In This Issue:
Michael Walters, MD JD FAAEM
President, GLAAEM Board of Directors
Greetings and welcome to GLAAEM’s fall newsletter. In this issue you will find excellent articles about several issues confronting emergency medicine. Dr. Otero, vice president of GLAAEM, writes about the safety and risk management of care transfers. Dr. Pruitt, Iowa State Representative, writes about the issues surrounding physician recruitment to rural areas, a struggle many of us have that work in non-urban areas of our member states. For my limited space I would like to begin a conversation about an issue that will probably raise the hairs on the back of your neck and make you want to punch me in Las Vegas in February, the patient experience. The conversation is not about the validity of patient satisfaction surveys, in my opinion they are here to stay, nor is this conversation intended to be a bitch session about how we cannot do anything. Rather, I would like to begin a conversation with the intent of creating a resource for our members when they need help with patient experience improvement issues.
Nicely defined by the Beryl Institute, the patient experience is the “sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.” The patient experience incorporates both quality and patient satisfaction. As a result, it is measured by quality metrics, such as core measures and internal performance improvement initiatives, and patient satisfaction surveys. In my opinion, this is an important concept to remember, patient satisfaction surveys only measure the experience. As a result, better scores should reflect positive efforts on your organization’s part. Insert negative comments about surveys here. Yes, nationally the response rate for emergency departments for satisfaction surveys is around 11%. Yes, as with any user review website, persons with negative experiences are more likely to place a review than those with a positive experience. Yes, some administrators just look at numbers without fully understanding the significance of the limitations. Please take a look at the article “The Patient Experience and Health Outcomes” by Manary, et al. from the New England Journal of Medicine. I think it begins to offer some insights into why the conversation needs to happen and the focus change.
As physicians, we should care about the patient experience. I believe we all want to deliver compassionate, quality, and satisfying care to our patients. Each of us would expect nothing less when we are patients. Additionally and more specifically, we should also care for the following reasons. First, higher patient satisfaction is associated with a perception of higher quality of care. If patients had a positive experience in your ED, they are more likely to believe in your diagnosis and follow the treatment plan you suggest. If you don’t believe me, just think about the last time you had a negative experience in the service industry that involved a recommendation. If you had a crappy experience, how confident were you in the service or recommendation? Second, money will be tied to patient satisfaction. Sorry folks, the train has left the building. If not already happening, some component of your compensation will be based on the patient experience (quality and patient satisfaction). More importantly, reimbursement to your hospital or group from Medicare will be dependent on the patient experience, including patient satisfaction. Already, if you have over 100 “eligible professionals” in your practice group and participate in PQRS, then one of the reportable metrics is patient satisfaction. Finally and most importantly, ensuring the patient has a positive experience is the right thing to do. Regardless of perceptions and money, we as physicians should be striving to create a positive experience for our patients. While ensuring a positive patient experience is important, I fully recognize that it is hard. Especially on a long shift where nothing has gone right and the patients have all been demanding. Likewise, when the hospital is asking you to do more with less.
I do not profess to know what the magic bullet or secret sauce is for improving the patient experience. However, I have begun to embrace the concept more knowing what the future holds for us. I believe that rather than complaining and stomping our feet, we should come together and offer guidance and assistance to each other. While there are idiosyncracies to each of our practice locations, there are concepts and themes that are universal in emergency medicine. I am sure that there have been positive projects and solutions in each of your practice locations. So now my ask. Like Dr. Pruitt, I want to hear from you. I want to begin a respository of ideas from our members and for our members. Please email your ideas to firstname.lastname@example.org.
Joshua Pruitt, MD FAAEM
Iowa State Representative, GLAAEM Board of Directors
Like a bad Jeff Foxworthy joke: “you might live in a rural state if - your injury patterns in the ED follow the agricultural calendars.” Iowa is most certainly a rural state, and shares the same problems many of you in the Midwest face. One of those is recruiting well-trained, board-certified or board-eligible emergency physicians to practice in these rural communities. Our rural EDs are commonly staffed with allied health providers and/or contract management groups who bring in out-of-state locums physicians to simply cover shifts. We have only one residency program in the state, the University of Iowa, and many of its graduates eventually leave the state as well.
Our democratic group in Cedar Rapids has begun to see a financially feasible model in delivering quality care to the surrounding communities in a “hub-and-spoke” method. Our long-term contract is with the second-busiest ED in the state in Cedar Rapids, but we also have contracts with three critical access hospitals in surrounding rural communities and actually hold the medical directorships at two of the three. In this way, we are able to recruit BC/BE physicians to join our group with the knowledge that we are also covering these outside hospitals. It seems to be working well for us, but I’d love to hear ways you are combating this problem in your own rural communities as well.
Ronny M. Otero, MD FAAEM
Vice President, GLAAEM Board of Directors
It’s 3:55pm on a Monday and as you are walking into a shift you pass a sea of patients, many with IV bags connected and infusing and patients with layers of blankets covering them – the “telltale” sign that they have been there a while. As you approach the workstation your colleague says: “Man, I hope your shift goes better than mine just did! You’ve got your work ‘cut out’ for you.” This is followed by a stream of interruptions by residents, nurses, and consultants trying to get the attention of your colleague before he/she hands-off the care of the patients for which he/she has been caring.
Or perhaps you work in a “shop” where when you arrive; you are greeted by a colleague who says “Hey! I’ve got a couple of “sick ones” and the rest are already admitted and there’s nothing to do, report has been called, all you have to do is babysit. Put down your stuff and I’ll tell you about them. By the way, I’ve got to get of here soon, I’ve got my kid’s recital in 30 minutes.” Maybe these shift change scenarios sound familiar or perhaps your ED has a formalized process where hand-off are perfect. If you are in the former category then you may have developed the feeling that most hand-offs seem like “we” are either trying to get in or trying to get out of the department and take care of business as expediently as possible. How can these interests be balanced while providing safe, conscientious and quality care to emergency department patients?
There are approximately 5,000 emergency departments in the United States and with two to three shifts/day there are at least 3.6-5.5 million end-of shift patient hand-offs every year.1 This estimate does not even include the handoffs that occur between emergency physicians (EPs) and admitting services. With increased scrutiny and efforts to decrease harm at the hands of clinicians a safe alternative to the “free-form” sign-out must be found.2 It is estimated that communication errors are the root of 70% of patient errors. It is also estimated that 84% of treatment delays are also due to miscommunication.3,4
Emergency departments are treating an increased number of patients, with a higher degree of acuity and a greater proportion of critical care provision in the emergency department.5 Hand-offs of such patients requires a delicate balance between detailed information and brevity to pass on to the oncoming physician. Due to the nature of the practice of emergency medicine where several shift changes occur throughout the day – multiple hand-offs are expected. What distinguishes EPs is that they never “cap,” meaning, they do not have an upper limit of patients they can “carry.” So in addition to accepting a transfer of patient care, EPs are expected to continue evaluating new patients while at the same time following-up on action items for patients received in hand-off.
The literature on patient hand-offs over the last decade has introduced numerous mnemonics and structured tools to provide a consistent manner in which to capture and pass-on key information. Some of the popular mnemonics include SBAR (S-situation, B-background, A-assessment, R- recommendations), SHOUT (S-sick or not, H-history or hospital course, O-objective date, U-upcoming plan, T-to do and time for questions) and SIGN-OUT (S- sick or DNR, I-identifying data, G-general hospital course, N- new events of the day, O-overall health status, U-upcoming possibilities with plan, T- tasks to complete and questions).6,7,8,9 Only recently is literature emerging about how to best handle hand-offs in the emergency department.3,10
“Safer Sign-Out” proposed by the Emergency Medicine Patient Safety Foundation has developed a commercial, fee-based toolkit which includes a template for the “sign out” (aka hand-off) which can be customized to a department and provides supportive literature and resources to assist in implementation. The origins of this “safer sign-out” began in a non-academic setting. However, the most recent emergency department hand-off literature is based in academic settings. The practice of emergency medicine however, has a majority of nonacademic departments and thus the difference between these settings creates dissimilar circumstances at the time of patient hand-off.
See Table I.
Table I. Differences between academic and non-academic emergency department hand-offs
It is clear that a single hand-off system may not be applicable to all emergency departments. A recent publication examined a process, which included “closed-loop” communication that led to a significant reduction in medical errors by utilizing a standardized approach to patient hand-off called “I-PASS.” This approach consisted of a bundle where physicians were instructed on the proper use of the mnemonic and consistently applied it in an inpatient setting. The investigators found a reduction in medical errors from 24.5 to 18.8 per 100 hospital admissions. In addition, they found a reduction of preventable adverse events decreased from 4.7 to 3.3 per 100 admissions.11 What was also an interesting finding was that there was no increase in the duration of the hand-off. Although this was a large multicenter study it was conducted solely in academic centers and in hand-offs between residents. Again, while this approach appears feasible for a process to be universally applicable, it should work for both residents and attendings as it has been demonstrated that hand-off between attendings and residents differ.12
Table II. Mnemonics for standardized hand-off information
Physicians are often interrupted in the normal course of patient care but perhaps none more than emergency physicians when performing tasks or when receiving information.13,14 Studies have revealed a correlation between medical errors and interruptions.15 Lastly, emergency physicians are often required to not only sign-out individual patients but to provide a catalog of operational issues to the oncoming physician so that circumstances that can impact the flow of the department can be addressed pre-emptively. A knowledge of the resources available and situational awareness is key for planning if the need arises to increase surge capacity or just to expedite the admissions process. Farhan et al. recently published the “ABC of handover” in which operational information that should be passed on at the beginning of a shift can be remembered by the mnemonic; “ABCDE”.16 These categories prepares the oncoming physician to be aware of issues which could impact patient flow such as personnel allocation to each area, bed situation, issues related to consultants and colleagues, etc.
In summary, as an emergency physicians we should be aware of the status of the emergency department, patient specific information with specific plans, contingency and follow-up information. Hand-offs should be done face to face with “closed loop” communication so that the receiver has adequate opportunity to process the information and pose questions regarding the “plan” and the ability to “repeat the plan”. Hand-off time should be uninterrupted. Lastly, a mechanism should exist by which the person “signing out” can find out what happened to the patient who was handed off.
Figure 1. Hand-off in the emergency department. Patient hand-off is affected by three predominant factors in the emergency department: departmental situation, patient specific information and interruptions. EPs must limit interruptions which can affect information processing. After the hand-off the new provider must follow through on action items and complete disposition plan whether to discharge, admit or in the rare case hand-off due to lack of beds or delay in consultations and diagnostic testing. Simultaneously, the new provider has the responsibility of assessing new patients.
There is a saying: “Sign-out is the most dangerous procedure in emergency medicine.” It is a fitting statement when one considers the impact of not following through on action items or if life-threatening information is omitted. When considering the responsibility one assumes when a patient is handed-off, it is important to take the necessary precautions to minimize harm as would be done with any other procedure in emergency medicine. As emergency physicians we should advocate that our hand-off time is sacred and operational plans should factor hand-off time into shift changes.
- http://www.emnet-usa.org/nedi/nedi_usa.htm, National Emergency Department Inventory- USA. 2015. accessed Sept 9, 2015.
- Kohn, L., J. Corrigan, and M. Donaldson, To err is human: building a safer health system. National Academies Press, 2000.
- Cheung, D., J. Kelly, and C. Beach, Improving Handoffs in the Emergency Department. Ann Emerg Med, 2010. 55(2): p. 171-180.
- Arora, V. and J. Johnson, A Model for Building a Standardized Hand-Off Protocol. Journal on Quality and Patient Safety, 2006. 32(11): p. 646-655.
- Herring, A., A. Ginde, and J. Fahimi, Increasing Critical Care Admissions from U.S. Emergency Departments, 2001-2009. Crit Care Med, 2013. 41(5): p. 1197-1204.
- Haig, K., S. Sutton, and J. Whittington, SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf, 2006. 32(167-175).
- Patient Safety Program, D.o.D.F.C., VA, Healthcare Communication Toolkit to Improve Transitions in Care. Available at : http://www.oumedicine.com/docs/ad-obgyn-workfiles/handofftoolkit.pdf?sfvrsn=2, 2005.
- Brownstein, A. and A. Schleyer, The Art of HANDOFFS: a mnemonic for teaching the safe transfer of critical patient information. Resident Staff Physician, 2007. 53(6): p. 196-204.
- Horwitz, L., T. Moin, and M. Green, Development and Implementation of an Oral Sign-out Skills Curriculum. J Gen Intern Med, 2007. 22(10): p. 1470-1474.
- Peterson, S., A. Gurses, and L. Regan, Resident to Resident handoffs in the Emergency Department: An Observational Study. The J of Emerg Med, 2014. 47(5): p. 573-579.
- Starmer, A., R. Spector, and R. Srivastava, Changes in Medical Errors after Implementation of a Handoff Program. New England J Med, 2014. 371(19): p. 1803-1812.
- Lane-Hall, M., R. Speck, and S. Ibrahim, Are Attendings Different? Intensivists Explain their handoff ideals, perceptions and practices. Annals ATS, 2014. 11(3): p. 360-366.
- Chisholm, C., E. Collison, and D. Nelson, Emergency Department Workplace Interruptions: Are Emergency Physicians "Interrupt-driven" and "Multitasking"? Acad Emerg Med, 2000. 7(11): p. 1239-1243.
- Jeanmonod, R., M. Boyd, and L. M, The nature of emergency department interruptions and their impact on patient satisfaction. Emerg Med J, 2010. 27(5): p. 376-379.
- Westbrook, J., A. Woods, and M. Rob, Association of interruptions with an increased risk and severity of medication administration errors. Arch Int Med, 2010. 170: p. 683-690.
- Farhan, M., R. Brown, and M. Woloshynowych, The ABC of handover : a qualitative study to develop a new tool for handover in the emergency department. Emerg Med J, 2012. Jan(10.1136).
Resources for Improving Patient Hand-offs:
- The American Medical Association: Resources on Improving Patient Handoff
- The Emergency Medicine Patient Safety Foundation
- Agency for Healthcare Research and Quality (AHRQ) Patient Safety Primers
- American College of Emergency Physicians: Transitions in Care Taskforce
Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM, its chapter divisions or affiliates. These articles are intended for the individual use of AAEM members.