Identifying emergency physicians’ strategies for mitigating workload transfers during end of shift patient handoffs – A qualitative analysis

• Patient handoffs in emergency departments contribute excess cognitive load to EPs. • EPs are flexible, adapting their handoff procedures to minimize load transfers. • The state of patients’ disposition is the most-relevant information in a handoff. • The state of patient disposition is a potential measure of EP cognitive load. In hospital emergency departments (EDs), emergency physicians (EPs) regularly handoff patients to one another at shift changes. While previous studies have focused on standardizing communication practices during handoffs, these efforts do not address how handoffs contribute to transfers of excess workload for EPs, nor the strategies utilized by EPs to mitigate such workload transfers. Forty-four observations were conducted at a large referral hospital and Level 1 trauma center. Observations of EPs’ workstations were conducted during 4-hour intervals centered on end of shift patient handoffs. Following observations, interviews were conducted with 12 attending EPs pertaining to the structuring of information during handoffs, strategies used to prepare for handoffs, interpersonal and environmental considerations that may affect handoffs, and any workflow adaptations that occur due to such considerations. Interview data were analyzed using qualitative coding and subsequent thematic analysis. Findings from this study revealed four thematic categories: traditional sign-out workflows, importance of the state of patient disposition, adaptive strategies for mitigating workload transfers, and EP motivations and obligations regarding sign-outs. Ultimately, the adaptive workflows and mitigation strategies utilized by EPs during end of shift patient handoffs demonstrate their ability to adapt and effectively reduce the amount of cognitive workload transferred during handoffs.