ED handoffs to inpatient: Patient safety at stake
By N. Beth Dorsey, RN, Esq.,
and Timothy A. Litzenburg, Esq.,
Hancock, Daniel, Johnson & Nagle
Richmond, VA.
The practice of emergency medicine is unique in that an emergency medicine physician acts as a gatekeeper. While treatment of a patient might be brief, initial examination and assessment often will dictate the course of the patient's treatment after admission to the hospital. Thorough, efficient communication between the emergency department (ED) and the hospital floor is essential to continuity and quality of care. This article addresses handoff pitfalls, pertinent law, and ideas for improvement.
"Handoff" or "handover" refers to transition of care, when control of, or responsibility for, a patient passes from one health care professional to another. Handoff occurs at many stages in the hospitalization of a patient. In the ED setting, the main transition episodes are presentation to the ED (particularly if by emergency transport), shift changes within the ED, and admission to inpatient care. This article focuses on handoffs at the time of hospital admission.
Historically, there has been a dearth of research and literature on the subject of handoffs. In recent years, however, interest in the subject has increased significantly. In 2006, The Joint Commission named as one of its National Patient Safety Goals the following: "Implement a standardized approach to 'hand off' communications, including an opportunity to ask and respond to questions."1
The World Health Organization also launched its "Action on Patient Safety:
High 5s" initiative, naming "communication during patient care handovers" as one of the five pillars.2 Indeed, patient safety is always at stake during a handoff, and it is crucial that no information be lost during the transfer. The ED-physician-to-admitting-physician handoff presents unique challenges in that, as opposed to shift or location changes, it is a cross-specialty transfer. Due to the nature of shift changes in the ED, there is more of an established procedure for handoffs to the oncoming physician. Admission handoffs represent a change in three domains: provider, department, and physical location.3
In general, the handoff process begins with the emergency physician's assessment of the patient's stability and acuity. Following that, the emergency physician will contact an admitting physician. At this point, it is important that a core of information passes between the physicians, whether by phone or in person. This information includes, at a minimum: chief complaint, past medical history, history and physical, reason for admission, any abnormal findings, lab and radiology results, the course of treatment in the ED, and whether the patient is stable.4
Handoff pitfalls
Errors in ED-to-hospital handoffs can result in dire, but preventable consequences. Failure to timely and accurately pass on important information can lead to a delay in diagnosis or treatment, or worse. There are societal dangers as well, with handoff fumbles leading to higher healthcare costs, public dissatisfaction, longer hospital stays, and a higher rate of return visits.
In one study, 29% of physicians reported that one of their patients had experienced an adverse event or a "near miss" because of inadequate communication between the ED and admitting physician.5
A situation that often leads to handoff problems is the practice of "boarding," or keeping a patient physically in the ED after he has been technically admitted to the hospital as an inpatient. This scenario arises when a hospital experiences a temporary bed shortage. The emergency physician has signed out the patient, and while he still bears some responsibility for the patient, often mentally "moves on," and considers the patient's care to be the admitting physician's responsibility. Particularly in a case where an admission is done over the phone, a patient who is being "boarded" can have a significant and dangerous gap in treatment simply because each physician thinks the other one is handling patient care.
Problems in handoff communication do not always originate with the physician making the handoff. When there is imperfect communication between the patient and the initial emergency physician or between emergency physicians at a shift change, this problem communication often will carry forward past admission, contributing to errors in diagnosis, treatment, and disposition.6
One key area rife with problems is lab results. Often, results of lab draws taken in the ED are returned after the patient has been admitted to the floor. If the results come back to the ED instead of being sent to the floor or the admitting physician, they might not make it into the hands of the doctor who is treating the patient. If it is unclear after a transition which physician is to follow up on certain studies, there is a danger that no physician will follow up. One study found that in one of six cases of missed diagnoses, test results had failed to reach the proper clinician.7
As an ED becomes busier, the attentions of the health care professionals become, by definition, more divided. When the provider responsible for signing out a patient is carrying a heavy workload, this workload inevitably can lead to faulty transitions. Not surprisingly, the likelihood of omission of information is higher when the handoff is rushed.
Likewise, an ED physician caring for a great number of patients may be operating based on, and reporting, information that is not current at the time of handoff.8 Another less concrete area in which handoff problems originate is physician bias. Some doctors see their specialty as superior to others, or they are dismissive of another doctor's opinions or recommendations. Bias can create holes in the handoff, as the receiving physician practices selective listening. For example, an internist might not trust the ED staff's ability or judgment.
Similarly, there can be a dogmatic divide of responsibilities. Some internists expect that emergency physicians will produce definitive diagnoses and provide complete treatment, while some emergency physicians think that their role is to stabilize and dispose of the patient.9
Finally, technology can complicate matters related to the handoff. Medical record format is often the partial culprit in improper information exchanges. As hospitals move toward electronic records, part of the record is often electronic and part is still paper. When a receiving physician sees only one or the other, he can make treatment decisions based on an incomplete picture. Furthermore, reliance on electronic records tends to reduce the "cognitive load" of physicians, making quick recall more difficult.10
Pertinent law
At first glance, the requirements of EMTALA appear to end once a patient has been admitted to the ED and stabilized.11 If, however, the patient cannot be "stabilized" in the ED, EMTALA might require admission. In a 2009 federal decision, the Sixth Circuit Court of Appeals ruled that there is a continuing obligation for a hospital to treat a patient after admission, for however long until "no material deterioration of the condition is likely" upon the patient's release.12 Depending on a patient's condition, EMTALA might require an ED physician to not only treat a patient, but to effect a handoff to an admitting physician. However, it is the position of the Centers for Medicare and Medicaid Studies that a "boarded" patient is outside of the scope of EMTALA.13
State laws require physicians to comply with the standard of care, which is generally defined as what a reasonably prudent physician would do in like or similar circumstances. Poor handoffs are specifically implicated in 24% of malpractice claims involving the ED.14
Communicating a clear division of responsibility, as well as other information, as part of patient handoff can prevent tragedy and costly malpractice litigation. ED physicians should communicate all vital information, but also clearly delineate responsibility and plan for information exchange after the moment of transfer. These simple steps can prevent adverse consequences and improve patient care.
References
- Joint Commission. National Patient Safety Goals: 2006 Critical Access Hospital and Hospital National Patient Safety Goals; Nov. 8, 2006.
- World Health Organization, Action on Patient Safety, available at www.who.int/patientsafety/solutions/high5s/High5_overview.pdf.
- Matthews A, et al. Emergency physician to admitting physician handovers: An exploratory study. Proc Human Factor Ergonomics Soc 2002; 1,511-1,515.
- Id.
- Horwitz L. Dropping the baton: A qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med 2009; 53:701-710.
- Id.
- Kachalia A, et al. Missed and delayed diagnoses in the ED: A study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2007; 49:196-205.
- Horwitz, supra note 5.
- Id.
- Hertzum M, Simonsen J. Positive effects of electronic patient records on three clinical activities. Int J Med Informat 2008; 77:809-817.
- 42 U.S.C. § 1395dd(1)A.
- Moses v. Providence Hospital and Medical Centers, Inc., 561 F.3d 573 (Sixth Cir. 2009).
- 68 Fed Reg 53221-53264 (Sep. 9, 2003).
- Cheung D, et al. Improving handoffs in the emergency department. Ann Emerg Med 2010; 55:171-180.
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