By Stacey Kusterbeck
Many patients are admitted to the intensive care unit (ICU) but remain in the ED waiting for an inpatient bed. Depending on how long the patient is boarded, emergency physicians (EPs) may need to hand the patient off at shift change.
“These are often the most complex and ill patients we care for in the ED, and we are very concerned about the fidelity of communication between EPs. I work in an academic center and community hospital, and we see this often,” says Joshua Kolikof, MD, a practicing EP at Beth Israel Deaconess Medical Center in Boston.
Kolikof and colleagues evaluated written handoff communication between ED teams for patients admitted to the ICU and boarded in the ED.1 “There is more boarding now than in the past. As a result, we are playing a dangerous and complex game of ‘telephone’ where we hand off the care of a boarding patient in the ED from one team to another,” Kolikof observes. This can sometimes go on for 24 to 48 hours. Kolikof and colleagues created a quality assurance tool to ensure that relevant and vital information is conveyed to ED teams. “We generated a novel rubric for scoring sign-out, where one had not been previously standardized,” says Kolikof.
Kolikof and colleagues analyzed 144 ED ICU boarders (defined as patients boarded in the ED for more than two hours after admission) with two or more EP teams involved in their care during the COVID-19 pandemic. Information that EPs consider crucial (code status, performed interventions, and contingency planning) was sometimes missing. Written handoffs included illness severity 84% of the time, pending studies 98% of the time, performed interventions 74% of the time, code status 21% of the time, and contingency planning 15% of the time.
If handoffs to oncoming EPs miss key pieces of information (such as an intervention), it could contribute to a patient’s bad outcome. Kolikof offers the example of a critically ill patient with sepsis waiting for an ICU bed. Two hours before handoff to a new team, a subclavian central line is attempted on the patient, but it is unsuccessful. After the failed attempt, the primary team places a femoral line, but this intervention is not documented and is omitted in the verbal report to the oncoming EP. The patient is becoming subtly tachycardic and has subtle hypoxia. Since the patient initially was admitted for sepsis, the oncoming EP likely will attribute the status change to the worsening of this underlying condition. The oncoming EP is less likely to consider another iatrogenic etiology, especially if he is unaware of the initial subclavian attempt.
“Knowing that an attempt at a subclavian line had happened would immediately clue the emergency physician into the possibility of a pneumothorax,” Kolikof says. Without that important piece of information, the oncoming EP might not suspect pneumothorax. A chest X-ray might not reveal the pneumothorax, either. “There may be a delay in making that diagnosis without obvious vital sign abnormalities, physical exam findings, or obvious imaging findings to support it,” Kolikof explains.
The handoff tool can help relay necessary information for the most seriously ill patients in the ED. “It is imperative that we remain vigilant during handoff and that we relay relevant information to each other,” Kolikof underscores.
Often, patients admitted to the ICU from the ED have some component of diagnostic uncertainty. “These patients may present to the ED in extremis and are resuscitated, stabilized, and consequently admitted. Sometimes, the actual underlying cause has not yet been determined,” notes Deepak Chandwani, MD, a practicing EP and chief medical officer at The Mutual Risk Retention Group in Walnut Creek, CA. Patients may have pathologies involving multiple organ systems. This necessitates input from multiple consultants, such as nephrology, neurology, or cardiology.
With so many healthcare providers involved, there are plenty of opportunities for miscommunication. For example, many hospitals employ an in-house intensivist who conducts handoffs in person or over the phone. Generally, consulting specialists are not in-house 24/7; in those cases, handoffs would be performed by phone. Chandwani illustrates this difficulty with the hypothetical example of a patient who was found unresponsive and brought to an ED with cardiopulmonary resuscitation in progress. The EP resuscitates the patient, who is admitted to the ICU intubated with vasopressor support. The underlying cause of the patient’s condition was not yet determined or addressed. However, the patient has renal failure, an elevated troponin, and an abnormality noted on head computed tomography (CT). These findings necessitate input from nephrology, cardiology, and neurology. During the handoff, the EP notes the patient’s abnormal head CT and renal failure but does not mention the elevated troponin. This results in a delay in obtaining cardiology input. “As with any handoff, there are risks. This can be related to incomplete or suboptimal transfer of clinically pertinent information,” Chandwani says.
With ICU patients, this risk is amplified because of the complexity of the patient’s clinical condition. “When turning over care of an ICU patient, there can be many active clinical issues that need to be addressed,” Chandwani says.
Chandwani notes that all these items must be discussed and determined:
- What did the ED provider address?
- What is pending?
- Who will follow up on those results?
- Who calls the consultants?
- Are there outstanding procedures?
- Who will perform the procedures?
“Due to overcrowding and capacity challenges, patients will often be admitted to the ICU, but due to a lack of beds, patients will be boarded in the ER. This creates some challenges,” Chandwani says. “It is vital to delineate who is managing that patient and directing care.”
Incorrect assumptions on who is going to obtain a specialty consult are problematic. Chandwani gives the example of a critically ill patient with gastrointestinal (GI) bleeding who presents to the ED. The intensivist accepts the admission, assuming that the EP called the gastroenterologist for a consult. The EP assumes that the ICU physician will obtain the consult. “Neither party calls the consult, and there is a delay in the GI consultation,” Chandwani says.
ED boarding of ICU patients is associated with increased length of stay and higher mortality.2 Boarded ICU patients may receive a different level of attention than they would in the ICU due to a lack of resources or experience. In such cases, “the ER provider shares the potential liability risk,” Chandwani says. If an EP admits a patient to the ICU but there are no beds, the patient will remain in the ED under the ICU’s orders. If those orders are not carried out, then there is liability risk. “The ED doc no longer directs care. However, a bad outcome puts all the providers who cared for that patient at risk,” Chandwani says.
REFERENCES
- Kolikof J, Shaw D, Stenson B, et al. Standardized evaluation of hand-off documentation of ICU boarders in the emergency department. J Am Coll Emerg Physicians Open 2023;4:e13039.
- Mohr NM, Wessman BT, Bassin B, et al. Boarding of critically ill patients in the emergency department. Crit Care Med 2020;48:1180-1187.
Many patients are admitted to the intensive care unit but remain in the ED waiting for an inpatient bed. Depending on how long the patient is boarded, emergency physicians may need to hand the patient off at shift change.
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