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Handoffs for Joint Service Casualty Care (HJSCC)



OBJECTIVE: Develop and validate empirically derived combat casualty handoff protocols and tools which can be used across all military branches of the armed forces with the potential application to other healthcare settings. 

DESCRIPTION: Prolific evidence indicates that quality patient care is contingent upon communication. To illustrate, the Joint Commission suggests that approximately 70% of sentinel events are attributed to communication mishaps, and 80% of severe medical errors are attributed to miscommunication during handoffs (i.e., the transferring of information, responsibility, and authority for patient care from one provider to another) [1]. Although handoffs are fundamental for clinical care, frequently conducted, and universally performed across sub-specialties, they are consistently inadequate and error prone. Miscommunications during handoffs have resulted in errors of medication, treatments, tests, and pending consultations [2]. In addition, research has demonstrated that inadequate handoffs are linked to poor outcomes including higher rates of readmission, longer lengths of stay and times to intervention, as well as increases in preventable adverse events [3]. Furthermore, mishaps in handoffs have repeatedly been one of the leading factors for malpractice claims [4]. In order to mitigate these communication breakdowns and issues that result from such failures, the Joint Commissions National Patient Safety Goal specifies that organizations should enhance communication between clinicians by implementing a standardized approach to conducting handoffs. Although numerous approaches to standardized protocols have been developed and have been shown to be beneficial within civilian environments, these protocols are often generic and not evaluated rigorously [2]. Additionally, handoffs become even more complicated when considering the austere environments and the nature of the traumatic injuries that occur in combat. Further, the Army Institute of Surgical Research, suggests that there is a poor translation of evidence-based practices to the battlefield (see These issues are compounded when considered in context of the realities of combat casualty care. Caregivers treating complex multi-trauma patients often operate in mass casualty scenarios, work under fire, have cultural communication barriers, and respond to situations of prolonged field care which can abruptly end or become extended as opportunities for transfer to patients emerge or become delayed. Handoff protocols should be flexible enough for providers with varying backgrounds (medical and non-medical individuals, teams, aircrews, and units, required for effective patient evacuation and transport) to rapidly provide the appropriate information that is critical for treating time-sensitive injuries under the variety of less than ideal conditions [5]. Further, the developed protocols should be capable of being modified and easily assessed for accuracy to meet service specific needs and be capable of being integrated with current DoD programs such as Virtual Battlespace 3 (VBS3), the Wide Area Virtual Environment (WAVE), and/or the array of technologies used by the Critical Care Air Transport Team (C-CAT1), the Center for Sustainment of Trauma and Readiness Skills (C- STARS), and the Army Medical Support Training Centers (MSTC). 

PHASE I: The team will design, develop a new concept for handoff protocols and associated tools for use through the continuum of care for combat casualty care situations. Handoff protocols and associated tools will be designed to be used by the variety of service members that are involved in patient handoffs in a joint environment. The proposed concept will show that it can be used across a range of challenging conditions set forth in the description. The handoff protocols and associated tools should be capable of being modified and easily assessed for accuracy and to meet service specific needs. Any technological solutions must be interoperable with current DoD programs and computer network systems. The Phase I Option, if awarded will include preliminary design concepts and propose capability descriptions for Phase II. An appropriate protocol for the protection of human subjects will be created and approved prior to research and/or testing involving human participants. 

PHASE II: Based on Phase I results and the statement of work for Phase II, the team will apply results from Phase I to develop a comprehensive curriculum and training approach to address the tasks, knowledge, and skills needed to effectively use the handoff protocols and associated tools; employ appropriate methods to test the proposed handoff protocols and tools; demonstrate the handoff protocol design approach in a prolonged combat casualty care scenario; and demonstrate improved performance using the prototype handoff protocols and tools over existing processes used to conduct patient handoffs. A commercialization plan will be developed during Phase II that addresses transition to industry and/or relevant users. A protocol for the protection of human subjects for this effort will be developed in Phase I for use in Phase II. 

PHASE III: The team will be expected to perform final testing and prepare any and all necessary documentation such as user's guides and instructor's manuals for transition of the program and protocols to the Defense Health Agency (DHA) and integrate the handoff protocols and associated tools into a training solution for combat casualty care and to applicable schoolhouses and simulation platforms. Private Sector Commercial Potential: Advances in this technology are applicable to the paramedic, emergency medicine and hospital care communities. Methods and technologies developed under this effort could be used by healthcare industry members who use handoff protocols to ward off information handoff-related decrements in performance of patient care. Additionally, organizations specializing in safety and communications in high-risk organizations could employ the tools and techniques developed here to ensure consistent performance outcomes and provide standardized communication of critical information for their clientele. 


1: Joint Commission. (2012). Sentinel event statistics data: root causes by event type. Accessed June 30, 2014.

2: Riesenberg, L. A. (2012). Shift-to-shift handoff research: Where do we go from here? Journal of Graduate Medical Education, 4(1), 4-8.

3: Catchpole, K.R., De Leval, M.R., Mcewan, A., Pigott, N., Elliott, M.J., Mcquillan, A., & Goldman, A.J. (2007). Patient handover from surgery to intensive care: using Formula 1 pitstop and aviation models to improve safety and quality. Pediatric Anesthesia, 17(5), 470-478. http://doi:10.1111/j.1460-9592.2006.02239.x

4: Gakhar, B., & Spencer, A.L. (2010). Using direct observation, formal evaluation, and an interactive curriculum to improve the sign-out practices of internal medicine interns. Academic Medicine, 85(7), 1182-1188.

5: Santos, E. Jr., Rosen, J., Kim, K.J., Yu, F., Li, Y., Guo, Y., Katona, L. (2012). Reasoning about intentions in complex organizational behaviors: Intentions in surgical handoffs. In E. Salas, S.M. Fiore, M.P. Letsky (Eds.), Theories of team cognition: Cross-disciplinary perspective (pp.51-85). New York, New York: Taylor & Francis.


KEYWORDS: Medical Handoffs, Combat Casualty Care, Medical Technology, Patient Safety, Team Communication 

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