What are the biggest risks involving ED handoffs?
What are the biggest risks involving ED handoffs?
The electrocardiogram (ECG) and X-ray of a chest pain patient in his mid-50s were both normal when examined by the treating ED physician. However, the physician's shift ended before the patient's lab results were back. Based on the test results that were back, the oncoming ED physician discharged the patient as "chest pain, non-cardiac." Several hours later, the lab results came back with critical values.
"At that time, the patient was just arriving at another hospital and was pronounced dead from a heart attack," says Stephen A. Frew, JD, vice president and risk consultant with Johnson Insurance Services, a Madison, WI-based company specializing in risk management for health care professionals. The discharging ED physician and the original hospital were cited for violations of the Emergency Medical Treatment and Labor Act (EMTALA), for discharging the patient without completing necessary testing and inadequate medical screening.
In another "handoff" lawsuit, a 38-year-old man with extreme, radiating pain in his back was evaluated by an ED physician who found no neurological involvement and diagnosed back pain. The patient was discharged with pain medications and instructions to apply ice. Before he left the hospital, the plaintiff screamed out in pain, said that he could no longer feel his legs, and said he had lost bladder control.
The ED nurses alerted the ED physician, who had just come on duty. "The new physician reviewed the first physician's notes, agreed with her assessment, and refused to see the plaintiff," says Frew. The patient went to another hospital where he was diagnosed with cauda equina syndrome and had back surgery. He was left with permanent bowel and bladder incontinence. The emergency physician and surgeon settled the malpractice claims prior to trial. The jury found $2.7 million in damages and apportioned 7% liability to nursing actions.
A dangerous time
In the ED, the patient handoff at change of shift is "one of the most dangerous times for a patient," according to Wayne Guerra, MD, MBA, vice president of Serio Physician Management, a Littleton, CO-based company that provides management services to hospital-based physicians and hospitals. "The normal vigilance of the physician assuming care is relaxed, since the patient has already been evaluated by another doctor," says Guerra.
The new provider, whether it be the oncoming ED physician, an admitting physician, or a consultant, must be aware of the pertinent aspects of the patient's history, exam, and results to ensure appropriate decision-making, according to Mary A. Cayley, MD, JD, a medicolegal fellow at Orlando (FL) Regional Medical Center and a member of the American College of Emergency Physician's medical-legal committee.
"Communication takes two forms: the verbal sign-out and the ED chart," she says. "No patient encounter or sign-out is complete until the documentation is finished. As much as possible, the ED chart should be complete before leaving at the end of a shift."
Cayley says the below items are particularly critical to note in a handoff situation:
- abnormal physical findings of concern;
- all results of labs and studies that are complete, including a comparison to an old ECG, if available;
- labs and studies that are ordered and pending;
- a progress note on the patient, including improvement of pain and normalization of abnormal vital signs;
- time of any information communicated to a consultant;
- the result of any conversation with a consultant.
"While most handoffs go exactly according to plan, we've all had situations where something unexpected arises," says Cayley. "It is impossible to cover every contingency in verbal sign-out. By ensuring that your handoff charts are appropriately documented, you will give your successor the best possible chance to have the information he or she needs quickly to get up to speed on what you have done for the patient."
Beware of these high-risk scenarios
Guerra says a particularly high-risk time is when the disposition of the patient has not yet been determined and is awaiting the result of an outstanding test. For example, the patient has had an abdominal CT scan that has not been read, and the result will determine if the patient goes home, needs a surgical consult, or needs further testing and admission.
Andrew Garlisi, MD, MPH, MBA, medical director for Geauga County EMS and co-director of University Hospitals Geauga Medical Center's Chest Pain Center in Chardon, OH, says these are all high-risk scenarios during change of shift:
- any critically ill patient or unstable patient;
- any patient requiring invasive procedures;
- patients considering signing out against medical advice;
- patients who are boarded in the ED and signed over;
- complex medical/surgical patients managed for several hours by an unsupervised physician's assistant (PA). "The incoming attending physician who must now cosign the chart and become the 'attending of record,' is now responsible for the work-up, or lack thereof, performed by the PA," says Garlisi.
For complex patients managed by a PA, Garlisi says that the day shift attending should sign off on the chart, and never hand off any unstable patients. "The physician initiating the management of a critical or unstable patient should finish the case," he says.
A lack of ownership
Pete Steckl, MD, FACEP, director of risk management for Emerginet, an Atlanta-based emergency medicine management group, says the oncoming ED physician may fail to take ownership of the patient and instead, merely checks pending studies without re-examining the patient. "This is especially critical in more complex patients with potentially dynamic processes such as abdominal pain, chest pain, transient ischemic attack [TIA], and stroke," says Steckl. "These are cases where negative [ECGs] and negative CTs of the head or abdomen don't necessarily indicate lack of pathology."
Risk is compounded by an accompanying failure to document re-examinations or final results of studies, which is a common oversight, or to cosign the chart, making it unclear who is making disposition decisions, says Steckl.
At the time of admission, there is often no documentation as to when information was exchanged with admitting doctors. "When suits get filed, it frequently becomes a question of who knew what and when," says Steckl. "I always advise our physicians and practitioners to document timing of discussions with admitting doctors, any abnormalities in vital signs, and clinical findings or labs relayed at the time of admission."
Document when the admitting doctor agrees to see the patient, especially an unstable patient, after admission. "This, in my experience, is hardly ever done," Steckl says.
Some likely lawsuits
"ED physicians are at greatest risk for a malpractice lawsuit when they fail to diagnose a patient," says Guerra. "In the patient handoff situation, failure to diagnose most often occurs when the patient's clinical condition has changed and the physician assuming care for the patient fails to recognize this change."
This failure is more likely when the physician assuming care for the patient does not re-evaluate and examine the patient before making a final disposition, says Guerra. To reduce risks, use a formal, standardized process; avoid all interruptions; and introduce the new physician to the patient.
"At a minimum, the exiting doctor should inform the patient her shift is over, and let the patient know the name of the physician assuming care," says Guerra. "Informing the patient he or she has a new doctor demonstrates respect. It prevents the feeling of abandonment that can occur in these situations."
For more information, contact:
- Stephen A. Frew, JD, Vice President, Risk Consultant, Johnson Insurance Services, Madison, WI. Telephone: (608) 245-6560. Fax: (608) 245-6585. Email: [email protected].
- Andrew Garlisi, MD, MPH, MBA, University Hospitals Geauga Medical Center, Chardon, OH. Phone: (330) 656-9304. Fax: (330) 656-5901. E-mail: [email protected].
- Wayne Guerra, MD, MBA, Vice President, Senior Physician Management, Littleton, CO. Phone: (303) 759-0854. E-mail: [email protected].
- Pete Steckl, MD, FACEP, Director of Risk Management, Emerginet, Atlanta. Phone: (770) 994-9326.
Some handoff issues raise risk for malpractice suits
Stephen A. Frew, JD, vice president and risk consultant with Johnson Insurance Services, a Madison, WI-based company specializing in risk management for health care professionals, says shift changes or "handoffs" in care often are associated with malpractice claims, typically for these three reasons:
1. An interruption in the flow of information from the initial provider to the new provider results in a delay, or sometimes loss of the information entirely.
"Typically, this involves test results or verbal information that is not communicated effectively," says Frew. "Cases often involve an important lab result that came back at shift change that neither physician saw or appreciated."
In this scenario, the newly responsible physician is almost always the one to whom the liability risk falls. "So, it behooves the oncoming physician to be relentless in seeking out any possible test results that might be overlooked," says Frew.
2. Anecdotal information from the EMS crew is lost with a provider change.
Important information, such as loss of consciousness for several minutes at the scene, isn't communicated verbally to the oncoming team by the original staff. EMS has left the ED, and the EMS record is not readily available in the chart.
"That leaves the new physician with a potentially dangerous lack of information," says Frew. "I generally recommend that EMS records be immediately available to the ED physician. Then, EMS and triage notes should be reviewed in detail by the ED physician to avoid being tripped up by data in 'someone else's' portion of the chart."
3. During change of shift, off-going physicians just want to wrap up their cases and leave, while on-coming physicians often are tempted to clear out the carry-over cases as quickly as possible and deal with "their own" patients.
"This somewhat common preference to be rid of the 'leftovers,' and the fact that it is sometimes hard to go back to the beginning to put yourself into the same view as the original physician, can be a recipe for problems," says Frew.
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