Every day in the emergency department there comes a time when the emergency physician must hand off a patient's care to another physician, whether it's one of his emergency medicine colleagues or a resident, attending, or hospitalist. How that information is communicated has a direct effect on the patient's safety and his ultimate outcome.
The handoff has been scrutinized as a particularly error-prone part of care that can have dramatic consequences for patients. Fifty-nine percent of medical and surgical residents reported that one or more of their patients had been harmed as a result of inadequate handoffs in one study reported in the Joint Commission Journal of Quality and Patient Safety. (2008;34:563.) Handoffs in the emergency department occur between shifts, among physicians and nurses in a busy area where all personnel are overtaxed, and where there is little calm space in which to exchange information.
Two investigators recently reported on 110 handoffs from EP to EP involving 992 patients over an eight-week period in a busy urban emergency department. (Am J Emerg Med 2011;29:502.) The observers found that clinical or laboratory findings were reported differently in the verbal handoff from in the electronic medical record in 130 patients, and information was omitted in 447 patients. Brandon Maughan, MD, the lead investigator who researched the issue while a medical student at Case Western University School of Medicine, said the issue is basically one of communication.
“From a systems standpoint, the advance of medical informatics and electronic medical records means that most people do signout in front of a computer. The benefit of that is that you are re-examining the patients. Results you may have seen earlier have a new meaning. You may think, ‘I didn’t realize that particular blood chemistry reading was that low.' It may trigger consideration of something else,” said Dr. Maughan, now an emergency medicine resident at Brown University's Alpert School of Medicine in Providence, RI.
Julie Apker, PhD, an associate professor of communication at Western Michigan University in Kalamazoo, has long been interested in communication among doctors, how they discuss medical mistakes and convey information to patients and families. Handoffs are based on good communication, she said.
“I was surprised by some of the statistics that are available about the level of mistakes that can happen in the handoff process,” she said. The issues first came to light in the wake of changes in the hours of residents, changes that resulted in more handoffs. This was a context in which I could benefit organizations by approaching it from a communications perspective,” Dr. Apker said.
She worked with a health care team in 2007 that included emergency physicians, hospitalists, emergency nurses, and health systems engineering experts to study the dynamics of handoffs between emergency physicians and hospitalists. (Acad Emerg Med 2007;14:884.)
That study identified a handoff “gray zone” characterized by poor communication practices and conflicting expectations that result in “insufficient information, incomplete data, omissions, and faulty information flow.” The authors also noted that poor handoffs threaten the safety of boarded patients and other ED patients. “Handoff communication is a ‘two-way street’ that depends on the mutual engagement of EPs and non-ED physicians to be successful,” the authors concluded. “Doing so will increase physician ownership of organizational practices, and offer physicians the opportunity to discuss their expectations of interservice handoff communication.”
One thing that stood out was that the specialties had different approaches to care that could affect the way they communicated and impede the flow of information, Dr. Apker said. “The emergency physicians just wanted the headlines. They reported not having a need for all the information at once or a need for a lot of give and take. On the other end, the hospitalists said, ‘We are planning for the future. The more I know in the handoff, the more I can plan for the next several days on the service.’ They wanted more detail about the patient from the emergency department. We found that these different approaches influenced communication.”
In a second more recent report, Dr. Apker and her colleagues describe an instrument they developed to categorize and understand the conversation between physicians in the handoff. In a preliminary study to validate the instrument, she said they found linkages back to their previous work. (Ann Emerg Med 2010;55:161.) “Emergency physicians talked more,” Dr. Apker said. “They dominate the conversations. Hospitalists were more passive, and had little chance to pose questions, which was challenging to accomplish because of the rapid-fire delivery [of the emergency physician].”
That may change in the future because the Joint Commission's National Patient Safety Goals now require an opportunity for a physician to ask questions during the handoff. “Another piece I found interesting was that health care teams should use ‘read back’ or paraphrasing as in, ‘Here's what I understood you just told me.’ The third thing that struck me in our interview study was that the emergency physicians talked about not having a sense of closure in the situation. In many conversations, the emergency physician would tell the hospitalist about the patient and the hospitalist would not say, “I will take the patient or I will come down and look at the patient. The hospitalist would say, ‘What room?’”
The notion of a specific written or electronic instrument comes up in conversations about handoffs, but those have positive and negative elements. It might help people remember information they need to give the accepting physician, but it might be so rigid that it constrains the conversation. “It might become something about hitting the boxes rather than contributing information,” Dr. Apker said.
Derek Cheung, MD, an emergency physician practicing in Colorado, was part of the American College of Emergency Physicians Section of Quality Improvement & Patient Safety that considered the issue of improving handoffs. (Ann Emerg Med 2010;55:171.) That group proposed a method for developing handoff quality measures and practical strategies to improve the handoff process in the emergency department.
Dr. Cheung said he looks at the issue from a process perspective. “I see it through an operational efficiency lens, but I recognize the patient safety issue as well.” He is working on a new handoff study with a group of hospitalists and other experts.
“Internists and emergency physicians are wired differently, and have different pressure,” he said, and handoffs are often underappreciated in terms of their effect on safety and efficiency. “We were never taught about them, and they weren't talked about,” he said. “That has changed over the past few years, starting with National Patient Safety Goals and Graduate Medical Education requirements.”
Handoffs are complicated by emergency physicians' distaste for them. “You do it reluctantly,” he said, a feeling shared by the incoming emergency physician who doesn't like taking responsibility for care already in progress. Other major barriers for handoffs include the lack of modeling for proper handoff behavior, meaning it is sometimes haphazard. The ED's distractions and the lack of a natural gap between shifts impede proper handoffs, too, Dr. Cheung said. “In our paper, we proposed that hospitals ought to have a gap so the oncoming physician doesn't have to start sprinting as soon as he or she gets there.”
Handoff training in medical school and the resident curriculum will be important moving the bar in handoffs, he said. Some sort of tool — electronic or written — would help, but he and his group are not sure what form it should take. “You can't just say it's important and expect things to change,” said Dr. Cheung.
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Fatigue and Medical Errors by EMS
Higher rates of injuries, medical errors, and safety-comprising behaviors are related to fatigue and poor sleep quality among EMS workers, according to a study by the University of Pittsburgh. (Prehosp Emerg Care 2012;16:86.)
“Emergency medical technicians and paramedics work long hours in a demanding occupation with an unpredictable workload, which can easily lead to fatigue and poor sleep,” said lead author P. Daniel Patterson, PhD, EMT-B, an assistant professor of emergency medicine at the University of Pittsburgh School of Medicine. “Our study shows how this may jeopardize patient and provider safety in the EMS setting.”
Dr. Patterson and his colleagues received complete data from 511 respondents. They used the Pittsburgh Sleep Quality Index to evaluate sleep quality and an adapted questionnaire to measure fatigue in the EMS environment. A 44-item survey elicited self-reported safety outcome data.
More than half of the respondents were classified as fatigued. Eighteen percent reported an injury, 41 percent reported a medical error or adverse event, and 90 percent reported a safety-compromising behavior.
Researchers found the odds of injury were 1.9 times greater for fatigued respondents than non-fatigued EMS workers, the odds of medical errors or adverse events were 2.2 times greater, and the odds of safety-compromising behavior were 3.6 times greater.
Respondents reported working between six to 15 shifts per month, and half reported regular shift lengths of 24 hours.