Stop ‘handoff’ errors when patients leave the ED
Stop handoff’ errors when patients leave the ED
(Editor’s note: This is the second of a two-part series on improving "handoff" communication in EDs. The new 2006 National Patient Safety Goal #2E requires implementation of a standardized approach to handoff communications, including an opportunity to ask and respond to questions. In this month’s story, we cover patients being transported from the ED to other areas of the hospital, including diagnostic testing and inpatient units. Last month, we gave strategies to improve communication at change of shift.)
Patients are transported out of the ED dozens of times a day, whether for diagnostic tests or to inpatient units. This is a high-risk time for errors due to lapses in communication during patient handoffs, says Trisha Flanagan, RN, MSN, CEN, ED nurse manager at Beth Israel Deaconess Medical Center in Boston.
"Ensuring safe handoffs is a top priority in our emergency department and throughout the hospital," she says. The hospital’s "Safe Handoffs" initiative is focusing on handoffs from the ED nurse to inpatient nurses.
At the University of Michigan in Ann Arbor, the biggest issue regarding handoff communication is with transfers between the ED and procedure areas, says Lori Pelham, RN, clinical nursing supervisor for the ED.
To improve communication during these handoffs, do the following:
• Send the patient’s record electronically.
"Our inpatient transfer report is computerized and printed out on the receiving unit for the nurse to review, along with labs and vital signs," says Patricia Scott, RN, BSN, CEN, former ED director at Martin Memorial Medical Center in Stuart, FL. "A follow-up call to ask any questions and confirm readiness for transfer from the ED helps make ED-to-inpatient turnover smooth and less risky for the patient."
At the University of Michigan, there were problems because the ED and inpatient units had different systems for documentation, so receiving nurses didn’t always know where parts of the record were located, says Pelham. "We use a computerized admit form which is completed by the ED nurses and then printed directly to the floor where the patient is going," she says. "The inpatient nurses also can view our clinical documentation on their units."
When the ED is ready to send the patient upstairs, the inpatient charge nurse is paged and the admit form is printed directly on the floor unit. "We wait 15 minutes and if the inpatient unit does not call us back with any questions, then we send the patient up," she says.
Although the official ED medical record is on the computer, a complete printed copy also is sent with the patient. "The concern has risen over the inpatient nurses saying that they didn’t receive enough information on the admit form, but they didn’t know what they were missing until the patient arrived," says Pelham. "The inpatient nurses aren’t used to using the computer for clinical documentation, so they expect papers."
To resolve this, a site on the computer allows the complete ED medical record to be viewed by the inpatient nurses, including the admit form with chief complaint, past history, and home medications, and a copy of the flow sheet that documents events in the ED and medications given. "This should provide a complete picture for the inpatient nurses," says Pelham.
• Require nurses to have verbal communication.
At William Beaumont Hospital in Royal Oak, MI, ED nurses no longer fax reports to inpatient units; instead, the ED nurse calls the inpatient nurse assigned to the patient. More substantial information can be given through verbal verses paper communication, says Linda E. Reetz, RN, director of emergency services. "Talking to someone is more effective because questions can be asked and answered," Reetz says.
A Transport/Procedure Checklist is completed whenever patients leave the ED to be admitted or for surgery, endoscopy, or an interventional radiology procedure. The checklist is completed at the bedside and is signed by the nurse relinquishing care and the nurse receiving the patient. (See Transport/Procedure checklist used for admitted ED patients.)
"The key to this check-off list is that the information is verified and signed right before transport, so any change of status can be noted and corrected if needed," says Reetz. This can help to prevent adverse outcomes by ensuring that nurses don’t overlook items such as oxygen tanks are not at least half full. This step prevents complications if the oxygen runs out while the patient is waiting in the hallway for a test.
There was a concern about delays that could occur if inpatient nurses were difficult to reach by phone, but this concern was addressed by giving nurses portable phones for immediate accessibility.
When patients are brought back to the ED after diagnostic testing, there is now direct communication between the two caregivers, says Reetz. "If your patient is back from an ultrasound, the staff might not realize it for a period of time. With the check-off list, the patient’s escort is accountable to get a signature before they leave the patient."
• Ask ED nurses for input.
As part of the "Safe Handoffs" initiative at Beth Israel, a focus group of ED and inpatient nurses will meet with hospital leaders including Flanagan, two medical nurse managers, and a physician hospitalist. "We’re sponsoring dinner and a discussion about the barriers they perceive, as well as a brainstorming session about how we can improve the process," she says.
All ED nurses are invited to share ideas for how to provide all of the required and relevant information about the patients, their needs, and their plan of care at the point of transition between nurses.
"Our hope is that we will develop a process to ensure that handoff communication addresses all of the critical issues and identifies safety concerns," says Flanagan. Also, it is critical that the process is embraced by both the sending and receiving staff, she says. "Having them involved at the very beginning is the key to success," she adds.
Patients are transported out of the ED dozens of times a day, whether for diagnostic tests or to inpatient units. This is a high-risk time for errors due to lapses in communication during patient handoffs, says Trisha Flanagan, RN, MSN, CEN, ED nurse manager at Beth Israel Deaconess Medical Center in Boston.Subscribe Now for Access
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