Uncertainty, Case Complexity and the Content of Verbal Handoffs at the Emergency Department

Handoffs are known to increase the risk of medical error and adverse events. Few electronic tools can support this process effectively, however. Our objective was to describe the relationship between clinical complexity, diagnostic uncertainty, fit with illness script and the content of case presentations by physicians. We observed the handoff of care for150 patients during eleven shift changes at a large urban emergency department (ED). Results indicate that as uncertainty about diagnosis and perceived illness script increased, more descriptive detail was conveyed to the incoming physicians. Physicians were concerned primarily with creating a shared mental model of a patient's clinical state and with describing the expected path to disposition rather than simply passing on data and findings. Electronic tools for ED handoffs should allow adjustment of structure and content to capture complexity and uncertainty appropriately without requiring extra effort for more routine cases that better fit to more standard narratives.