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The One Key to a Successful Handoff

Posted on Tue, Jan 20, 2015
The One Key to a Successful Handoff

By Michael Lozano, Jr. MD, FACEP
Executive Vice President, EmCare South Division


From what seems like the dawn of time, emergency physicians have encountered various degrees of conflict when attempting to admit patients to the hospital. Frequently, barriers are thrown up on the receiving end when the admitting diagnosis is elusive, “soft” or simply not clear cut. From time to time I am asked to opine – or perhaps officiate is the better word – when ED physicians and hospitalists are at loggerheads. In trying to score points in an ego contest, we often forget that the occasion of a handoff between physicians is critically important from a risk and safety perspective. What I see as central to these types of conflicts is a communications gap. Borrowing a phrase from John Gray, I would hazard to say that “ED Docs are from Mars, Hospitalists are from Venus.” The difference in communication styles is the root cause of much conflict. Recast in a scientific frame, ED docs prize sensitivity while hospitalists value specificity. Emergency physicians cast the net and search for conditions that will kill you before tomorrow morning. The pulse quickening phrase, “Remember that patient you sent home?” is what we truly dread. There are multiple forces that have molded us into this form.

Emergency department annual visits have been steadily increasing for the past decade. Despite the common misconception that most ED visits are routine, the truth is that more and more patients are presenting with multiple co-morbidities and neglected medical conditions.[i] Coupling this with a workforce crisis in emergency medicine, and you have the situation across the country where emergency healthcare providers are forced to provide more and more care in an accelerated timeframe. As the rate of arrivals increases, the pressure is on to clear the department. The push is to “treat ‘em and street ‘em.” When one encounters a patient that needs to be admitted (or even smells like they need to be admitted), it’s sometimes more of a visceral rather than a cognitive decision; secondary details are jettisoned as Dr. Ahab admits his White Whale. What we have here is an incubator for the classic anchoring heuristic.        

This is not to say that patients that clearly need to be admitted shouldn't be moved upstairs expeditiously. Outcomes for certain patient cohorts (ICU, pneumonia, chest pain, CHF) have been shown to be significantly better when they are moved out of the ED into the hospital setting.[ii],[iii], [iv] On a human level, patients are more comfortable when moved out of the ED setting as their perception is that they are getting more personalized care on the nursing unit.[v] That being said, we need to be sure that any movement of the patient is always effected in a safe manner. If a patient is an appropriate candidate for the ICU where the patient to nurse ratio is 1:1 or 2:1, then it doesn’t serve them in any capacity to be placed on a med-surg unit with a 6:1 ratio just to get them out of the ED. For that reason a robust physician to physician conversation needs to be had at handoff – some would even say that it should be memorialized in the medical record or similar archived document.

I used to have my five top admitters on speed dial. I would present a case succinctly yet completely. We had enough trust that they would be comfortable with my treatment plan and bridge orders. Balancing that however, I felt the responsibility toward them to ensure that their patient would not crash on the floor before the morning. Did I wait for every test to come back? No, not always; just when it was appropriate. Was I wrong occasionally? Sure, but they would come and talk to me privately knowing that I always had the patient’s best interest in mind and frequently did not have, as Paul Harvey used to say, “the rest of the story.”

Not every patient needs to have every test result back before they are moved upstairs. In fact, that is counterproductive based on what is known about modern ED patient throughput. If I’m admitting someone for chest pain, having an ECG done is pretty basic. If a patient has sepsis, let’s focus on getting them early goal directed therapy and not on who gets to do what. Let’s have common sense and professionalism prevail. In a similar vein, a policy of calling the hospitalist immediately upon arrival of a patient suspected of needing admission promotes a culture that places the ED physician at a higher risk of anchoring on their first differential diagnosis. In other words, we can’t have the ED physicians put into a situation where they feel compelled to become fast and sloppy. That helps no one. The answer is not to have the hospitalist see every single patient before they are moved upstairs. When I see that in a hospitalist practice, it is a symptom of professional distrust between hospitalists and ED physicians. The answer to cases of incomplete work ups is effective peer review. Part of the discussion between ED physician and hospitalist should be on determining if the patient is safe to go to the floor (or the floor’s hallway) and safely wait for up to a couple of hours. When the hospitalist gets multiple admissions simultaneously (mathematically this is inevitable) then the discussion about clinical stability is even more important. Let’s get back to civil discussions that are more centered on patients and not our egos.

Refs

[i] The Moran Company (2013). Trends in the Provision of Emergency Department Evaluation and Management Services. Arlington, VA.
[ii] Singer, A. J., Thode Jr, H. C., Viccellio, P., & Pines, J. M. (2011). The association between length of emergency department boarding and mortality. Academic Emergency Medicine, 18(12), 1324-1329.
[iii] Al-Sultan, M., Al-Qahtani, S., Haddad, S., Al Shehri, M., Alsaawi, A., Tamim, H., ... & Arabi, M. (2014). The Association Of Duration Of Boarding In The Emergency Room And The Outcome Of Patients Admitted To The Intensive Care Unit. Am J Respir Crit Care Med, 189, A2541.
[iv] Grimaldo, F. H., Lewis, T. J., & Christian, E. L. (2014). 176 Does Time Matter?: The Relationship Between Emergency Department Boarding and Congestive Heart Failure Patient Outcomes at a Large Urban Public Hospital. Annals of Emergency Medicine, 64(4), S63-S64.
[v] Pines, J. M., Iyer, S., Disbot, M., Hollander, J. E., Shofer, F. S., & Datner, E. M. (2008). The effect of emergency department crowding on patient satisfaction for admitted patients. Academic Emergency Medicine, 15(9), 825-831.

ABOUT THE AUTHOR
Dr. Lozano has been an Executive Vice President for the South Division of EmCare since 2009. Prior to his current role, he worked for EmCare as the medical director and chairman of the Department of Emergency Medicine at Northside Hospital in St. Petersburg, Fla. He is also the medical director for Hillsborough County Fire Rescue in Tampa, Fla. In his role as medical director for Florida’s Urban Search and Rescue System (U.S.A.R.) Task Force 3, Dr. Lozano has personally responded to several disaster scenes including the aftermath of hurricanes Charley, Ivan and Katrina. He is a highly-skilled physician with 18 years of medical and leadership experience. Learn more about Dr. Lozano here. Click here to follow him on Twitter.

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