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Does your staff provide conflicting, inadequate info to receiving units?
Don't miss important facts during handoffs
If you forget to tell an inpatient nurse that your ED patient has an allergy or was given a certain medication, the consequences could be dire.
"Any patient can have a death associated with a handoff," says Sommer Alexander, MS, senior quality consultant at Fairview Health Services in Minneapolis, which participated in a handoff collaborative led by The Joint Commission's Center for Transforming Healthcare.
Four handoffs would occur when a child was admitted from the ED, which took 40 minutes, says Alexander. The ED nurse called the inpatient nurse, an ED doctor called an inpatient attending, that same ED doctor called an inpatient resident, and those two inpatient physicians then would discuss the patient.
"We found that different information was being given to each of those people," says Alexander. "Everyone had heard something slightly different, and no one knew what the other people on their team knew. This put our patients at risk, because everyone had a different clinical picture for that patient."
Report is now given during a conference call, says Alexander, with the ED nurse, physician, inpatient nurse, and inpatient physician all on the call together. "Instead of having all those disjointed phone calls, we have one call," she explains.
It is sometimes a challenge, though, to get all the participants on the conference call at the same time, says Anne Renaker, RN, DNP, CNS-BC, the ED pediatric clinical nurse specialist at University of Minnesota Amplatz Children's Hospital in Minneapolis. If the receiving nurse wasn't available to be on the call, the unit charge nurse would receive report instead, Renaker explains. "If there were additional questions, the receiving nurse would then call back, and the ED nurse would repeat a similar report," she says.
When a call was arranged, the page went out to the ED charge nurse, who was carrying the pager, says Renaker. "This was not a consistent practice, and some pages were missed," she says. A change was made to have the pediatric ED nurse carry the pager instead, because it saved time to connect directly with the nurse caring for the patient, she says.
The new process means that everyone hears the information at the same time, with the opportunity to ask questions, says Renaker. "The old method was multiple phone calls between several individuals, and the story was never shared," she says. "Once the one phone call is complete, the patient is ready to go to the inpatient unit. The outcome is a safe and efficient handoff."
With the old process, ED nurses didn't always convey important clinical information to the rest of the health care team, such as a patient becoming increasingly agitated, says Renaker. To address this problem, a standardized list was created that the ED nurse follows as he or she begins the handoff, she says. The list covers the patient's name; date of birth; diagnosis; history; relevant past medical, surgical, and social history; medications; allergies; ED interventions; and the plan of care.
"Secret shoppers" were used to observe the handoff process, and they found that key information sometimes was being overlooked, says Hallie Rector, RN, an ED manager at LDS Hospital in Salt Lake City, which also participated in the handoff initiative.
A standardized format was developed for ED nurses to give report. "This way, we are sure that we are hitting all of the critical things we need to be communicating to whoever we are handing off our patients to," Rector says.
Inpatient nurses taking the report use the same format, so that if a piece of information is missed, it's noticed by both nurses immediately, she says.
Initially, the new process was a little more time-consuming on both ends, acknowledges Rector. "But our ED nurses have found they are communicating vital information more consistently," she says.
For more information on ED handoffs of admitted patients, contact:
Tell inpatient nurses what wasn't done in ED
If a medication or intervention was ordered in the ED for your admitted patient, but not yet given or completed, be sure to inform the receiving inpatient nurse, says Anne Renaker, RN, DNP, CNS-BC, the ED pediatric clinical nurse specialist at University of Minnesota Amplatz Children's Hospital in Minneapolis.
The patient may have been given one dose of an antibiotic in the ED, but the second dose has not yet been given, says Renaker, or a patient may have not yet had an ordered urine specimen or stool sample collected.
"In our current world, we transfer a patient from a department that is on paper to a department that is on an electronic medical record," explains Renaker. "The receiving nurse is not as likely to see an incomplete order on the paper form."