Change of shift high-risk for ED patients

Communication lapses can cause adverse outcomes

Both nurses and physicians are at high risk for communication lapses during change of shift, says Francis L. Counselman, MD, chairman and program director for the department of emergency medicine at Eastern Virginia Medical School. The departing physician often is anxious to leave and does not have the same degree of vigilance for that last patient of the day, he explains. As a result, all of the necessary information may not be communicated to the physician taking over the patient. "The arriving physician often never examines the patient, or does not really consider the patient 'theirs,'" he says. "There is often no sense of 'ownership' of the patient for the physician coming on."

Similarly, orders at the very end of a nurse's shift may not get done, yet the nurse coming on may assume they have been done. "The bottom line is that the order is not performed," says Counselman. "Another scenario is a compulsive nurse completes all of the orders on her patient such as hanging medications, but forgets to document these actions." The nurse coming on does not think the medication has been given and administers it, so the patient receives two doses.

The absolute worst scenario is when both physicians and nurses change shift at the same time, says Counselman. "There is then no caregiver who has a full understanding of the patient."

Improve communication

Information related to patient plan of care, diagnosis, and suspected complications is essential to safecare delivery, says Pamela S. Rowse-Schmidt, RN, quality/risk consultant and former ED manager at St. Rose Dominican Hospitals-Rose de Lima Campus in Henderson, NV.

Rowse-Schmidt gives a hypothetical example of a patient admitted from the ED as a rule-out acute coronary syndrome, with the first troponin level coming back negative. The patient is held for an admission to a medical/telemetry bed. While the patient is still in the ED, the next troponin level comes back critically elevated. "If it's a different shift, who communicated that very valuable information to the current caregiver? Probably no one," says Rowse-Schmidt.

After being admitted to the medical/telemetry bed, the patient's condition deteriorates and it becomes clear that patient is having an evolving myocardial infarction. As a result, the patient is transferred to the ICU in an emergent condition.

The delay in admitting to the appropriate level of care, based on the critical lab value, has the potential for resulting in additional myocardial damage and ultimately extending the patient's length of stay, as well as resulting in a further diminished cardiac functioning. "In this case, delay in identifying a potentially life threatening event could result in death," she says.

Particularly if the patient died, or suffered long-term affects from the event, the family would have a case for litigation, says Rowse-Schmidt.

Here are risk reduction strategies for change of shift:

  • Have the oncoming physician sign the chart of all patients being turned over to them. "This will often have the effect of making the oncoming physician more diligent in following up on results and rechecking the patient," says Counselman. "The patient is now 'theirs' without question."
  • Have the oncoming physician examine all patients turned over to them, except for the most benign cases such as those waiting for a single, simple laboratory test, and write a brief note on their chart. "This gives the oncoming physician the opportunity to form their own impression of the patient, and also allows the patient to know who their doctor is in case they have questions," says Counselman.

This is much better than having a patient who has been in the ED for several hours and wants to talk to their physician to be told "your doctor has gone home," he says.

At George Washington University Hospital in Washington, DC, change of shift is viewed as "an opportunity rather than a risk," says Robert Shesser, MD, professor and chair of the department of emergency medicine. The physician leaving reviews all patients with the second physician who is coming on shift who asks the "hard" questions. "They generally ask the physician to explain any lab abnormalities that are already identified, what labs or X-rays have been sent and have not yet returned, and what the plan would be depending on what is found," he says.

Make every effort to have physician and nurse shift changes occur at different times, not the same time.

Schedule the physician going off service one additional paid hour to stay in the ED and help with the transition. "We also schedule our senior resident shifts to overlap the attending shifts so there is some continuity of care for the critical patients," says Shesser.

Some EDs have a culture of not signing out patients, which means that a physician going off service stops seeing new patients some amount of time before shift change. "Our culture has always been to see new patients right up until the last minute and feel free to check them out," says Shesser. The new physician always goes to see patients who have been checked out to them, so the patient gets two evaluations versus one. "I think over time, we have caught more problems with this approach than had things slip between the cracks because there was checkout," says Shesser.

Use an electronic medical record (EMR). Since an EMR is used at George Washington University's ED, there is very little chance of any key information getting lost, because the record is the repository for all information developed during the previous shift. "All lab and X-ray data are in one place and color coded according to whether it is normal or abnormal," says Shesser.