High Quality Handovers

Mackenzie Barker

Use “handoff” tab in eStar and update daily.

Synopsis

  • Name, age, relevant hx, and key hospital diagnoses/events i.e.: “57 yo M w/ HTN and HLD admitted for NSTEMI s/p LHC on DAPT.” 
  • Document code status and capacity to AMA.

To-dos

  • Provide explicit, time-stamped instructions ie: “21:00 – I/O check. If UOP <2L, give 160 mg IV Lasix.” Ensure cross cover has resources to act (reliable access and blood consent if trending CBC in GIB).

Contingencies

  • Offer patient-specific guidance for common overnight issues. Focus on how this patient differs from others. 
  • At minimum address fever, hypotension, hypoxia, pain, nausea, AMS. Add other likely issues based on chief complaint (i.e. CP and tachycardia in cards patients). 
    • Fever 
      • Source: New? Known infection? Likely source? Noninfectious causes (inflammation, DVT)? 
      • Workup: Needed studies (CXR, RPP, UA, cultures)? 
      • Abx: Current regimen? Recent changes? When to start/broaden vs defer? 
      • Antipyretics: Ok for antipyretics? Note contraindications (limit acetaminophen in cirrhosis, avoid NSAIDs if AKI/bleeding risk). 
    • Hypotension 
      • Etiology: New? Baseline BP? Target MAP? Most likely shock type (hypovolemic/hemorrhagic, septic, cardiogenic, obstructive, neurogenic, anaphylactic)? Consider orthostasis, autonomic dysfunction, meds.
      • Hypovolemic: Cause (poor PO, GI loss, over-diuresis)? Fluid deficit? 
      • Hemorrhagic: Source? Anticoagulation? Prior transfusions? Active T&S? Consent? Recommend STAT CBC, imaging, surgical/IR consult as appropriate. 
      • Septic: See fever contingency 
      • Cardiogenic: Volume status? EF? Consider EKG, troponin, BNP, CXR, POCUS. Diuresis? 
      • Obstructive: PE risk? CTA threshold? Renal function? Safe to anticoagulate? 
      • Fluids: Ok for fluids? EF? Specify type, amount, and whether to examine/POCUS. 
      • Medications: Hold BP-lowering meds or continue? 
      • Escalation: MICU/CCU for pressors? Goals of care? 
    • Hypoxia 
      • Etiology: New? Baseline O₂? Target sat? Likely causes (atelectasis, PNA, aspiration, pulmonary edema, PE, asthma, COPD, OSA, opioid-induced hypoventilation)? 
      • Workup: Most need CXR. Consider vBG, RPP, etc. 
      • Treatment: Tailor to cause. Duonebs for COPD. Diuresis for overload. Abx/AWC for PNA. ICS for atelectasis. CTA for PE if appropriate. CPAP for OSA. Naloxone for overdose. Consider repositioning (upright for aspiration or pulmonary edema, bad lung up for atelectasis, prone for PNA or ARDS). 
      • Escalation: MICU for BIPAP/intubation? 
    • Pain 
      • Etiology: Clarify baseline pain, severity, and effective prior therapies. 
      • Workup: Note red flags requiring further evaluation. 
      • Treatment: Provide current regimen, recent changes, what can be added (acetaminophen, NSAIDs, muscle relaxants, gabapentin, opioids, topicals, heat), dosing guidance, and contraindications (NSAIDs in AKI, limit acetaminophen in cirrhosis, avoid deliriogenic or high-risk meds). 
    • Nausea 
      • Etiology: New? Likely causes: GI (constipation, ileus, gastritis), metabolic (uremia, DKA), neurologic (increased ICP, posterior stroke, migraine, BPPV), cardiac (ACS), infectious (PNA, viral gastro), medication-related? 
      • Workup: Note red flags requiring further evaluation. 
      • Treatment: If QT normal: ondansetron, prochlorperazine, promethazine. If prolonged: diphenhydramine, scopolamine, dexamethasone, alcohol swabs. Avoid anticholinergics in delirium. Consider IV fluids if poor PO. If obstruction, NPO and NGT. If >2 antiemetic doses, repeat EKG. 
    • AMS 
      • Etiology: Baseline mental status and neuro exam? Likely causes (metabolic, hypoxia/hypercarbia, stroke, hypoglycemia, seizures, infection, medications, delirium)? 
      • Workup: If new, evaluate at bedside. POC glucose, vBG, lactate. Code stroke for new deficits. 
      • Treatment: Treat underlying cause. For agitation, specify preferred agents (olanzapine, haloperidol, benzodiazepines) based on QT and comorbidities. Consider sitter. Avoid restraints unless absolutely necessary.

I-PASS for Verbal Handoff

  • Illness severity (stable, watcher, unstable) 
  • Patient summary (diagnosis, hospital course, key exam/labs) 
  • Action list (to-dos) 
  • Situational awareness (contingencies) 
  • Synthesis by receiver (recap and clarify questions)
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