Miscommunication during ED handoffs paves the way for patient harm opportunities

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Miscommunication during ED handoffs paves the way for patient harm opportunities

ED physicians call for a new approach to handoffs that standardizes communication while incorporating computerized health information


Over the last decade, patient handoff procedures have become an integral part of the patient care process, accompanied by a slew of acronyms and standardized procedures meant to improve continuity of care and prevent patient errors.

However, many of these models focus on intra-unit handoffs, particularly during change of shift. Meanwhile, handoffs that occur from one unit to another?most frequently from the emergency department (ED) to an inpatient unit?have received significantly less attention despite the risk of potentially dangerous adverse events.

A recent survey published in the July issue of the Journal of Hospital Medicine indicates that the handoff exchange between ED physicians and admitting doctors is frequently wrought with patient safety risks born from miscommunication. The survey polled admitting and ED physicians at the University of Nebraska Medical Center in Omaha looking at communication quality, clinical information, interpersonal perceptions, assignment of responsibilities, organizational factors, and patient safety. Twenty-nine percent of physicians indicated that adverse events were a result of ineffective communication during the handoff process, and 78% indicated that sequential handoffs negatively impacted patient care.

Furthermore, 34% of admitting physicians and 19% of ED physicians reported that a patient was harmed in the previous three months because of problems during the handoff from the ED. More than half of those that reported patient harm cited two or more examples.

The survey offers a peek at some of the major issues tied to inter-unit handoffs, particularly when it comes to physician communication, says Christopher Smith, MD, assistant professor of internal medicine in the division of general internal medicine at the University of Nebraska Medical Center, and lead author of the study. Given the overwhelming patient safety concerns, he hopes the study offers a jumping-off point for hospitals to identify ways in which they can improve this particular process.

"From a communication standpoint, there needs to be a shift in the model of how we communicate with one another as physicians," he says.

Although ED handoffs have received much less attention than traditional handoffs, Smith's survey is not the first to point out some of the primary issues with the handoff process. A 2010 report published by the Annals of Emergency Medicine found that ED handoffs are accompanied by a number of issues that vary in complexity. The report laid out a road map for the ED handoff process that focused on clear communication between both physicians, but the authors also recognized that variability within each hospital's handoff process makes for complex process improvement.

Smith says his recent survey echoes similar concerns and reinforces the need for a significant overhaul of the handoff process. "We need to shift gears on the information that is important during ED-to-inpatient handoffs and change from the traditional model, which is largely kind of a one-way data dump where the ED doctor regurgitates a bunch of lab data and the admitting physician is a passive listener," he says. "In that paper, [the authors] really outline that it needs to be more collaborative and a two-way conversation that focuses on things like the pending tests with closed-loop communication and feedback."


Opportunities for miscommunication

Multiple factors impact effective communication between physicians in an ED environment that is increasingly overcrowded, hectic, and filled with interruptions.

Smith says there is tremendous disagreement between ED physicians and admitting physicians about how well pertinent information is communicated, ranging from physical exam findings to pending test results.

"It probably speaks to the fact that we're not doing a very good job of creating a shared mental model, meaning we're not coming to an agreement on the patient's course up to the call and the treatment plan moving forward," he says.

One reason that disparity may exist is because ED physicians and admitting physicians have very different approaches to patient care. ED physicians are required to evaluate a patient for life-threatening complications, stabilize him or her, and then discharge or transfer the patient to the appropriate unit. Alternatively, internists are looking for a long-term diagnosis that will cut to the core of the patient's health problems, an issue rarely addressed during the abbreviated course of an ED stay.

This can lead to a pervasive defensiveness among ED physicians. According to the survey, 94% of ED physicians reported feeling defensive during the handoff process at least "sometimes." This attitude can lead to "overselling" patients, Smith says, in which an ED physician overstates a diagnosis or frames it in such a way that he or she will not get pushback from the admitting doctor. "I think it's more fruitful and important to discuss any uncertainty and be up front about it in order to have a conversation," he says.

But miscommunication is compounded by a number of other factors. For instance, ED physicians conduct handoffs with dozens of specialties within the hospital, each with its own process for patient handoffs. Although each of those units requires some measure of flexibility in approaching the handoff process, there should be a standardized approach to effective communication.

Sequential handoffs may play a role in miscommunication as well, essentially devolving into a game of telephone in which information is lost or misrepresented in the process.

Additionally, with rising volumes, EDs are busier and more complex than ever before, which leads to unsafe levels of crowding as well as frequent interruptions during the handoff process, says Arjun Venkatesh, MD, MBA, MHS, an emergency medicine physician, director of quality and safety research and strategy, and researcher at the Centers for Outcomes Research Evaluation at the Yale University School of Medicine in New Haven, Connecticut, as well as a spokesperson for the American College of Emergency Physicians. These factors make the current state of ED handoffs unique, and should prompt hospitals to reconsider how that process fits in with their long-term goals.

"Taken together, this leaves very little opportunity for the 'traditional handoff,' which included either face-to-face or at least phone presentation and discussion of each patient," Venkatesh says. "Without building a handoff communication model that fits the needs of patients and providers in the modern hospital, handoff communication is destined to continue to worsen."

Although the University of Nebraska survey shows that both ED and admitting physicians believe pervasive miscommunication contributes to patient errors, it's unclear exactly how and when those patient errors occur. Anecdotally, however, Smith says that patient harm can emerge in a number of ways, ranging from missed test results to medication errors.

"There are all kinds of potential issues that can happen in that transition phase," he says. "I think it's something that would be really fascinating to look at it in a more prospective basis."


Making improvements

For the University of Nebraska Medical Center, the recently published survey results served as a wake-up call to review its policies surrounding ED handoffs and initiate a pilot project in an attempt to improve communication.

The pilot project focused on standardizing the type of information that is communicated during the ED handoff, including any diagnostic uncertainty, specific concerns that may impact patient care, and language barriers or psychiatric concerns associated with the patient. The hospital also created a written handoff template embedded in the patient's electronic health record (EHR) that pulled out key pieces of information, which it hoped would combat issues with sequential handoffs.

"It's really focusing on standardizing the things we talk about, having a two-way collaborative discussion, and agreeing on a shared plan," Smith says.

The medical center also developed explicit expectations redefining when the responsibility of care transfers between physicians. Problems often arise during the time when patients have been scheduled for an admission, but haven't been seen by the admitting physician?a period Smith refers to as a "gray area"?or when patients have been "boarded," or held in the ED while they wait for an inpatient bed, an issue that has become increasingly common in many hospitals around the country.

"If a patient is in that limbo phase and something happens and we're not sure which physician is responsible, we can run into problems," he says. "[Having a policy] also helps nursing staff and ancillary staff know who to communicate with if they have issues."

Venkatesh says that the university-affiliated Yale-New Haven Hospital made unique changes to its ED handoff process years ago, first by replacing phone calls with more convenient audio recordings, and then by incorporating the EHR into the handoff process with selective phone calls when necessary.

Although EHRs offer a more effective way to transfer patient information, using them has also limited the amount of direct communication physicians have with one another.

"While our system is efficient and may relieve some pressures and challenges, we have limited the personal communication between emergency physicians and hospitalists, which I fear hinders the development of relationships within the hospital as well as the communication of more subtle nuances of a patient's care or social circumstances that may not be documented explicitly within the electronic health records," Venkatesh says.

Restructuring the ED handoff process requires a collaborative effort between admitting and emergency physicians. During the pilot project, Smith says the medical center focused on educational interventions aimed at internal medicine physicians and hospitalists, and created a video that demonstrated optimal elements of an ED handoff.

However, he adds that a multidisciplinary approach to education would ultimately provide even greater benefits, if only to allow ED physicians and admitting physicians to interact with one another.

"This gets back to that issue of mistrust and allowing people to interact face-to-face and have a little time to get to know each other, which is going to have a lot of benefits in improving their future interactions," he says.

But that face-to-face interaction is becoming much harder to achieve in the modern ED, Venkatesh says. Structured handoff tools, checklists, and communication best practices will help standardize handoffs in the short term. But hospitals should turn their focus toward improving EHR utilization in a way that offers fast and easy dissemination of patient information, while maintaining more modern lines of communication. Although much research has focused on handoff models like I-PASS, very little research has looked at ways that new technology can reshape this process.

"We need to change the system that surrounds handoffs," he says. "In the long term, we need to develop a variety of tools and processes that move away from the traditional face-to-face conversation, which is untenable and likely suboptimal in modern acute care, and move towards the use of information transfer through electronic health records, the use of asynchronous communication tools such as text, and the selective use of synchronous conversations for select, complex patients."