The Hospitalist phenomenon is changing the way that inpatient medical care is delivered across the country. Several different and compelling reasons support the use of the Hospitalist (Table 1); however, there are features of Hospitalist practice that may promote concerns among observers. Perhaps the biggest feature for concern is the “handoff.”

Physicians and nurses have been exchanging data about patients among themselves, both verbally and in writing, for as long as the professions have existed. Why is it then that this type of exchange between Hospitalists is subject to additional scrutiny?

By definition, a handoff occurs when one Hospitalist “signs off” or “signs out” a patient to another Hospitalist. This is the case whenever a patient’s care must be turned over to another clinician – it generally happens at the end of a shift. As with any meaningful communication, it is complicated and, if done poorly, it can result in inefficiency or a poor outcome for the patient.

Since it involves people, the handoff is not analogous to copying a file from a hard drive to a floppy disc. When data is exchanged electronically, redundant safeguards are invoked automatically to prevent corruption of the original file. When patient information is exchanged between clinicians, there is tremendous potential for the essential data to be confused, disorganized, or omitted.

Some reasons why the transmission of data between Hospitalists is challenging are common to all human transactions: the inherent tendency for people not to listen, or to listen poorly, and the lack of an organized approach to the data. Other impediments are unique to demanding settings: the magnitude of fatigue or anxiety the Hospitalists are experiencing, the quality and complexity of the information, the degree of similarity between cases, and the extent to which trust and respect forms the foundation of the relationship between the parties. These hurdles must be minimized for Hospitalist programs to be successful.

Listening
The handoff should be conducted in a suitable environment, e.g., face to face in a quiet room. The on-coming Hospitalist must be attentive and should be making notes. Both parties should be sure that writing does not distract from listening, i.e., the presenter’s pace should reflect the receiver’s needs. The handoff should not be attempted when either clinician is distracted by other factors such as driving or the background noise of a busy ICU.

Use a Template
Key data elements should be communicated about every case at every sign out (Table 2). This reduces the likelihood that important information will be missed. Signing out should not require creativity if the proper template is used. Established procedures should guide both the presentation of data and the questions from their receiver, e.g., “You forgot to mention the patient’s code status – does he have any advance directives?”
All of these elements may be communicated verbally or presented in writing and followed by a brief oral review.

Fatigue and Anxiety
The departing Hospitalist may be so exhausted that he or she forgets to share key data. One strategy that may mitigate the negative contribution of fatigue is to start the sign out the night or evening before the actual change of shift. Then, at the actual change of shift, only an update is necessary. This also minimizes pressure by the on-coming Hospitalist to hurry the sign out because of a desire to proceed without delay to the work at hand. Experienced Hospitalists acknowledge that the first day of any shift may be the worst because of the necessity to assume the care of patients with whom he or she is unfamiliar.

Case Complexity
It should be possible for organized, motivated, and skilled listeners and communicators to transmit a large amount of complex data quickly. With proper preparation, even the most complicated cases can be signed out in a matter of minutes.
Patients with similar presentations pose a unique challenge. Individual preferences will dictate how to orchestrate sign out to avoid confusing individual clinical data; however, carefully written notes will help to surmount the difficulty created by caring for patients who have similar diagnoses and/or demographic features.

Inadequate Databases
Collecting a relevant database is essential to the proper allocation of resources for managing a patient. Conversely, it is often difficult to reverse the momentum established when incorrect assumptions are made at the time of admission. The Hospitalist assuming responsibility for inpatients must feel free to form his or her own opinion regarding the patient’s diagnoses and treatment plans. Clinicians must be able and willing to change the directions of interventions if the data proves that the existing approach is inadequate or incorrect.
The corollary is that change should be undertaken responsibly. Clinicians should accept an established care plan if it achieves proper goals efficiently. Differences in opinion about how to establish diagnoses or to effect treatments are of no merit unless they convey clear benefit to the patient. In any case, Hospitalists must remember that differences in opinion regarding patient management issues should be communicated with great care and professionalism to nursing staff, patients, and families in order to avoid giving the impression that games of one-upsmanship are being played within the Hospitalist team.

Respect
The proper Hospitalist model is that of a group practice, consisting of practitioners with different skills and deficiencies. In reality, there will rarely be unanimous feelings of mutual acceptance and respect between all members of the group at all times. This mandates that colleagues be determined to listen, ask questions, and filter information as carefully as possible in order to start with the best possible framework for each case.

-by Bruce Gipe, MD,

It’s 8am on Monday, and Hospitalist A has been up most of the night for the last two nights, having covered the service over the weekend. There are 12 patients to sign out. The most recent admission was just seen in the Emergency Department. In addition to being exhausted, there is the pressure to catch a 10am flight to Maui. Hospitalist B receives three pages on his beeper as they sit down together in the hospital cafeteria...

A: Let me start with the guy that I just admitted through the ER. He’s a 60-ish male on coumadin who woke up this morning with a headache. His CT is being done now. I’ve written down some admitting orders.
B: (Interrupts) Uh, this is the ICU calling, let me see what they want (leaves to call, returns). They want to move a guy named Smith who they say was extubated last night.
A: Yeah, he’s a 74-year-old with COPD who was admitted Saturday morning with pneumonia. He’s doing a lot better and should go home in a few more days. Next in ICU bed 4 is Mrs...Mrs...oh, I can’t remember her last name but she’s got a GI bleed and should be ‘scoped this morning. Yesterday she got two units of cells. Bed 7 is a 24-year-old drive-by shooting victim who has a 9mm bullet in his left frontal lobe. He’s on a vent and the neurosurgeon said that he might go back in today if the ICP stays up.
B: What’s his blood pressure?
A: Oh, it hasn’t been too bad. He has prn labetolol ordered. Anyway, on the observation unit is John Doe, a 17-year-old heroin addict who I admitted yesterday afternoon. He OD’d and was found by his girlfriend. He woke up with Narcan but has required a drip because he keeps wanting to stop breathing. He should go out tomorrow. Then there is a ruptured ectopic who had some pulmonary edema after receiving 8 units of blood. On the telemetry unit is Mr. Smith, a 62-year-old smoker who I admitted two days ago for chest pain. He ruled in and cardiology is following him - he may get cath’ed today.
B: Uh oh, I’m getting stat paged to the ER.
A: That’s OK, I’ll walk over there with you and tell you about the others on the way..

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