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ED Handoffs: Patient Safety at Stake in Transition from ED to Inpatient
By N. Beth Dorsey, RN, Esq., and Timothy A. Litzenburg, Esq., Hancock, Daniel, Johnson & Nagle, PC, Richmond, VA.
The practice of emergency medicine is unique in that an emergency medicine physician acts as a gatekeeper: while treatment of a patient may be brief, initial examination and assessment will often dictate the course of the patient's treatment after admission to the hospital. Thorough, efficient communication between the emergency department (ED) and the hospital floor is essential to continuity and quality of care. This article addresses handoff pitfalls, pertinent law, case studies, and ideas for improvement.
Nature of Admission Handoff
"Handoff" or "handover" refers to transition of care, when control of, or responsibility for, a patient passes from one health care professional to another. Handoff occurs at many stages in the hospitalization of a patient. In the ED setting, the main transition episodes are presentation to the ED (particularly if by emergency transport), shift changes within the ED, and admission to inpatient care. This article focuses on handoffs at the time of hospital admission.
Historically, there has been a dearth of research and literature on the subject of handoffs. In recent years, however, interest in the subject has increased significantly. In 2006, the Joint Commission named as one of its National Patient Safety Goals "Implement a standardized approach to 'hand off' communications, including an opportunity to ask and respond to questions."1 The World Health Organization also launched its "Action on Patient Safety: High 5s" initiative, naming "communication during patient care handovers" as one of the five pillars.2 Indeed, patient safety is always at stake during a handoff, and it is crucial that no information be lost during the transfer.
The ED-physician-to-admitting-physician handoff presents unique challenges in that, as opposed to shift or location changes, it is a cross-specialty transfer. Due to the nature of shift changes in the ED, there is more of an established procedure for handoffs to the oncoming physician. Admission handoffs represent a change in three different domains: provider, department, and physical location.3
In general, the handoff process begins with the emergency physician's assessment of the patient's stability and acuity. Following that, the emergency physician will contact an admitting physician. At this point, it is important that a core of information passes between the physicians, whether by phone or in person. This includes, at a minimum: chief complaint, past medical history, history and physical, reason for admission, any abnormal findings, lab and radiology results, the course of treatment in the ED, and whether or not the patient is stable.4
Errors in ED-to-hospital handoffs can result in dire, but preventable consequences. Failure to timely and accurately pass on important information can lead to a delay in diagnosis or treatment, or worse. There are societal dangers as well, with handoff fumbles leading to higher healthcare costs, public dissatisfaction, longer hospital stays, and a higher rate of return visits. In one study, 29% of physicians reported that one of their patients had experienced an adverse event or a "near miss" because of inadequate communication between the ED and admitting physician.5
A situation which often leads to handoff problems is the practice of "boarding," or keeping a patient physically in the ED after he has been technically admitted to the hospital as an inpatient. This scenario arises when a hospital experiences a temporary bed shortage. The emergency physician has signed out the patient, and while he still bears some responsibility for the patient, often mentally "moves on," and considers the patient's care to be the admitting physician's responsibility. Particularly in a case where an admission is done over the phone, a patient who is being "boarded" can have a significant and dangerous gap in treatment simply because each physician thinks the other one is handling patient care.
Problems in handoff communication do not always originate with the physician making the handoff. When there is imperfect communication between the patient and the initial emergency room physician or between emergency physicians at a shift change, this will often carry forward past admission, contributing to errors in diagnosis, treatment and disposition.6
One key area rife with problems is lab results. Often, results of lab draws taken in the ED are returned after the patient has been admitted to the floor. If the results come back to the ED instead of being sent to the floor or the admitting physician, they may not make it into the hands of the doctor who is currently treating the patient. If it is unclear after a transition which physician is to follow up on certain studies, there is a danger that no physician will follow up. One study found that in one of six cases of missed diagnoses, test results had failed to reach the proper clinician.7
As an ED becomes busier, the attentions of the health care professionals become, by definition, more divided. When the provider responsible for signing a patient out is carrying a heavy workload, this inevitably can lead to faulty transitions. Not surprisingly, the likelihood of omission of information is higher when the handoff is rushed. Likewise, an ED physician caring for a great number of patients may be operating based on, and reporting, information that is not current at the time of handoff.8
Another less concrete area in which handoff problems originate is physician bias. Some doctors see their specialty as superior to others, or are dismissive of another doctor's opinions or recommendations. Bias can create holes in the handoff, as the receiving physician practices selective listening. For example, an internist may not trust the ED staff's ability or judgment. Similarly, there can be a dogmatic divide of responsibilities. Some internists expect that emergency physicians will produce definitive diagnoses and provide complete treatment, while some emergency physicians think that their role is to stabilize and dispose of the patient.9
Finally, technology can also complicate matters related to the handoff. Medical record format is often the partial culprit in improper information exchanges. As hospitals move toward electronic records, part of the record is often electronic and part is still paper. When a receiving physician sees only one or the other, he can make treatment decisions based on an incomplete picture. Furthermore, reliance on electronic records tends to reduce the "cognitive load" of physicians, making quick recall more difficult.10
At first glance, the requirements of EMTALA appear to end once a patient has been admitted to the ED and stabilized.11 If, however, the patient cannot be "stabilized" in the ED, EMTALA may require admission. In a 2009 federal decision, the 6th Circuit Court of Appeals ruled that there is a continuing obligation for a hospital to treat a patient after admission, for however long until "no material deterioration of the condition is likely" upon the patient's release.12 Depending on a patient's condition, EMTALA may require an ED physician to not only treat a patient, but to effect a handoff to an admitting physician. However, it is the position of the Centers for Medicare and Medicaid Studies that a "boarded" patient is outside of the scope of EMTALA.13
State laws require physicians to comply with the standard of care, which is generally defined as what a reasonably prudent physician would do in like or similar circumstances. Poor handoffs are specifically implicated in 24% of malpractice claims involving the ED.14
In a 2006 Texas case, a patient presented to the ED with abdominal pain. The ED physician made a diagnosis of pancreatitis and recommended admission, which was done by an internist over the phone. The patient, however, remained "boarded" in the ED, waiting for a bed. No ED physician evaluated the patient after 2:00 pm, and the internist never saw him. Around 8:00 pm a code was called, and the patient died after resuscitative efforts failed. In this case the internist was sued, and the jury awarded the plaintiff $1.2 million.15 While it was the admitting physician who was found liable, the problem likely occurred because there was no clear delineation of responsibility at the handoff point. Had the two physicians agreed who was to monitor the patient while he was boarded, his pancreatitis likely would not have resulted in death.
In a 2006 Maryland case, a patient presented to the ED with nausea, vomiting, and a bump on the head oozing pus. The initial ED physician ordered x-rays and blood work. The lab results were returned on the next shift, showing WBC 15,300 and creatinine 1.6. The x-rays, also read during the next shift, showed two cavities in the lungs. The ED physician telephoned the on-call internist, who admitted the patient to the floor over the phone with a diagnosis of pneumonia and gastroenteritis. The patient, however, was "boarded" in the ED. Following that call, further lab reports came to the ED showing bandemia (45%) and blood in the urine. The ED physician did not report these to the internist. For over six hours no physician saw the patient. The ED doctor testified that the patient was no longer his responsibility. When a night resident examined the patient, he was septic, with renal failure. The patient continued to deteriorate and died. The case resulted in multiple settlements (including by the emergency physician who performed the handoff) and a verdict of $2.9 million.16 The ED physician should have passed on the test results he received after admission, and he should have agreed on a plan with the internist as to who would care for the patient while he waited for a bed.
In a 2008 Pennsylvania case, a patient presented to the ED with cyanosis, bloody diarrhea, rapid breathing, hypertension and tachycardia. The ED physician called a critical care doctor for a consult, and ordered one liter of IV fluid. Thereafter, no physician saw the patient for an hour and a half, during which the patient was left in a hallway. She died shortly thereafter. Both the critical care physician and the emergency room physician insisted they were relying on the other to care for the patient. A jury returned a verdict against both doctors for $1.2 million.17 While this was not technically an admission case, it is analogous to the admission handoff. The death was caused by a failure of the two physicians to communicate about whom was responsible for the care and treatment of the patient.
Ideas for Improvement
Given the various difficulties mentioned in the preceding section, it is important to take preventative measures and to establish practices and protocols pertaining to handoffs. Many suggestions for establishing protocol offered in the literature have their basis in other industries, and health care presents a situation where every interaction is going to be different. Applying assembly-line efficiency to handover procedure should be done with care.18
Therefore, any discussion of improvements in the handoff process is by necessity limited to generalities. Obviously, optimizing communication is paramount. Most proposals involve greater standardization of the handoff process. There should be a minimum set of essential data to be passed on in each circumstance, agreed upon by the outset by physicians on both sides of the exchange.19
In addition to the medical information to be shared, the physicians need to agree upfront on who is to follow up on test results. This will prevent the situation where each physician assumes the other will follow up. This is particularly important in academic hospitals, where several interns and residents are likely to see the patient. There is often, of course, a third physician involved. The pathologist or radiologist must also develop a fail-safe method of making sure that results make their way to the correct clinician.20
Furthermore, a precise and distinct point of transition should be established. The more ambiguous the shifting of responsibility, the greater chance there is of an adverse outcome. At every point in the patient's care, all physicians involved should be clear on who is responsible for the patient. To the fullest extent possible, phased handovers, in situations like boarding, should be eliminated.21
Patients should themselves be used as a sort of fail-safe. The more information to which the patient is privy, the less likely that information will get lost during transition. This can be accomplished by conducting the handoff at the patient's bedside. This will also allow the patient to have some input, and it gives the receiving physician an opportunity to directly examine the patient at the point of transition. The downside to this plan is that it may curtail access to computerized records or to the whiteboard. Therefore, it is important for the ED physician to bring and use parts of the record as "visual aids" in the handoff.22
Improving hospital-wide patient flow, while not under the control of the ED physician, will certainly help to diminish the likelihood of handoff errors. Reducing crowding in the emergency room will allow the physicians to more carefully treat, and less crowding on the floor makes it unlikely that ED physicians will have to "board" patients who have already been admitted. Hospitals should also work to standardize medical records and make sure that every part of the record and all diagnostic studies can be stored and retrieved electronically.23
As illustrated by the legal cases above, communicating a clear division of responsibility, as well as other information, as part of patient handoff can prevent tragedy and costly malpractice litigation. ED physicians should communicate all vital information but also clearly delineate responsibility and plan for information exchange after the moment of transfer. These simple steps can prevent adverse consequences and improve patient care.