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Both emergency and inpatient physicians agree that miscommunication during interunit handoffs can compromise patient care and that sequential handoffs are particularly problematic, according to a new study conducted at the University of Nebraska Medical Center (UNMC) in Omaha, NE. The study highlights physician survey data showing that there is mistrust between inpatient and emergency physicians, and that which provider is responsible for patient care can be unclear when a verbal handoff is made. To make improvements, UNMC has been piloting a tool aimed at standardizing verbal and written handoff communications.
Both emergency and inpatient providers understand that key bits of information can easily be missed or miscommunicated when a patient is passed from one setting to another, and that such interunit handoffs are often the source of problems that can affect patient care. However, devising a solution to this problem requires a full understanding of the issues and challenges that exist for each side. That’s why Christopher Smith, MD, an assistant professor of internal medicine and an admitting physician at the University of Nebraska Medical Center (UNMC) in Omaha, NE, and a few of his colleagues decided to query 32 providers from the ED and 94 physicians from five inpatient medical services that account for roughly two-thirds of the hospital’s admissions.
“We all have a lot of incidents where we have near-misses or patient care isn’t as optimized as it should be because sometimes that communication breaks down,” Smith notes. “We wanted, on an institutional level, to get more of a sense of where there might be barriers to effective handoffs for patients being admitted from the ED.”
Smith found that nearly a third of all the participating physicians reported having handoff-related adverse events, and most put the blame on ineffective communication. There was also evidence of distrust between the emergency and inpatient physicians and a general lack of confidence in the handoff process. However, the exercise did provide researchers with a roadmap to follow in devising improvements, and the lessons learned are certainly applicable to other medical centers, many of which grapple with the same sort of interunit communications challenges.1
In the survey, both the emergency and inpatient physicians seemed to agree that sequential handoffs were a problem area. More than three-quarters of the participating physicians said sequential handoffs negatively impact patient care. However, Smith acknowledges that while all of the different admitting services have their own processes and procedures for how to handle admissions from the ED, sequential handoff processes are pretty well ingrained on the admitting side.
“In my service line for academic internal medicine we have a central-ized triage pager, so we have one pager that all admissions go through,” he explains. “At any given time we have multiple teams that may be admitting patients, so the job of the physician on the triage pager is to get the necessary information from the emergency medicine physician, and then distribute the patients accordingly to the different services that are admitting that day.”
How can this be a problem? Because every time the information is passed from one physician to another, there is an opportunity to miss or miscommunicate a key aspect of the patient’s information.
“You can make the argument that if [someone] is spending most of their time being the triage officer that they develop a skill set in doing that, so maybe there is an advantage in having this sort of triage specialist,” Smith notes. “But that really has to be weighed versus the potential for that information to be degraded as it gets passed forward to other providers.”
On the emergency side, sequential handoffs come into play when there is a shift change and a new physician needs to take over the care of a patient. Also, in academic medical centers like UNMC, Smith observes that sequential handoffs can also occur when an emergency physician calls on senior staff or a senior resident, for example, to take care of a patient, and that physician then refers the case to a more junior person. At any point in the chain, information can be lost or miscommunicated, Smith observes.
The survey also highlighted a significant divide between the two physician groups, with 94% of the emergency physicians reporting that they had to defend their clinical decisions at least some of the time. The admitting physicians largely validated this concern, with more than 25% noting that they usually disagree with decisions made in the ED.
There are many potential explanations for this distrust between the two groups, but Smith acknowledges that it is a concern.
“Certainly there are cultural differences between different disciplines. We go through different training and we sometimes have different expectations for each other,” he says. “An emergency physician may look at his [or her] role in a patient’s care as being different than I do, and if you have disagreement with those expectations, that can lead to conflict. And it is definitely problematic when your physicians or any members of the healthcare team are not having an optimal relationship because that can have real impact on how well we communicate, and subsequently, on how we work in teams to take good care of patients.”
Given the level of distrust that was evident from the survey, Smith thought that any successful intervention to improve the handoff process would need to be a collaborative effort between the emergency physicians and the admitting providers. He aimed for a standardized form of communication that would be acceptable to both sides.
Chad Branecki, MD, an assistant professor and associate residency program director for emergency medicine at UNMC, observes that one of his chief goals for this process was to devise a handoff tool that would clearly signify when the admitting physician is assuming responsibility for a patient who is being handed off from the ED.
“There has never been any documented process or time from the point when the ED physician makes a consult [to when] … that care is officially turned over,” he says.
As a result, which physician is actually responsible for a patient’s care is not always clear, and there can be duplicate orders as well as other problems.
“This has been going on for years,” Branecki notes. “We wanted to improve the handoff process by going through a very streamlined phone conversation [covering] what are the risks to this patient, what is the clinical certainty on the diagnosis, and [the fact that] we can we go ahead and turn over care now by putting in a bed request that signifies that [the admitting] team is now responsible for this patient.”
Additionally, as the associate residency program director, Branecki wanted to make sure that there was some sort of formalized educational process to show students how to make a good handoff, and what the components of the process should be.
Using the standard situation, background, assessment, recomm-endation (SBAR) form of commun-ication as a starting point, the intervention development team added content areas and made some tweaks to arrive at a standardized communications format for how to discuss patient care in the context of a handoff.
“We also developed a written handoff note in our electronic medical record [EMR], so it is a template that can be added just at the end of the emergency physician’s notes,” Smith explains. “It pulls in a lot of information automatically, such as what medications were given, any pending studies that haven’t resulted yet, and those kinds of things.”
The note also allows for some free text information, and provides for an explicit assignment of responsibility for patient care so that there is no longer any gray area on which provider is taking charge of the patient, Smith observes.
“We tried to do both a verbal and a written piece to make sure that we are addressing the issues on two fronts,” he says. “The other advantage of the written note is that if there are sequential handoffs where maybe the person admitting isn’t the person who spoke with the emergency physician, at least the note is available to anyone — ancillary staff, nursing, the physician. They can all see the note in the EMR and it has a lot of the same information [as the verbal handoff].”
The development team then provided education on how to use the new tool, and then piloted it with a select group of emergency and admitting physicians. “Now we have collected two months of pre–intervention and two months of post-intervention handoff recordings,” notes Smith, explaining that the phone lines used to conduct the handoffs were equipped with recording capability. “We are going to take those conversations, transcribe them, and evaluate how well we did at communicating critical pieces of information both before and after our intervention.”
As with anything new, it was a struggle getting physicians to actually use the new handoff tool, but Branecki observes that many of the emergency physicians do appreciate the benefits. For instance, in the past, they would be called on continually to make treatment decisions on patients whom they had already passed off to an inpatient physician, but the admitting physician hadn’t yet taken responsibility for care.
“The benefit [with the new process] is that once you have deemed that a patient is an acceptable admission, you have then given the nurse a direct line of communication to the [inpatient] physician who is going to be taking care of him, so it ultimately lessens the emergency physicians’ workload,” he explains.
Additionally, at the change of shift in the ED, physicians no longer have to provide turnover notes on patients who have already been flipped to admitted status, even if those patients have yet to be transferred to an inpatient floor.
“Most residents and faculty felt that if you did this [handoff] process, it was better for patient care, because then there weren’t duplicate orders being written, and the treating team was actually being involved with the nurse taking care of the patient, and they were updated on any changes in clinical course,” Branecki notes. “Also, you weren’t having to check these patients multiple times. We all know the game of telephone. The more times you hear the story, the story changes, so this was a way to streamline that continuity.”
Russell Buzalko, PhD, an assistant professor in the Department of Emergency Medicine at UNMC, helped design the intervention tool and is now involved with analyzing the data from the pilot.
“We have the phone calls and we also have some physician perception surveys that we need to go through to see how they viewed the intervention,” he explains.
Once all the information is analyzed, Buzalko anticipates further improvements, but with any project of this nature, he stresses that it is important to guard against creeping expectations.
“It is human nature that when you are developing something like this and people get excited about it … there is a tendency to keep adding onto it and make it better,” he says. “But it can become unwieldy at that point or go beyond the scope of your project.”
Smith agrees with these sentiments, observing that changing the way physicians do handoffs is a huge, complicated process.
“It is going to be hard to make one intervention that will address every potential problem,” he says. “Every institution is going to have to figure out where they want to start the process or where the biggest holes in the process are.”