Emergency Medicine · Year 3 · from Emergency Medicine
Case 2: Handoff Communication - The Night Shift Transfer
Patient Demographics
- Age: 78 years
- Sex: Female
- Occupation: Retired librarian
Clinical Scenario
Setting: It's 7 AM shift change. The night shift physician is handing off to the day shift. Mrs. Williams has been in the ED since 2 AM and needs to be "signed out" for continued care.
Patient Summary for Handoff
One-liner: 78-year-old female with CHF and CKD presenting with 2 days of progressive dyspnea, found to have acute CHF exacerbation with volume overload.
IPASS Handoff Framework
I - Illness Severity: "Mrs. Williams in Room 12 is SICK but STABLE. She's on BiPAP with improved work of breathing but still requiring respiratory support."
P - Patient Summary: "She's a 78-year-old with systolic CHF (EF 30%), CKD stage 3, and atrial fibrillation. She presented at 2 AM with 2 days of worsening shortness of breath. She ran out of her Lasix a week ago. On arrival she was in acute respiratory distress with bilateral rales, JVD, and peripheral edema. She was placed on BiPAP and given 80mg IV Lasix. She's put out 1.8 liters of urine and her work of breathing has significantly improved."
A - Action List: "Three things I need you to do:
- Repeat her BMP at 8 AM - her potassium was 5.1 initially and creatinine 2.4. Make sure it's not worsening with diuresis.
- Cardiology is coming to see her this morning to decide between admission to their service vs. obs unit
- She's still on BiPAP - try to wean her if she continues to improve; she should be able to come off in the next couple hours"
S - Situational Awareness and Contingency Planning: "If she worsens on BiPAP or can't wean off, she may need intubation - I've already discussed with her and she is FULL CODE. Her daughter is here and is the healthcare proxy if needed. Contact number is in the chart. Also be aware her potassium was borderline - if it rises, hold the Lasix and treat the hyperkalemia."
S - Synthesis by Receiver: "Let me repeat back: 78-year-old with CHF exacerbation on BiPAP, been diuresing well. I need to recheck her labs at 8 AM, coordinate with cardiology for disposition, and try to wean BiPAP. If she deteriorates she's full code, and I need to watch the potassium. Anything else?"
Critical Information Included
What Makes This Handoff Complete:
- Illness severity clearly stated
- Pertinent history and overnight course summarized
- Active issues identified with specific tasks
- Anticipatory guidance provided ("if/then" statements)
- Code status clarified
- Family/decision-maker identified
- Opportunity for questions
Common Handoff Failures to Avoid
| Failure | Example | Better Approach |
|---|---|---|
| Missing acuity | "She's a CHF patient in 12" | "She's SICK - on BiPAP" |
| No action items | "Cardiology will see her" | "Cardiology needs to decide admit vs obs, call them at 8 if they haven't come" |
| No contingency | "She's doing okay" | "If she can't wean BiPAP, may need intubation" |
| Buried code status | Not mentioned | "Full code, daughter is proxy" |
| No read-back | "Any questions?" (and move on) | Actually wait for synthesis |
Subsequent ED Course
8 AM Labs:
- Potassium: 4.8 (improved)
- Creatinine: 2.6 (slightly worse but expected with diuresis)
- BNP: 1840 (down from 2400)
9 AM:
- Successfully weaned from BiPAP to nasal cannula 4L
- Breathing comfortably
- Cardiology saw patient
Disposition:
- Admitted to cardiology observation unit
- Continued diuresis
- Discharged day 2 with medication reconciliation
Handoff Documentation
Documentation Note:
"7:00 AM - Handoff given to Dr. Smith (day shift):
- Patient remains on BiPAP with improved respiratory status
- 1.8L diuresis overnight
- Pending: 8 AM labs (BMP), cardiology evaluation for disposition
- Contingency planning discussed: If unable to wean BiPAP or respiratory deterioration, may require intubation; patient is FULL CODE
- Family aware and updated (daughter present)"
Teaching Points
- Structured handoffs reduce errors: IPASS, SBAR - use a framework every time
- State illness severity upfront: "Sick" vs "stable" frames the conversation
- Action items must be specific: Not "follow up labs" but "repeat BMP at 8 AM"
- Anticipatory guidance is key: "If X happens, do Y"
- Code status is essential: Always know and communicate
- Read-back confirms understanding: Don't skip this step
- Face-to-face is preferred: More effective than written alone
- Document the handoff: Protects patients and providers
Clinical Image
Image Description: Diagram illustrating the I-PASS handoff communication framework showing the five components: Illness severity, Patient summary, Action list, Situation awareness/contingency planning, and Synthesis by receiver.
Attribution: Image from I-PASS Study Group materials. Educational use. Source: https://www.ipasshandoffstudy.com/