Handoff Communication Between Outpatient Clinics and the Emergency Department: A Needs Assessment for Developing Standard Tools and Training

Abstract

Background: Miscommunication during transfers in patient care is a known leading source of medical errors. Standardizing handoff communication in the inpatient setting has been associated with reduced medical errors but less is known about best practices for the handoff of patients from outpatient clinics to the Emergency Department (ED). Objective: The purpose of this study is to 1) identify key elements of handoffs from outpatient clinics to the ED to inform the development of a standardized handoff tool, 2) assess for the presence of key elements in audio-recorded handoffs, examining how handoff quality varies according to patient and provider characteristics, and 3) to identify potential associations between handoff quality and clinical outcomes in the ED. Methods: The study uses both quantitative and qualitative methods and was conducted in two phases: 1) consensus development via stakeholder provider surveys and in-person meetings, and 2) retrospective observational study of audio-recorded verbal handoffs and associated medical chart documentation. Descriptive statistics measured importance of key elements. Chi-square statistics compared proportions across provider groups. Qualitative content analysis identified themes in free-text responses. Univariate poisson and logistic regression models tested associations between patient and provider characteristics and miscommunications in the ED on handoff quality. Results: 129/152 healthcare providers (85%) completed the survey. The handoff element indicated by most respondents to be very or extremely important to communicate was illness severity (96%). Free-text responses aligned with quantitative survey data regarding standard handoff content. In a random sample of 60 handoffs, a median of 6 out of 12 key elements were communicated. Miscommunications relevant to the patient’s care in the ED occurred in 28% of patient transfers. Handoffs where patient complexity prompted transfer were twice as likely to have a discrepancy in illness severity upon presentation to the ED (p=0.04). Conclusion: Content and quality of handoff communication is variable when transferring patients from outpatient clinics to the ED. These results will inform the development of a standardized handoff tool and training in this context, and provide a benchmark for interventions targeted at improving quality of care surrounding patient transfers.