Handoff Quality for Obstetrical Inpatients
Varies Depending on Time of Day and
Provider Type
Sarah L. Goff, M.D., Alexander Knee, M.S., Michelle Morello, R.N., B.S.N.,
Daniel Grow, M.D., and Fadi Bsat, M.D.
OBJECTIVE: To determine whether obstetric handoff
midwives. Only 169 (40%) of all handoffs met criteria for
quality differs morning versus evening, weekend versus
high quality. A greater percentage of all morning handweekday, or based on provider type.
offs met criteria as compared to evening handoffs (45%
STUDY DESIGN: Using the American College of Obvs. 34%, p < 0.05). There was no significant difference
stetricians and Gynecologists
between the overall percent(ACOG) handoff guidelines,
age of weekday and weekend
A low percentage of all inpatient handoffs meeting criteria
we developed an observational tool to assess whether
obstetrical handoffs met criteria (39% vs. 42%, p = 0.48).
handoffs included its 8 recResidents had a higher perfor high quality.
ommended elements. We obcentage of high-quality handserved handoffs between atoffs as compared to nurses
tending obstetricians, Obstetrics and Gynecology
(55% vs. 32%, p < 0.001).
residents, labor and delivery nurses, and certified nurse
CONCLUSION: Based on criteria developed for this
midwives. Observation times included a balance of
study, handoff quality may vary based on time of day and
morning, evening, weekdays, and weekends. Participrovider type. These findings present an opportunity to
pants were blinded to the study objectives. We defined
further assess reasons for variation and propose changes
high-quality handoffs as those that included 7 of the 8
to standardize and improve the handoff process. (J Rerecommended ACOG elements.
prod Med 2014;59:95–102)
RESULTS: A total of 425 inpatient handoffs were
observed: 233 (55%) were morning handoffs and 189
Keywords: best practices; handoffs; health care
(45%) were evening; 251 (59%) were on weekdays and
quality assessment; inpatients; nurse’s practice
171 (41%) on weekends. Of the handoffs observed, 201
patterns; obstetrics; obstetrics department hospital;
(48%) were presented by residents, 139 (33%) by nurspractice guidelines as topic; physician’s practice
es, 56 (13%) by attending obstetricians, and 26 (6%) by
patterns; quality assurance, health care.
From the Departments of Medicine and of Obstetrics and Gynecology, the Center for Quality of Care Research, and the Division of Academic Affairs, Epidemiology & Biostatistics Research Core, Baystate Medical Center, Springfield, Massachusetts; and Tufts University
School of Medicine and Tufts Clinical and Translational Science Institute, Boston, Massachusetts.
Supported by a grant from the Baystate Health Insurance Corporation and the National Center for Research Resources Grant No. KL2
RR025751, and the National Center for Advancing Translational Sciences, National Institutes of Health, Grant No. KL2 TR000074 (Dr.
Goff). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Presented in poster format at the 2013 Society of Maternal Fetal Medicine Annual Meeting, San Francisco, California, February 16, 2013.
Address correspondence to: Sarah L. Goff, M.D., Center for Quality of Care Research, Baystate Medical Center, 280 Chestnut Street, 3rd
Floor, Room 305, Springfield, MA 01199 ([email protected]).
Financial Disclosure: The authors have no connection to any companies or products mentioned in this article.
0024-7758/14/5903-04–0095/$18.00/0 © Journal of Reproductive Medicine®, Inc.
The Journal of Reproductive Medicine®
95
ORIGINAL ARTICLES
The Journal of Reproductive Medicine®
96
Health care quality depends on providers’ awareness of patients’ medical conditions and care plans.
When patient care is transferred from one provider
to another (handoff), effective communication may
reduce both medical errors and adverse events by
fully preparing the receiving provider to assume
care of the patient.1,2 Effective patient handoffs
require accurate and current clinical information,
an opportunity for interactive discussion between
the provider “handing off” and the one taking over,
limited interruptions, and a process for verifying
that the information given is understood.3 Inpatient
obstetrical care is particularly sensitive to handoff
quality because patients may labor throughout the
day and night, and multiple providers make patient
care decisions throughout the hospital stay. Variation in maternal and newborn outcomes based on
time of day and day of the week suggests that care
quality may have temporal variation.4-8 Poor handoff quality has explained some of the variation in
care quality in internal medicine and surgery1,9 and
may contribute to variation in obstetric outcomes as
well.
Although handoff processes have been evaluated
in several disciplines,10-19 there is a paucity of research regarding handoff quality for inpatient
obstetrics.20 The American College of Obstetricians
and Gynecologists (ACOG) published handoff
guidelines in June 2007 (reaffirmed in 2009),3 but
we know of no studies that have assessed overall
handoff quality using these guidelines as criteria for
handoff quality.
Our primary aims for this study were to compare the quality of morning and evening handoffs
among attending obstetricians, Obstetrics and Gynecology (OB-GYN) residents, labor and delivery
nurses, and certified nurse midwives (CNMs). A
new observation tool was developed to assess
handoff quality. Secondary aims of this study were
to assess variation in handoff quality depending on
the day of the week (weekend versus weekday) and
provider type. We hypothesized that evening and
weekend handoffs would be of lower quality as
compared to morning and weekday handoffs, respectively.
Materials and Methods
This study was approved by the Baystate Medical
Center Institutional Review Board. We conducted a
cross-sectional observational study from October
2011 through June 2012 at an academic tertiary care
center with approximately 4,000 deliveries annual-
The Journal of Reproductive Medicine®
ly. All group and individual patient handoffs were
eligible for observation.
Handoff Observation Tool
We selected 8 observable elements from the ACOG
guidelines for patient handoffs2: (1) a physical environment free of distractions, (2) maintenance of
patient confidentiality, (3) use of nontechnical language, (4) an environment (organizational culture)
that supports questions being asked during handoffs, and (5–8) use of the 4 aspects of SBAR reporting (Situation, Background, Assessment, and
Recommendation). SBAR is a standardized communication method that has been implemented
by nurses and other care providers from a number
of disciplines.21,22 We established criteria for fulfillment of each element: (1) Physical environment
criteria were met if there were no distractions by
external interruptions (e.g., pagers, phone calls, or
people), (2) Confidentiality criteria were met if the
handoff took place in a separate room or away from
a location where patients or visitors could be within hearing, (3) Criteria for nontechnical language
were met if standard medical terminology that a
non–OB-GYN clinician or medical student would
likely be familiar with was used and no colloquialisms, jargon, or abbreviations were used, (4) If
team members asked questions and no comment
that could be considered demeaning was made
when questions were asked, the handoff met criteria for a supportive environment, and (5–8) Criteria
for SBAR were met if used at any point in a handoff.
Use of each of the 4 SBAR elements was counted
individually toward the quality score. In addition,
we collected information on how the handoff was
delivered (face-to-face, phone, verbal/written),
whether it took place in a group or individual format, whether the team was familiar with the patient
from the previous shift (yes or no), and whether the
patient needed acute care (yes or no). Acute care
was defined as a patient in active labor, one with
medical complications, or one judged to likely need
active care within an hour. The total number of
patients discussed during a handoff session was
also recorded.
The research team designed an observational tool
(see Appendix) for recording whether criteria were
met for each of the 8 recommended elements during a handoff. The observational tool was pilot tested for completeness, clarity, and ease of use. During
pilot testing, 2 research assistants (a CNM and a
labor and delivery nurse) observed 45 handoffs,
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Volume 59, Number 3-4/March-April 2014
simultaneously scoring the handoffs independently. Scores were then compared and discussed with
the research team to develop consistency in interpreting the 8 criteria. Disagreements were discussed and simultaneous handoff observations
repeated until > 90% agreement was achieved.
Clinical supervisors for each provider type (attending obstetricians, OB-GYN residents, labor and
delivery nurses, and CNMs) were informed of the
study. Providers who were observed were not told
of the precise nature of the study in order to limit
potential bias due to behavior change. After pilot
observations were complete, each research assistant
observed handoffs independently.
A multidisciplinary handoff took place every
weekday at 7:00 AM. Labor and delivery nurses and
CNMs also held separate morning handoffs with
peers. Evening handoffs took place at the change of
shifts at 7:00 PM for nurses, 5:00 PM for attending
obstetricians, and change of shifts for residents
(5:00 PM to 9:00 PM). For the purpose of this study,
handoffs were categorized as either morning or
evening. Handoffs were also categorized as weekday or weekend based on day of the week (Monday
through Friday or Saturday/Sunday). Handoffs
were observed across a 6-month period in order to
achieve a balance of morning/evening and weekday/weekend handoffs while varying our sample
of provider types.
Analysis
Each patient handoff was categorized by 1 of 3
exposures: morning or evening, weekday or weekend, and presenting provider type (attending
physician, CNM, nurse, or OB-GYN resident).
Handoffs were defined as high quality if they met
criteria for 7 of the 8 recommended handoff elements. We had 80% power to detect an absolute difference of 12% between the groups (α = 0.05). Fisher’s exact test was used to evaluate differences in
both handoff characteristics (e.g., method, group,
etc.) and the percent of handoffs that met criteria for
high quality (morning versus evening, weekday
versus weekend, and provider type).
A secondary aim was to evaluate differences in
handoff quality across provider types for morning
versus evening and weekday versus weekend. We
restricted this analysis to nurses and residents only
because our sample had limited numbers of attending physicians and CNM handoffs. We evaluated
these effects using relative risks estimate by interaction terms in a single Poisson regression model with
robust standard errors. The model was adjusted
for group versus individual handoffs, familiarity of
the team with the patient, and whether the patient
needed acute care. Bonferroni corrections were
used to adjust confidence intervals for multiple
comparisons.
Because the decision to use 7/8 elements as criteria for a high quality handoff was grounded in part
on clinical perspective, we conducted a sensitivity
analysis to determine how the results varied with
more conservative criteria (8/8) for a high-quality
handoff. We also tested the strength of the associations between handoff quality and time of day and
day of the week when specific criteria were excluded. Statistical significance for all tests was set at
p < 0.05.
Results
A total of 425 handoffs (approximately 20% of deliveries over a 6-month period) were observed; 3
phone handoffs were excluded because they were
incompletely assessed. Inter-rater reliability was
100% for the final 19 patients observed simultaneously. Of the 422 observed handoffs, 201 (48%) were
presented by OB-GYN residents, 139 (33%) by labor
and delivery nurses, 56 (13%) by attending obstetricians, and 26 (6%) by CNMs. There were a total of
233 morning handoffs (55%) and 189 evening handoffs (45%). When categorized by day of the week,
251 handoffs (59%) were on weekdays and 171
(41%) were on weekends. The number of patients
discussed at each handoff session was 1–30 (median, 8) (Tables I–III).
Overall, only 169 (40%) of the handoffs met criteria for high quality. Criteria for a supportive environment were met in 95% of handoffs, and 84%
were free of distractions. Confidentiality was maintained in 66% of handoffs, and criteria for use of
nontechnical language were met in only 25% of
handoffs. Use of SBAR elements ranged from 83%
for A (assessment), followed by 78% for R (recommendation), and 75% for both S (situation) and B
(background).
Morning Versus Evening
Nearly 70% of the morning handoffs observed were
presented by OB-GYN residents, and a higher percentage of morning handoffs took place in a group
format when compared to evening handoffs (89%
vs. 41%, p < 0.001) (Table I). Criteria for use of SBAR
were met more frequently in the morning (Table I).
The percent of handoffs meeting the composite
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The Journal of Reproductive Medicine®
criteria for a high-quality handoff (7 of 8 elements
present) was higher in the morning (45%) as compared to the evening (34%) (p < 0.05) (Table I).
Weekday Versus Weekend
A higher proportion of the observed weekday handoffs were presented by nurses (49%) as compared to
other provider groups, and most of the observed
weekend handoffs were presented by OB-GYN residents (70%) (Table II). More of the observed weekend handoffs took place in the morning as compared to weekday handoffs (90% vs. 32%, p < 0.001),
and the group format was used more often on
weekends as compared to weekdays as well (75%
vs. 64%, p < 0.01). More weekend handoffs met criteria for good physical environment (90% vs. 80%,
p < 0.05) and confidentiality (72% vs. 61%, p < 0.05)
as compared to weekday handoffs. SBAR components were similar across weekdays and weekends.
There were no differences between weekdays and
weekends in handoffs meeting criteria for a high
quality (39% vs. 42%, p = 0.48) (Table II).
Provider Type
The percent of handoffs meeting criteria for a supportive environment was high among all providers
but was lowest among attending physicians (Table
III). SBAR components also varied across groups,
with nurses having the highest S (situation) and B
(background) scores and residents having the highest A (assessment) and R (recommendation) scores.
The percent of handoffs meeting criteria for high
quality (criteria for 7 of 8 elements met) varied
across providers and was highest among residents
(Table III).
Multivariable Analyses
Our multivariable model showed that OB-GYN residents were nearly twice as likely to meet criteria for
a high-quality handoff in the morning as compared
to the evening (95% CI 1.13–4.05) and that residents
were 7 times as likely to have a high-quality handoff in the morning as compared to nurses (95% CI
2.34–21.48) (Table IV). In regards to weekday and
weekend time periods, residents were 2.4 times
Table I Characteristics and Quality of Morning and Evening Handoffs
Parameter
Primary presenter
Nurses
Attending physicians
Residents
CNMs
Method
Face to face (no written element)
Phone
Face to face (verbal and written)
Type of written handoff (n = 396)
Computer
Handwritten
Typed
Familiar with patient
Acute care
Weekend
Group
Recommended handoff element present
Physical environment
Confidentiality
Language
Supportive environment
S (Situation)
B (Background)
A (Assessment)
R (Recommendation)
High quality (7 out of 8)
*Fisher’s exact test.
Morning
N = 233 (55.2%)
No. (%)
Evening
N = 189 (44.8%)
No. (%)
55 (23.6)
15 (6.4)
161 (69.1)
2 (0.9)
84 (44.4)
41 (21.7)
40 (21.6)
24 (12.7)
1 (0.4)
2 (0.9)
230 (98.7)
15 (7.9)
8 (4.2)
166 (87.83)
0 (0)
5 (2.2)
225 (97.8)
39 (16.7)
11 (4.7)
153 (65.7)
209 (89.7)
8 (4.8)
66 (39.8)
92 (55.4)
38 (20.1)
11 (5.8)
18 (9.5)
78 (41.3)
0.378
0.663
< 0.001
< 0.001
194 (83.3)
154 (66.1)
64 (27.5)
219 (94.0)
183 (78.5)
183 (78.5)
209 (89.7)
204 (87.6)
104 (44.6)
159 (84.1)
123 (65.1)
42 (22.2)
183 (96.8)
133 (70.4)
132 (69.8)
141 (74.6)
123 (65.1)
65 (34.4)
0.895
0.837
0.259
0.249
0.056
0.044
< 0.001
< 0.001
0.036
p Value*
< 0.001
< 0.001
< 0.001
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Volume 59, Number 3-4/March-April 2014
Table II Characteristics and Quality of Weekday and Weekend Handoffs
Parameter
Primary presenter
Nurses
Attending physicians
Residents
Staff CNMs
Method
Face to face (no written element)
Phone
Face to face (verbal and written)
Type of written handoff (n = 396)
Computer
Handwritten
Typed
Familiar with patients
Acute care
Morning
Group
Components of handoff
Physical environment
Confidentiality
Language
Supportive environment
S (Situation)
B (Background)
A (Assessment)
R (Recommendation)
High quality (7 out of 8)
Morning
N = 233 (55.2%)
No. (%)
Evening
N = 189 (44.8%)
No. (%)
123 (49.0)
33 (13.2)
81 (32.3)
14 (32.3)
16 (9.4)
23 (13.5)
120 (70.2)
12 (7.0)
12 (4.8)
8 (3.2)
231 (92.0)
4 (2.3)
2 (1.2)
165 (96.5)
8 (3.5)
59 (25.5)
164 (71.0)
42 (16.73)
14 (5.6)
80 (31.9)
158 (63.0)
0 (0)
12 (7.3)
153 (92.7)
35 (20.5)
8 (4.7)
153 (89.5)
129 (75.4)
0.369
0.825
< 0.001
0.008
201 (80.1)
154 (61.4)
58 (23.1)
245 (97.6)
194 (77.3)
195 (77.7)
208 (82.9)
188 (74.9)
97 (38.7)
152 (88.9)
123 (71.9)
48 (28.1)
157 (91.8)
122 (71.4)
120 (70.2)
142 (83.0)
139 (81.3)
72 (42.1)
0.016
0.028
0.255
0.009
0.172
0.088
1.0
0.154
0.481
p Value*
< 0.001
0.202
< 0.001
*Fisher’s exact test.
as likely to have a high-quality handoff during the
weekday as compared to nurses (95% CI 1.31–4.46)
(Table IV). No other pairwise comparisons were
found to be significant.
Sensitivity Analyses
To determine the stability of our high-quality criteria, we evaluated different cut-points for these criteria. When the criterion for high quality was set
at 8 of 8 elements, only 12% of observed handoffs
were categorized as high quality. Using these more
stringent criteria, morning versus evening differences in percent of handoffs meeting high-quality
criteria were no longer significant (p = 0.14). However, the significance of the associations was still
the same for weekday versus weekend and for providers (data not shown).
Few (25%) handoffs met criteria for use of nontechnical language. When we removed this element and classified subjects as high quality if they
achieved at least 6 of the remaining 7 measures,
our estimates stabilized as compared to our
othermodels. Using 6 of 7 elements to define a high-
quality handoff, resident morning handoffs were
1.5 times as likely to be high quality as compared to
their evening handoffs (95% CI 1.01–2.14). In addition, we found that resident versus nursing morning handoffs were 1.5 times as likely to meet criteria
for a high-quality handoff (95% CI 1.06–2.22). The
other pairwise comparisons remained insignificant.
Weekend pairwise comparisons were also no longer significant.
Discussion
This study suggests that overall inpatient obstetrical handoff quality was suboptimal, with only 40%
of handoffs meeting ACOG guideline–based criteria for high quality. We also found that the percent
of handoffs meeting criteria for high quality varied
based on time of day, with a higher percentage of
high-quality handoffs observed in the morning as
compared to the evening (45% vs. 34%, p < 0.05).
Some of the differences observed between morning
and evening handoff quality may have been due to
variation in quality between provider types.
This study expands upon prior inpatient obstet-
100
Table III
The Journal of Reproductive Medicine®
Characteristics and Quality of Provider Handoffs
Parameter
Method
Face to face (no written element)
Phone
Face to face (verbal and written)
Type of written handoff (n = 396)
Computer
Handwritten
Typed
Recognized patients
Acute care
Morning
Weekend
Group
Components of handoff
Physical environment
Confidentiality
Language
Supportive environment
S (Situation)
B (Background)
A (Assessment)
R (Recommendation)
High quality (7 out of 8)
Attendings
N = 56 (13.3%)
No. (%)
Staff CNMs
N = 26 (6.2%)
No. (%)
Nurse
N = 139 (32.9%)
No. (%)
Residents
N = 201 (47.6%)
No. (%)
9 (16.1)
10 (17.9)
37 (66.1)
6 (23.1)
0 (0)
20 (76.9)
0 (0)
0 (0)
139 (100)
1 (0.5)
0 (0)
200 (99.5)
0 (0)
0 (0)
37 (100)
8 (14.3)
1 (1.8)
15 (26.8)
23 (41.1)
14 (25.0)
0 (0)
7 (35.0)
13 (65.0)
7 (26.9)
0 (0)
2 (7.7)
12 (46.2)
11 (42.3)
0 (0)
64 (46.0)
75 (54.0)
22 (15.8)
4 (2.9)
55 (39.6)
16 (11.5)
69 (49.6)
0 (0)
0 (0)
192 (96.0)
40 (19.9)
17 (8.5)
161 (80.1)
120 (59.7)
193 (96.0)
0.418
0.055
< 0.001
< 0.001
< 0.001
54 (96.5)
9 (16.1)
9 (16.1)
49 (87.5)
30 (53.6)
30 (53.6)
29 (51.8)
19 (33.9)
4 (7.1)
23 (88.5)
16 (61.5)
6 (23.1)
26 (100)
18 (69.2)
18 (69.2)
21 (80.8)
22 (84.6)
9 (34.6)
105 (75.5)
70 (50.4)
31 (22.3)
138 (99.3)
117 (84.2)
115 (82.7)
113 (81.3)
108 (77.7)
45 (32.4)
171 (85.1)
182 (90.6)
60 (29.9)
189 (94.3)
151 (75.1)
152 (75.6)
187 (93.0)
178 (88.6)
111 (55.2)
0.002
< 0.001
0.145
0.002
< 0.001
0.001
< 0.001
< 0.001
< 0.001
p Value*
< 0.001
< 0.001
rical handoff studies. Although a handoff tool for
nurses has been developed23 and opportunities for
improvement in communication between nurses
and physicians caring for obstetrical inpatients
have been identified,24 our study provides a unique
direct assessment of inpatient obstetrical handoff
communication quality. Pettker et al implemented
a comprehensive patient safety initiative for obstetrics that included team skills such as communication, which reduced the study institution’s Adverse
Outcome Index.20 Like in our study, the multidisciplinary nature of inpatient obstetrics was taken into
account, but direct assessment of handoff quality
was not conducted. Our study identified variation
in handoff quality as a potential opportunity for
interventions to improve quality, such as through
standardization of the handoff process.
We found that, despite the 24-hour nature of inpatient obstetrical care, handoff quality for nurses
was better in the evening as compared to the morning. This could be reflective of differences in nurse
staffing levels at different times of day or differences in the type of patient care provided on day
shifts as compared to night shifts. The finding that
the OB-GYN residents’ handoffs were higher quality in the morning may have been related to a per-
ception that the daytime is a more active time for
care and the handoff should be more comprehensive. It may also be due to the handoff style, which
most often entailed a group or multidisciplinary
handoff in the morning but not in the evening.
Given that maternal and newborn outcomes are
worse in the evening, even after adjustment for
acuity,4,7,8 it is important to determine whether the
Table IV
Relative Risks for Adjusted Comparisons of Nurse and
Resident Handoff Quality by Time and Day*
Parameter
Nurse
Evening
Morning
Resident
Evening
Morning
Nurse
Weekday
Weekend
Resident
Weekday
Weekend
Within provider**
Across providers**
Referent
0.65 (0.23–1.85)
Referent
Referent
Referent
2.14 (1.13–4.05)
2.16 (0.63–7.43)
7.10 (2.34–21.48)
Referent
0.19 (0.01–2.50)
Referent
Referent
Referent
0.96 (0.70–1.32)
2.42 (1.31–4.46)
12.07 (1.02–142.32)
*Multivariable estimates from single Poisson regression model with robust
standard errors.
**Pairwise comparisons among providers with Bonferroni adjustments.
Volume 59, Number 3-4/March-April 2014
quality of OB-GYN residents’ evening handoffs
contributes to this variation.
Differences in the percent of OB-GYN residents’
handoffs that met criteria for high quality as compared to those of nurses suggest there may be
differences in how different providers are trained
to communicate during care transitions. ACOG
guidelines were used for this analysis, and it is
possible that different results may have been obtained with the different groups using other criteria
for handoff quality. However, handoff guidelines
are becoming increasingly aligned across disciplines.25 For example, the Joint Commission National Patient Safety Goals on unit-wide handoffs26
recommend “a standardized approach that includes
opportunity to ask and respond to questions” and
are referenced in the ACOG handoff guidelines.
Although the ACOG guidelines could be interpreted as intended only for OB-GYN physicians, a case
can be made for communication standards applying across the disciplines, particularly in a clinical
setting such as labor and delivery that relies heavily on a multidisciplinary team. Ongoing efforts to
ensure consistency among guidelines are crucial
for standardization of handoff practices.
Labor and delivery nurses and OB-GYN residents were observed more frequently than were attending obstetricians and CNMs in our study. This
may be partially due to a lower patient volume for
the CNMs and inconsistent handoff locations for
both attending obstetricians and CNMs. This raises
several important questions about the potential
value of standardizing handoff processes. First, although standardized handoff processes are recommended,2,3 there is little evidence clearly connecting standardization to improved patient outcomes.
Second, it is not clear whether the potential benefit
of handoff standardization is similar across experience levels and provider types. Third, the absence
of observable attending obstetrician handoffs may
have educational implications in a teaching hospital. If medical students and residents do not observe
their instructors performing high-quality handoffs
and see this as an important part of practice, they
may be less likely to carry on best practices once
they leave residency.27
This study has strengths and limitations. By
blinding participants to the nature of the study,
we reduced the potential for artificially increasing quality of handoffs in response to performance
measurement. The effectiveness of this approach
is supported by a low overall proportion of high-
101
quality handoffs. Although observing different
provider groups increased the heterogeneity of the
population studied, we attempted to address this
potential issue with our secondary and sensitivity
analyses. By including different provider types,
we took into account the multidisciplinary nature
of inpatient obstetrical care and applied a common
standard of quality. In the absence of an existing
tool to measure inpatient obstetrical handoff quality, we developed a novel method to do so. We elected to set the standard for a high quality handoff at
7/8 criteria (87.5%) for the following reasons: (1) although the ACOG handoff guidelines have high
face validity, the association between 100% adherence to these guidelines and improved clinical outcomes is not yet established, making decisions
about cutoffs for high quality somewhat arbitrary,
and (2) research team members who practice obstetrics felt that the degree of subjectivity of some
of the ACOG criteria (e.g., use of nontechnical language) could result in uneven awarding of credit
for meeting criteria if used outside of the research
setting. Because of these reasons, it was felt that it
was most fair to set the standard for a high quality
handoff above 80% but less than 100%. We did test
this decision with our sensitivity analyses, which
suggested that the criteria we developed to define
a high-quality handoff may benefit from further
refinement, particularly for use of nontechnical language. Additional studies that assess the impact of
use of nontechnical language on trainees’ learning
and performance may help to expand our knowledge in this area as well. This study took place at
one institution, limiting generalizability. We did
not observe all eligible providers, nor collect demographic data on the individuals handing off, but
we made efforts to limit repeat observations of providers by observing over a 6-month time period,
observing different floors in the labor and delivery
unit and observing different days of the week to
reduce potential clustering effects. Given that the
observed differences were relatively large (e.g., 10%
for morning versus evening and 23% for residents
versus nurses), this method was likely successful
in reducing the potential for clustering effects. We
were unable to easily observe attending physician
handoffs because they were less predictable in timing and took place over the phone more often than
did handoffs between other types of providers. This
limited our ability to fully assess attending OB
handoffs. We gave equal weight to each of the
elements of quality measured, although it is possi-
102
ble that some may have a greater impact on patient
safety and care quality than others. Finally, we
chose not to observe handoffs between community
obstetricians and CNMs, but comparing the quality
of handoffs between faculty and community providers may reveal further opportunities for improving handoff quality.
In conclusion, we found that a low percentage
of all inpatient obstetrical handoffs met criteria for
high quality and that the percent of handoffs meeting criteria for high quality varies depending on
time of day and provider type. Determining whether standardization of handoffs improves the overall
quality and reduces variation is an important next
step. Testing whether expansion of a multidisciplinary team handoff28 to include evenings improves
handoff quality is also warranted. Finally, assessing
how better quality handoffs improve patient outcomes will also further advance our understanding
of the role handoff quality plays in inpatient obstetrical outcomes.
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