American Journal of Medical Quality

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Systematic Review of Handoff Mnemonics Literature

Lee Ann Riesenberg, Jessica Leitzsch and Brian W. Little
American Journal of Medical Quality 2009; 24; 196 originally published online Mar 5, 2009;
DOI: 10.1177/1062860609332512

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Systematic Review
of Handoff Mnemonics Literature
Lee Ann Riesenberg, PhD, RN
Jessica Leitzsch, BS
Brian W. Little, MD, PhD

A systematic review of published English-language to another for the purpose of ensuring the continu-
articles on handoffs is conducted (1987 to June 4, ity and safety of the patient/client/resident’s care.”5
2008). Forty-six articles describing 24 handoff mne- The Joint Commission has reviewed data from
monics are identified by trained reviewers. The 4977 sentinel events that occurred between 1995
majority (82.6%) have been published in the last 3 and March 31, 2008.6 In organizations accredited
years (2006-2008), and SBAR (Situation, Background, by the Joint Commission, communication problems
Assessment, Recommendation) is the most frequently have been identified as one of the contributing
cited mnemonic (69.6%). Of 7 handoff research arti- causes in more than 60% of the sentinel events
cles, only 4 study mnemonics. All 4 of these studies reviewed. As a result, the Joint Commission created
have relatively small sample sizes (10-100) and lack a new National Patient Safety Goal in 2006: 2E
validated instruments. Only 1 study has obtained “Implement a standardized approach to ‘hand off’
IRB approval. Scientifically rigorous research stud- communications, including an opportunity to ask
ies are needed to assess the effectiveness of handoff and respond to questions.”7 This goal has remained
mnemonics. These should be published in the peer- unchanged and was repeated in 20078 and 2008.9
reviewed literature using the Standards for QUality In 2005, the average length of stay for all
Improvement Reporting Excellence (SQUIRE) guide- hospitalized patients was 4.8 days.10 Assuming that
lines. (Am J Med Qual 2009;24:196-204) patient care transfers occur between physicians at
Keywords:   handoff; handoffs; mnemonic; sign-out least twice per day and between nurses at least 3
times per day, the average patient will be handed off
Effective communication is central to safe and effec- a minimum of 24 times per admission. This
tive patient care. Handoffs or transfers of patient represents 24 opportunities for inadequate
care from one health care provider to another are communication, each of which could result in reduced
known to be vulnerable to communication failures.1-4 patient safety and increased medical errors.
As defined by the Joint Commission, handoff com- Mnemonics are commonly used to enhance
munication “refers to a real-time process of passing memory. In the case of handoffs, mnemonics may
patient/client/resident-specific information from one increase memory of important steps and provide a
caregiver to another or from one team of caregivers structured process to follow. Our experiences lead
us to believe that many hospitals have responded
AUTHORS’ NOTE: Dr Riesenberg is with Academic Affairs, to the Joint Commission handoff requirement by
Christiana Care Health System, Newark, Delaware, and adding a mnemonic to their handoff protocol. The
the Jefferson School of Population Health, Philadelphia, purpose of the current study was to identify all
Pennsylvania. Ms Leitzsch is with Academic Affairs, Christiana
handoff mnemonics, describe their use, and
Care Health System, Newark, Delaware. Dr Little is with
Academic Affairs, Christiana Care Health System, Newark, summarize outcomes data from studies using these
Delaware, and Jefferson Medical College, Philadelphia, mnemonics.
Pennsylvania. The authors have no conflicts of interest to disclose
with regard to this article. Corresponding author: Lee Ann
Riesenberg, PhD, RN, Academic Affairs, Christiana Care Health METHODS
System, 4755 Ogletown-Stanton Road, Suite 2A00, Newark, DE
19718 (e-mail: [email protected]). We conducted a thorough and systematic literature
American Journal of Medical Quality, Vol. 24, No. 3, May/June 2009 search of English-language articles published on
DOI: 10.1177/1062860609332512 handoffs using Ovid MEDLINE, CINAHL, and
Copyright © 2009 by the American College of Medical Quality HealthSTAR (1987 to June 4, 2008), followed by

196

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AMERICAN JOURNAL OF MEDICAL QUALITY Review of Handoff Mnemonics Literature      197

reference section review of all included articles. 25

22
The search terms used were (hand-off$ OR handoff$
20
OR signout$ OR sign out$ OR sign-out$ OR
handover$ OR hand-over$ OR signover$ OR sign- 15 14
over$). A total of 2590 articles were identified. All
10
titles were reviewed for possible inclusion, and 401
articles were obtained for further review. Trained 5
2 3
reviewers deemed only 46 articles to meet the 1 1 1 2

inclusion criteria of focusing on handoffs and 0

1987 2002 2003 2004 2005 2006 2007 2008
including a handoff mnemonic. Two reviewers (LR
and JL) independently abstracted data. Figure 1.   Year of publication of 46 English-language
articles focused on health care handoffs, including
a handoff mnemonic, 1987 to June 2008.
RESULTS

Forty-six articles that focused on health care

Horwitz and colleagues43 demonstrated a
handoffs yielded 24 handoff mnemonics, with
statistically significant increase (P < .001) in
SBAR (Situation, Background, Assessment,
perceived comfort with providing sign-out after a
Recommendation) cited most frequently (Table 1).
1-hour educational intervention with medical
Thirty-eight articles (82.6%) were published
students and residents. Their intervention appears
between 2006 and 2008 (Figure 1).
to be well designed, including a systematic
Thirty-nine articles presented anecdotal
development process. The educational intervention
data,11,14,19-22,24,26-33,36,41,44,47,50-52,55-56 with 15 of these
included discussion, modeling, and real-time
providing a patient vignette18,23,33 or case study
practice, with feedback and evaluation for all
example12,17,25,35,37-38,42,45-46,48-49,53 depicting the use of
learners. This was the only study reporting
the mnemonic, and 1 of those providing a brief
institutional review board (IRB) approval. However,
literature review.12 There were 7 research studies
the evaluation instrument appears to be modeled
of handoffs,15,40,54 with only 4 of these actually
after the traditional course satisfaction form, with
studying a mnemonic13,16,39,43 (Table 2).
some items added about attitudes toward and
comfort with sign-out. Although this is standard
DISCUSSION educational practice, it is not an ideal research
practice, where use of a validated instrument or
We identified 46 articles describing handoff some attempt at validation is at least encouraged.
mnemonics. Thirty-two articles (69.6%) included In the only study that examined practice
SBAR (Situation, Background, Assessment, behavior, there was a decrement in the accuracy of
Recommendation). The majority (82.6%) of articles recall of handover information when a mnemonic
were published in recent years, which is not (DeMIST) was used.16 Accuracy of recall was higher
surprising given that the Joint Commission’s (56.6%) without the mnemonic than with the
National Patient Safety Goal on handoffs was first mnemonic (49.2%). The authors are to be
issued in 2006. What is surprising is the lack of commended for the assessment of practice; however,
high-quality outcomes studies. this study has several shortcomings. The sample
Only 4 of 46 (8.7%) reviewed articles collected was quite small: 18 observed handovers without
data on handoff mnemonics. These had relatively the mnemonic and 10 observed using DeMIST. The
small sample sizes (10-100) and failed to use authors noted the small sample and explained that
validated instruments or to conduct validation of this sample size was used to obtain initial data
the instruments used. One study used self-reported without delaying patient care in busy emergency
familiarity with 2 mnemonics. 13 Haig and departments (EDs). The authors also acknowledged
colleagues39 assessed knowledge of SBAR using a that they did not control for staff seniority or
telephone survey of 10 nurses prior to their experience. The ambulance crews simply agreed to
intervention. The authors reported achieving 96% structure their handover using the mnemonic
use of SBAR post intervention but did not provide DeMIST. The authors did not report providing
details on how this was measured. training or practice time using the new handover

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198      Riesenberg et al AMERICAN JOURNAL OF MEDICAL QUALITY

Table 1
Handoff Mnemonics Identified in the English-Language
Literature, Including Type of Staff Reported Using the Mnemonic, 1987 to June 2008
Mnemonic Disciplines or Departments Description

AIDET 11
Perioperative staff, including A Acknowledge the patient
nurses, anesthesiologists, I Introduce yourself
physicians, and surgical D Duration of the procedure
technologists E Explanation of process and what happens next
T Thank you for choosing our hospital (note: handoff done at bedside)
ANTICipate12 Physicians, residents A Administrative data
N New information (clinical update)
T Tasks (what needs to be done)
I Illness
C Contingency planning/code status
ASHICE13 Ambulance/emergency A Age
department S Sex
H History
I Injuries
C Condition
E Expected time of arrival
CUBAN14,15 Emergency department nurses, C Confidential
nurses, perioperative staff U Uninterrupted
B Brief
A Accurate
N Named personnel
DeMIST16 Ambulance/emergency De Patient demographics
department M Mechanism of injury
I Injuries sustained
S Symptoms and signs
T Treatments given
GRRRR17 Nurses, physicians G Greeting
R Respectful listening
R Review
R Recommend or request more information
R Reward
HANDOFFS18 Physicians, residents H Hospital location: wing, room number
A Allergies/adverse reactions/medications
N Name (age, gender)/number (medical record)
D Do not attempt resuscitation (DNAR)?/diet/deep-vein thrombosis (DVT)
prophylaxis
O Ongoing medical/surgical problems
F Facts about this hospitalization
F Follow-up on . . .
S Scenarios
I PASS the General nurses, perioperative I Introduction: introduce yourself and your role
BATON19,20 nurses, physicians P Patient: name, identifiers, age, sex, location
A Assessment: presenting chief complaint, vital signs, symptoms, diagnosis
S Situation: current status and circumstances; including codes status,
level of certainty, recent changes, and response to treatment
S Safety concerns: critical lab values and reports, socioeconomic factors,
allergies, alerts (eg, falls, isolation)
B Background: comorbidities, previous episodes, current medications,
family history
A Actions: which were taken or are required, providing brief rationale
T Timing: level of urgency, explicit timing, and prioritization of actions
O Ownership: who is responsible (eg, nurse, doctor, team), including
patient or family responsibilities
N Next: what happens next (eg, any anticipated changes in condition or
care, the plan, any contingency plans)
(continued)

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AMERICAN JOURNAL OF MEDICAL QUALITY Review of Handoff Mnemonics Literature      199

Table 1 (continued)
Mnemonic Disciplines or Departments Description

Just Go NUTS 21,22

Nurses, physicians, N Name of patient, diagnosis, room number
transporters, and other U Unusual or unique; variances identified on the individual care plan
clinical staff including critical lab values, pain management, etc
T Tubes such as IV, NG, catheters, drains, ostomies
S Safety concerns such as falls, medication reconciliation
MIST13,16 Ambulance/emergency M Mechanism of injury
department I Injuries sustained or suspected
S Signs—vital signs
T Treatment initiated (and timing)
PACE23 Nurses P Patient/problem
A Assessment/actions
C Continuing/changes
E Evaluation
PEDIATRIC24 Residents P Problem list
E Expected tasks to be done
D Diagnostic one-liner
I If/then
A Administrative data/advanced directives
T Therapeutics
R Results and other important facts
I IV access/invasive devices
C Custody and current issues
SBAR14,17,19–22,25–51 Anesthesiologists, mid-level S Situation
practitioners, nurse B Background
assistants, nurses, nursing A Assessment
students, OR staff, PACU R Recommendation
staff, perioperative staff,
pharmacists, physical
therapists, physicians,
transporters, radiologists
I-SBAR19,29 Nurses, physicians, transporters I Introduction
S Situation
B Background
A Assessment
R Recommendation
SBARR38 Nurses, physicians S Situation
B Background
A Assessment
R Recommendation
R Response or read back
SBAR-T36 Nurses S Situation
B Background
A Assessment
R Recommendation
T Thank patients for opportunity to work with them (note: handoff done at
bedside)
SHARED34,52 Emergency department, S Situation
surgery, PACU, and other H History
nurses; pharmacists, physical A Assessment
therapists, physicians, R Request
respiratory therapists, and E Evaluate
other staff D Document
SHARQ20 Perioperative nurses S Situation: describe the situation
H History: medical history, allergies, home medications
A Assessment: current medications, intake, output, status
R Recommendations: results, discharge planning
Q Questions: opportunity to ask questions
(continued)

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200      Riesenberg et al AMERICAN JOURNAL OF MEDICAL QUALITY

Table 1 (continued)
Mnemonic Disciplines or Departments Description

SIGNOUT 43
Internal medicine residents, S Sick or DNR? (highlight sick or unstable patients, identify DNR/DNI
medical students patients)
I Identifying data (name, age, gender, diagnosis)
G General hospital course
N New events of the day
O Overall health status/clinical condition
U Upcoming possibilities with plan, rationale
T Tasks to complete overnight with plan, rationale
SOAP53 Ambulance/emergency S Subjective information about the patient’s concerns, sensations, and/or
department, neuroscience behavior related to the problem
nurses O Objective information related to the problem (eg, level of consciousness,
activity tolerance, effect of medication received, postprocedure signs,
laboratory values)
A Assessment of the patient’s condition as substantiated with the data
from S (subjective) and O (objective) and an indication of the direc-
tion of change in the patient’s condition
P Plan of what has or should be done for/with the patient
STICC17,54 Nurses, physicians, residents S Situation
T Task
I Intent
C Concern
C Calibrate
4 P’s55 P Purpose: Why is the patient here? What priorities does she have?
P Picture: What results are we looking for, both short-term and long-term?
How can we picture the patient’s current condition?
P Plan: What did or didn’t work?
P Part: What part can you play during the next shift?
5P’s v.120,56 General nurses, perioperative P Patient identity
nurses P Plan of care
P Purpose of plan: clinical findings supporting plan of care
P Problems: abnormal findings, pain scale, vital signs
P Precaution: isolation, falls, etc
5P’s v.220 Perioperative nurses P Patient: identify
P Precautions: allergies, isolation, falls, specialty bed
P Plan of care: fluids, intake, output, IV access
P Problems: assessment, review of systems, pain scale
P Purpose: goals to be achieved

IV, intravenous; NG, nasogastric; OR, operating unit; PACU, post-anesthesia care unit; DNR, do not resuscitate; DNI, do not intubate.

mnemonic. The article provides an example uncertain.57 These authors concluded that formulaic
transcript using an unstructured handover and a approaches to handoffs will not adequately deal
handover structured using DeMIST. Although the with critical care uncertainty and complexity.57
structured handover is obviously an example of a Others have warned against the use of standardized
superior handover, it is possible that the ambulance handoffs for physicians, stating that this will tend to
crew’s handovers suffered when using an unfamiliar “exacerbate the common problems of handoffs being
tool. Also, ED staff may have been familiar with ‘data transfers’ rather than meaningful discussions
the ambulance crews and their idiosyncratic about the patient’s status and treatment.”58(p93)
communication styles. This may have contributed
to the decrement in recall when hearing a different Limitations
presentation format.
In a small study of intensive care unit handoffs, The current study is limited by the Ovid search
the authors noted that handoffs are complex, take strategy used. Specifically, the selected search terms
many forms, and need to focus on what was may not have included all relevant terms. We

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AMERICAN JOURNAL OF MEDICAL QUALITY Review of Handoff Mnemonics Literature      201

Table 2
Research Studies of Handoff Mnemonics Identified
in the English-Language Literature, 1987 to June 2008
First Author, Year Type of Research Mnemonic
Published Study Subjects Studied Results

Budd, 2007 13
Cross-sectional mailed 100 randomly selected MIST and
*
One of 10 questions on the emergency
questionnaire emergency departments ASHICE† department questionnaire referred to
and all ambulance services handoff mnemonics: 27.4% reported
(32) in England and Wales. being familiar with MIST and 45.5%
Questionnaires returned reported being familiar with ASHICE. One
from 34 (34%) emergency in 7 questions on the ambulance service
departments and 15 (50%) questionnaire referred to handoff
ambulance services. mnemonics: 15.4% reported being
familiar with MIST and 86.7% reported
being familiar with ASHICE.
Haig, 200639 Intervention with Nursing staff in Bloomington, SBAR‡ 60% of 10 nurses contacted in 2004 by
pre-intervention Illinois. Total number of phone (pre-interventions) correctly
phone survey. subjects was not reported. described the use of SBAR and provided
Methods for an example of its use. Authors reported
collecting that use of SBAR reached a mean of
postintervention data 96% in fiscal year 2005, but did not
not described. describe how this was assessed.
Intervention
described as
following the Plan,
Do, Study, Act
(PDSA) cycle and
resulting in the
creation of an SBAR
trigger tool.
Horwitz, 200743 One-hour educational Internal medicine interns and SBAR and Perceived comfort with providing sign-out
intervention with medical students in SIGNOUT§ increased from 3.27 ± 1.0 to 3.94 ± 0.90,
retrospective pretest Connecticut. Session P < .001. Sign-out was ranked as
and posttest included facilitated important or very important to patient
self-reported discussion, modeling, and care by all participants (mean score 4.88
attitudes at the end observed individuals practice ± 0.33). The mnemonic SIGNOUT was
of the 1-h session. with feedback. Did not take rated as useful or very useful (mean
attendance at the score 4.46 ± 0.78) by all participants and
educational session; received a slightly higher rating than
collected 34 completed SBAR (mean score 4.18 ± 0.83).
evaluations.
Talbot, 200716 Cross-sectional Observed 18 unmodified DeMIST¶ Accuracy of emergency department staff
observational study handovers from ambulance recall was higher without the mnemonic:
staff to emergency 56.6% accuracy without DeMIST and
department staff. Then 10 49.2% accuracy with DeMIST.
consecutive ambulance
crews were asked to
structure their handover
using the DeMIST format.
Observed these handovers.
All subjects were in
Birmingham and London,
United Kingdom.
*
MIST refers to Mechanism of injury, Injuries sustained or suspected, Signs—vital signs, Treatment initiated (and timing).
†
ASHICE refers to Age, Sex, History, Injuries, Condition, Expected time of arrival.
‡
SBAR refers to Situation, Background, Assessment, Recommendation.
§
SIGNOUT refers to Sick or DNR? (highlight sick or unstable patients, identify DNR [do not resuscitate]/DNI [do not intubate] patients), Identifying data
(name, age, gender, diagnosis), General hospital course, New events of the day, Overall health status/clinical condition, Upcoming possibilities with plan/
rationale, Tasks to complete overnight with plan/rationale.
¶
DeMIST refers to Patient demographics, Mechanism of injury, Injuries sustained, Symptoms and signs, Treatments given.

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202      Riesenberg et al AMERICAN JOURNAL OF MEDICAL QUALITY

strengthened the possibility of identifying all patient outcomes, (3) determine the best mnemonics
articles meeting inclusion criteria by reviewing the for different settings and different practitioners,
reference sections of the 401 reviewed articles. and (4) identify the best implementation strategies.
Although this strategy minimizes the risk of missing These studies should be reported using the SQUIRE
germane studies, it does not eliminate the possibility. guidelines. Outcome studies designed and reported
Another issue is publication bias. Here we refer using the aforementioned recommendations are
to the possibility that high-quality studies with needed to implement a safe, efficient, and
negative results may not have been published. effective standardized handoff process as required
Others have noted that many quality improvement by the Joint Commission. Without such studies,
(QI) projects are not published.59 In addition, we countless hospitals across the United States are
have observed that some QI projects are published doomed to waste time, resources, and effort on
in newsletters, with the authors never submitting flawed handoff practices.
to peer-reviewed journals. Thus, there may be
outcomes studies of handoff mnemonics that are
not in the peer-reviewed literature. ACKNOWLEDGEMENTS

Special thanks to Ellen M. Justice, MLIS, AHIP,

Recommendations medical librarian for conducting literature
searches; Dolores Ann Moran, medical library
Small studies and anecdotal reports will not yield assistant II; and Janice Evans, medical library
the essential answers. Numerous authors have assistant II, for their assistance in locating
noted the lack of published research on structured articles; and Donald Riesenberg, MD, for feedback
handoffs12,40,48,53,56 and the need to demonstrate the on the manuscript.
value of mnemonics. In addition, there are risks
involved in implementing interventions without
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