Ensuring the continuity of care: approaches to improve handoffs and subsequent patient management

Healthcare is a collaborative practice, which relies on team skills such as communication, mutual support and leadership. Teams maintain continuity of care through handoffs, which are the transfer of patient information and accountability between clinicians. In hospital settings, handoffs occur at the beginning and end of every shift between day and night teams to provide 24h/24 care. Handoffs and other defaults in communication are involved in the large majority of preventable adverse events. After receiving a handoff, physicians need to retrieve and integrate additional information in their mental models of the patients to manage their patients. Although much focus has been placed on the verbal handoff, it is important to consider the whole process. This thesis aims to better understand the various processes that help ensure the continuity of care, through handoffs and subsequent patient management and to discuss approaches for improvement. Focusing on day and night team transitions in internal medicine wards, I present four studies that span the process: from the preparation of handoffs, the concept of collaborative reasoning, the search for additional information in the electronic health record (EHR) during chart biopsies, to the errors that can occur during the handoff process. Approaches for improvement involve concepts in medical education and in medical informatics. Medical education can help train students for verbal handoffs, during clinical reasoning sessions or simulations for example. Medical informatics can improve the support tools for handoffs, as well as the information retrieval process in the EHR through the use of a dashboard. Future perspectives also include the use of mobile devices throughout the process