Transitions in Care: When Words Can Save Lives

Abstract

Among the myriad of skills required of emergency medicine (EM) physicians, communicating concise and effective transitions in care is one of the most critical for patient safety. EM physicians transition care daily, both within their own department and among other specialties. We will discuss the crucial link between care transitions and patient safety, the processes and challenges in the hand-over exchange, and recommend an approach to improve your current system with transitions in care.

Background

Patient safety and quality care are imperative to the practice of medicine. Transitions in care (hand-over) is an important component of a physician’s practice as patients often have multiple health care providers participating in their care.¹ In fact, The Joint Commission (TJC) has identified communication breakdowns during handoffs as the single greatest patient safety threat.² Hand-over communication is a daily part of emergency medicine (EM) practice. EM physicians may transition the care of patients that will remain in the emergency department (ED) after their shift to an on-coming EM physician who is now responsible for finalizing patient disposition decisions; for example, after an observation period or when the results of diagnostic testing is complete. Additionally, for the EM physician, hand-over includes communicating a concise patient summary to non-EM physicians who will be assuming the responsibility of the patient during an admission, consultation, transfer, or in follow-up care.

Underscoring the importance of handoff communication, the Accreditation Council for Graduate Medical Education (ACGME) mandates that all specialty residency programs ensure that their residents are competent in this skill.³ Recently, specialty specific milestones to measure key achievements of residents during their training have been implemented by the ACGME in collaboration with the American Board of Medical Specialties (ABMS) and other specialty organizations.⁴ The ability to transition patient care in an accurate and efficient manner is defined as one of the skills in the Team Management Milestone for EM.⁵ For the practicing EM physician, The Model of Clinical Practice for EM describes skills to admit, discharge, transfer, and collaborate with physicians and other healthcare team members as requisite for board certified emergency physicians.⁶

The focus of this article will be on transitions in care in the ED; however, we feel it is applicable to most medical specialties. To frame our discussion, we will first review why transitions in care are a critical safety issue and discuss some of the specialty specific challenges in this process for EM. We will examine how system and communication issues within the specialty and practice of EM can impact and serve as obstacles to this key patient care process. And finally, we will present a quality improvement approach to examine your department’s current transition in care practices and recommend areas to review to ensure quality care and patient safety.

Hand-overs and Patient Safety

When reviewing the causes of reported sentinel events to TJC, errors in communication and continuum of care (which include patient continuity and transfers) were among those most frequently cited. Underscoring TJC’s concern that transition errors are a patient safety threat, data demonstrated that communication errors were the third most common cause of reported sentinel hospital events in 2011 and 2012, rising to the second most frequent cause in 2013.⁷ Moreover, 80% of serious medical errors are caused by ineffective transitions in care.⁸ Delays in or inappropriate patient treatment, increased length of hospitalization, more frequent readmissions, and an increased patient care cost have been attributed to poor hand-overs.⁹ Perhaps most concerning to EM physicians is that up to 24% of ED malpractice claims implicate poor patient handoffs as a factor.¹⁰ Despite hand-over communication being critical to patient safety, it is alarming to realize that only 8% of United States medical schools provide formal training in this essential skill.¹¹ Furthermore, physician experience alone does not seem to significantly improve the effectiveness of transitions in care.¹²

So, why is the ED recognized as a high-risk area for adverse events,¹³ and why are transitions in care critical for emergency medicine physicians? The scope of practice for EM provides unique challenges to the transition in care process. EM physicians are shift workers that do not know the volume, complexity, and acuity of the patients that will present to the ED on any given day. EM physicians usually don’t know their patients. Task switching to efficiently and effectively manage multiple patients frequently fragments and interrupts patient care, as we need to direct our attention to the most critically ill patients first. Patient care in the ED is a continuum that is often still evolving at the end of the shift. Anticipated and actual patient disposition and follow up plans rely on reassessment after a period of observation, treatment, and analyzing diagnostic findings. Therefore, what is expected to happen and what is the final conclusion of the ED visit for a patient is often not known when the hand-over of care and responsibility for the patient occurs.

Identifying High Risk Transitions in Care

The ED environment and workflow can be an obstacle to this key patient care process. As previously discussed, we rarely know our patients and are forced to make decisions with limited information. Given these constraints, EM physicians are at risk for cognitive bias errors. We often fail to ask if the handoff originator “got it wrong?” However, there are several red flag scenarios that are high-risk transitions in care that have been previously identified in the EM literature.¹⁴

Patients with unclear diagnoses are susceptible to error at the time of hand-overs.¹⁴ We are often prone to diagnosis momentum when given a diagnosis.^14,15 For instance, if an oncoming EM physician is told that a patient has a flare of chronic pancreatitis despite normal labs, he may fail to consider other possibilities such as perforated ulcer if the patient worsens. Risk can be reduced by identifying uncertain diagnoses during transitions in care, this provides the opportunity for “fresh eyes” to review the case.^14,15 Similarly, patient hand-overs involving deviations from a typical diagnosis or treatment plan are high-risk.¹⁴

Even when the diagnosis is clear, patients with unclear dispositions require additional attention.¹⁴ For example, consider an intoxicated patient who is to remain in the ED for observation after the initial EM physician’s shift is complete. How is it decided if the patient is progressing as expected or when further diagnostic evaluation is indicated? A more in-depth discussion may need to occur during the hand-over of these cases and it may be useful to evaluate the patient at the bedside with the outgoing EM physician before completing the handoff process.¹⁶

Another care transition that requires special consideration is when disposition decisions are based solely on imaging studies.¹⁴ What is the oncoming physician to do if there is an incidental finding or an unexpected finding, such as a computerized axial tomography (CAT) scan done to evaluate a patient for appendicitis that demonstrates colitis? Can this patient be safely discharged or do they need to be admitted? If the patient has a history and exam highly suggestive of appendicitis and the imaging scan is negative, what is the next course of action?

The same inherent problem holds true for consultant-driven disposition plans.¹⁴ When we allow disposition and treatment plans to be determined by consultants we risk premature closure. Anticipatory guidance can be used to mitigate risk in the case of imaging based dispositions, consult based dispositions, and diagnosis and treatment plans that deviate from normal practice.¹⁴

Patients that require additional caution include unstable patients, those with psychiatric illness, and those with prolonged stays in the ED.¹⁴ The unstable patient’s clinical condition can rapidly deteriorate; it may be beneficial to physically evaluate these patients with the handoff originator during the transition process.¹⁶ Psychiatric patients, including persons with substance abuse problems, are high risk because of communication difficulties associated with disease or intoxication. We are at risk for cognitive bias, subjective inferences about patients or scenarios affecting our judgment or the reality of the situation. This includes both our preconceptions about patients such as high ED utilizers and biases that are introduced when patient cases are discussed during hand-overs.¹⁵ Side effects from psychiatric medications or mental illness may confound the expression of symptoms and physical findings. For patients that remain in the ED for an extended period of time and are transitioned to multiple providers, an increase in omission errors may result.¹²

We believe that transitions in care of non-English speaking patients and those that are elderly or very young should receive additional scrutiny. For patients that are non-English speakers, both the patient and the provider must rely on the interpreter’s ability to accurately convey information between the two parties. The patient-physician relationship may be compromised when a “third party” is involved. Also, the perceived increased time associated with using an interpreter may dissuade the oncoming provider from re-evaluating these patients. Patients at the extremes of age are at risk as they may have atypical presentations of emergent complaints. Younger patients may not be able to accurately communicate their complaints and physicians must trust their caregivers to provide history. Likewise, older patients with cognitive, receptive, or expressive communication barriers may also find it difficult to communicate. In addition, multiple medications may mask or confound physical exam findings in the elderly and the physician assuming care of these patients must take care to ensure that inadvertent drug-drug interactions don’t result when medications are provided.

Barriers to Effective Communication

Sub-optimal communication is the most commonly linked cause of poor patient outcomes during transitions in care. ^{12, 17} One aspect of this transition of care process that is unique to EM physicians is the diversity that this communication may require. The information that is communicated about a patient between EM physicians may be very different than the conversation between an EM physician and a surgeon or primary care physician assuming care for the patient. As a result, EM physician needs to develop flexible communication practices as the situation warrants.

Without a physical space devoted to the hand-over process, EM physician to EM physician transitions in care occur in the midst of numerous distractions. Both providers may be distracted by various needs of the department, interruptions by other staff, and by the ambient noise of the ED.¹⁴ In addition to these distractions, the lack of a physical space with access to a tracking board could lead to omitting a patient during this process. ¹⁸ Electronic health record access during care transitions is important to adequately review up-to-date critical information.^{12, 19}

It is important to balance the amount of information exchanged about each patient during the transition process. Too little information may make it difficult to effectively carryout patient care plans; extraneous information may distract from the essential aspects of the case. Templates such as SBAR, I-PASS, SHOUT, and, SIGNOUT have been developed to standardize the hand-over process and are provided in Table 1.^20–24 However, these tools have never been validated.^15,20 They should be thought of as a minimal data requirement for the hand-over of patients.^{15,16, 25} It is important to note that patients at high-risk for hand-over related errors should be openly discussed and anticipatory guidelines should be developed.^{16, 18}

Table 1.

Transition in Care Templates

SBAR

S - Situation

B - Background

A - Assessment

R - Recommendation

SHOUT

S - Sick or not sick

H- History and Hospital course

O - Objective Date

U - Upcoming Plan, Disposition

T - To Do, Time for Questions

IPASS

I - Illness Severity

P - Patient Summary

A - Action List

S - Situation Awareness and Contingency Planning

S - Synthesis by Receiver

SIGNOUT

S - Sick or DNR

I - Identifying data

G - General hospital course

N - New events of day

O - Overall health status

U - Upcoming possibilities with plan

T - Tasks to complete overnight with plan rationale

? - Any questions

Even after the hand-over process is completed it may be unclear who is responsible for the patient. Does responsibility for the patient occur when the outgoing provider completes his verbal hand-over or is it when the outgoing clinician physically leaves the ED? This lack of clarity can be confusing for both ED staff and patients.

EM physician to admitting or consulting physicians hand-overs are fraught with communication barriers as well. There is rarely devoted space or time for this EM to non-EM physician exchange to occur. Rather, this process most often occurs while directly engaged in the care of other ED patients. We often page a consultant or admitting physician and do not have time to wait by the phone for a response. Because of this, EM physicians may be distracted and may not have access to the electronic health record when the hand-over occurs. Since most hand-overs occur over the phone, “read back” practices (such as in the aviation industry) and time for questioning may be helpful methods to address the non-face-to-face information exchange.¹⁹ In addition, consultants and admitting physicians often have different expectations from the EM physician of what information should be relayed in a hand-over and when care should be transitioned. ²

In the case of admitted patients who remain in the ED, it may not be clear who is responsible for the care of the patient. When does responsibility transition, is it when the hand-over is completed, when orders are placed, or when the patient leaves the department? Likewise, when consultants present to the ED to see a patient, responsibility for patient care may be unclear for both the patient and the healthcare team. Is the orthopedist responsible for the management of the fracture or is it the EM physician? Many of these ambiguities can be addressed by engaging all key stakeholders involved in the patient’s care.² A multidisciplinary approach to hand-over can benefit patients by improving interdepartmental relations, ensuring transfer of essential information, and providing seamless transition of responsibility during patient care.

Improving Current Transition in Care Practices

Recommendations to improve ED hand-overs supplement proposals put forth by the American College of Emergency Physicians Transition in Care Task Force.¹⁵ To improve care transition practices, an objective analysis of current end-of-shift processes between EM physicians as well as discussions with consulting, admitting, and transferring physicians should occur. For non-EM physicians, recommendations about the type of patient care information needed during transition exchanges would be beneficial. As time can be a constraint for both the giving and receiving physician, providing all the necessary information while omitting needless discussion can assist both parties. Understanding of “special circumstances” that need to be relayed at the time of the care transition, such as a patient’s psychosocial situation should be included.

Scrutiny as to whether the ED’s current transition process allows adequate time for the sharing of critical information should be examined. Off-going physicians may be motivated to rush as they may have tasks to complete before they leave and other obligations to attend to. On-coming physicians may already have patients to evaluate and may be reluctant to assume care of patients that they did not initially evaluate. Formalizing the hand-over process can help facilitate acceptance of this crucial point in patient care and ensure that both physicians understand the care plan. Understanding that patient care priorities may necessitate the interruption of the hand-over process, but that it nevertheless needs appropriate attention when circumstances stabilize, is key to ensuring that transitions provide patients with safe, on-going quality care.

When reviewing current hand-over systems in your ED, consider how the electronic health record can facilitate this process. Can a transition record help clarify when role and responsibility for patient care has occurred between physicians? Additionally, implementation of a systematic process for all care transitions may negate the loss of critical information during this process. However, physicians must realize that hand-over templates may not capture all the nuances of the individual patient. To truly support a performance improvement approach, continuous review of hand-over processes should be implemented. As a result of performance review, implementation of system changes and enhanced education can improve the culture of safety for our patients. Table 2 summarizes recommendations for an approach to review and implement processes to improve your current transition in care practices.

Table 2.

Recommendations to Improve Transition in Care Practices

Recommendation	Rationale
Review current practices	May allow identification of specific issues that should be changed or implemented -EM-to-EM process -EM-to-other specialty physician
Identify key information that should be included	Information may be different depending on the recipient and the patient’s condition
Identify specifically when responsibility for the patient changes	Clarifies expectations for patient care
Provide time at shift transitions devoted to transitions in care	Acceptance of process as important and not rushed, provide opportunity of provider who is assuming responsibility to summarize and clarify questions
Method of Communication	Electronic health record can identify the timing of change in responsibility and record exchanged information
Consider using a template as a guide	Ensures that crucial information will not be excluded if process is done the same way every time
Provider adaptability	Understanding that process is fluid based on current ED situation
Review problematic hand-overs	Allows for recognizing system issues and provider education issues

Conclusion

Physicians must embrace hand-over communication as one of the most critical aspects of patient care before any substantial improvement in this process can occur. EM physicians should understand that the environment and practice that makes our specialty unique also increase the likelihood for patient care errors. Examination of system and communication issues may identify processes that can be improved upon to enhance patient care transition safety.

Biography

Christine Sullivan, MD, FACEP, (top), MSMA member since 1983, is Associate Professor of Emergency Medicine, and Associate Dean for Graduate Medical Education, and Designated Institutional Official. P. Charles Inboriboon, MD, MPH, (bottom left) is Assistant Professor and Director of International Emergency Medicine Programs. Shelley Bridgford, MD, (bottom right) is a Third Year Emergency Medicine Resident. All are at the University of Missouri - Kansas City School of Medicine and Truman Medical Center in Kansas City, Missouri.

Contact: christine.sullivan@tmcmed.org