ED especially vulnerable to temp risks, doctor says

The emergency department (ED) is perhaps the worst hospital unit in which to have strangers working together, says Dan Sullivan, MD, FACEP, JD, president and CEO of The Sullivan Group, a risk and safety consulting group in Oakbrook Terrace, IL, and an associate professor of emergency medicine at Cook County Hospital/Rush Medical College in Chicago.

Twenty years ago, an emergency physician was likely to know everyone working in an ED, which were smaller because the patient volume was much less, he says.

"You knew their routines, their subroutines, and the spirit of teamwork was tremendous. You knew who you could rely on and not rely on," Sullivan says. "Now I work with hundreds of emergency departments around the country, and every single department has PAs, NPs, other physician extenders, and almost every one has temporary staff. I do believe that the temporary people are high quality individuals, but that does not make us immune to the risks of someone who is new to the department."

Although the risks might be most acute in the ED, temp staff pose potential problems in any part of healthcare, says Ron Calhoun, managing director for Aon Risk Solutions in Charlotte, NC. "It's a foregone conclusion that pressure on the healthcare delivery system, in the ED and beyond, will only increase if mandated coverage kicks in in 2014, given the shortage of primary care physicians," Calhoun says. "The use of nurse practitioners, PAs, and other physician extenders is going to increase, and the consequence of that will be realized most in the ED."

The actual skills of the temporary staff, or lack thereof, are not what increases the risk, Calhoun says. The threat to patient safety and liability comes more from the temporary staff's "systemic unfamiliarity" with the local care management systems, protocols, and procedures. Errors are more closely related to the systems in place rather than the temporary individual's skill level, he says.

"Communication errors are the most insidious. The credentialing of temporary staff tends to be pretty good, but they are dropped into a local environment where communication protocols are already in place," he notes. "I don't care how good the individual is, if they come into a system that has an established communication protocol, both formal and informal, they are at a disadvantage."

Temps often are responsible for their own continuing medical education (CME), which might be out of sync with the local provider's efforts, Calhoun notes. This situation leaves the temp without education on topics that are of special focus for everyone else at the institution, he says. Working with temps who use a CME platform common to your institution or health system can help, he says.

Another potential problem is hiring temps for the ED from other specialties, Calhoun and Sullivan say. When staffing is difficult, there can be a temptation to fill an ED position with someone who — while highly skilled and credentialed in intensive care, for instance, or another field — is not an emergency specialist. "I don't think enough attention is given to that problem," Calhoun says. "It can be highly impactful in these scenarios."

Clinical decision support and clinical assessment are key protections when using temporary staff, Calhoun says. There must be a system in place to provide immediate feedback for the temporary employee from the system level and the individual physician level, he says. Sullivan agrees, and he says that education and orientation to the local systems are critical. "Those systems are critical for bridging this gap as you bring in temporary staff to a local emergency environment," he says.

Individual temps might come and go, but the use of temps is here to stay, Sullivan says. That means healthcare providers might need to adjust their own policies and procedures to make them as homogenous as possible on an industrywide basis. When you could count on your staff being long term, it was easier to justify having your own way of doing things, Sullivan explains. But with more temps, providers might have to seek uniformity so that the temp doesn't have to learn a new procedure at each facility, he says.

"That may not sound like the ideal strategy, bending to the need of the temps, but it works in your favor," Sullivan says. "If you're seeking improved patient safety and outcomes, it is to your advantage to have the temp merge into your systems as easily as possible. If your system is the same as the one the temp used across the country last month, everybody wins."


• Ron Calhoun, Managing Director, Aon Risk Solutions, Charlotte, NC. Telephone: (704) 343-4128. E-mail: Ron.calhoun@aon.com.

• Dan Sullivan, MD, FACEP, JD, President and CEO, The Sullivan Group, Oakbrook Terrace, IL. Telephone: (630) 268-1188. Web: www.thesullivangroup.com.