbose
  4. Quiet place
  5. No interruptions
  6. Adequate time
  7. Beware of egocentric heuristic
  8. If/Then items
  9. To do items
  10. Readback

Links