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ED-to-inpatient transfers are flawed with safety gaps

Hospitalist Management Advisor, October 1, 2008

New study

ED-to-inpatient transfers are flawed with safety gaps

Why one-quarter of ED-to-inpatient transfers are near misses

For years, the inpatient medicine leaders at Yale-New Haven (CT) Hospital (YNHH) fielded complaint after complaint from house staff members and hospitalists about new admissions from the emergency department (ED). Both groups complained of poor communication.

What might seem like cross-specialty bickering actually is something more serious. As the hospital leaders were aware, ED physicians were becoming increasingly frustrated with their inability to reach internal medicine (IM) physicians to safely transfer care of patients because of their busy schedules.

More than one-quarter of patients transferred from the ED to IM experience an adverse event or near miss, according to a recent study, “Dropping the Baton: A Qualitative Analysis of Failures during the Transition from Emergency Department to Inpatient Care,” published in the Annals of Emergency Medicine and conducted by the hospital.

Twenty-nine percent of the 139 respondents reported an adverse event or near miss related to the ED-to-inpatient handoff, according to the study.

“ED and IM leaders debated several proposed solutions, but we quickly realized that we didn’t exactly understand what was going wrong and why,” says Leora Horwitz, MD, MHS, associate medical director of Center for Outcomes Research and Evaluation at YNHH.


A search for answers

Like many healthcare organizations, communication gaps exist between different specialties of care providers at YNHH. Although a common problem, there is little existing literature to guide organizations. “Most of the work to date has focused on patient transfer within the same specialty, such as shift-to-shift handoffs. Much less work has been done to evaluate handoffs between specialties, one of the most common being the ED-to-medicine transfer,” says Nidhi Shah, MD, MPH, hospitalist attending physician and chief medical information officer at YNHH.

As part of the YNHH research team, Horwitz and Shah closely examined the vulnerable aspects of ED-to-IM transitions within their organization to identify potential deficiencies in care that they hoped to solve.


The survey spots a red flag

After designing its own survey on ED-to-IM transitions, YNHH administered it to every physician or physician assistant who provided or received a sign-out slip about patients transferred from the ED to the inpatient medical units. That list included every ED house staff member, ED physician assistant, IM house staff member, and IM hospitalist. Researchers chose these staff members because they are the “frontline staff,” as Shah calls them (i.e., those with significant insight into the handoff process). In addition, all the hospitalists were targeted for the survey particularly because YNHH has a separate hospitalist medicine service unconnected to the teaching service.

“They are in the best position to know what is and what is not working in a process because they live it every day,” Shah says.

Although only half of the selected staff members completed the survey, YNHH still garnered plenty of useful information. Specifically, 29% of responders reported that a patient had experienced an adverse event or near miss after ED-to-inpatient transfer. These 40 respondents described specific incidents of errors: diagnosis (13), treatment (14), and disposition (13), after which patients experienced harm or a near-miss event. Six patients even required an upgrade from the floor to the ICU.

What was the cause? Many surprisingly responded by describing a variety of safety gaps that affected the transfer of patients from ED to IM floors, not just direct communication errors, Horwitz says.

Participants identified the following problematic areas:

  • Communication within the ED
  • Communication between the ED and IM
  • Environment of the ED and hospital (physical space, crowding, workload)
  • Information technology
  • Flow of patients from the ED to the floor
  • Assignment of responsibility for patients and results


ED speak vs. IM talk

In addition, researchers learned that ED staff members were not as aware of adverse events as their IM counterparts; only 13.5% of ED respondents said they knew an adverse event occurred after the transfer process, compared to 38% of both hospitalists and medicine residents.

“Even restricting ourselves to communication—our original interest—we were interested to see that failures were not solely (or perhaps even typically) due to lack of content, which is what people typically assume is a communication failure,” Horwitz says.

Rather, a variety of factors played into miscommunication, including the following variables:

  • Conflicting expectations about what content each side should convey
  • Mutual misunderstanding of job roles
  • Pronounced bias and mistrust of other specialties
  • Insufficient prioritization of real-time interaction


Because the roles of ED and IM doctors differ, they tend to be concerned with different objectives and ask different questions.

The role of an IM physician is primarily to definitively determine a patient’s diagnosis and initiate the proper long-term treatment, Horwitz says. The role of an emergency physician is to assess and maintain the patient’s current stability.

“We found that internal medicine and emergency physicians did not always appreciate these fundamental role differences, creating or exacerbating communication failures,” Horwitz says.

One oversimplified example is if a patient with shortness of breath presents to the emergency room, ED physicians would first ask themselves the following questions: How sick is this patient? Does he or she belong in the ICU or on a regular unit? Does this patient have a medical problem or a surgical problem? Where should I admit this patient? ED communication at YNHH was thus often focused around these key issues.

IM physicians, on the other hand, wanted to hear whether this patient had heart failure or pneumonia. “These sorts of conflicting expectations were a setup for mutual frustration and negative stereotyping,” Horwitz says.


Which specific factors led to adverse events?

The study identified several factors responsible for the adverse events. Omission of pertinent patient data played a role, most commonly following omission of the most recent vital signs.

Environment played a factor too. When the ED was crowded, handoff communication was rushed, and there was less opportunity for interaction between the sending and receiving team, Shah says. Patient flow was also identified as a vulnerability in the transfer process.

“For example, if a patient was booked to a medicine team but continued to board in the ED while waiting for a bed, sometimes additional test results to assess the patient’s current condition during the wait period was not communicated back to the receiving team,” Shah explains.


Tips for improvement

Horwitz suggests the following tips to improve communication failures:

Improve intraspecialty relations to reduce stereotyping and bias. Clarify roles and responsibilities. Hold a monthly ED-IM joint conference to discuss a case study. Conduct intraspecialty social events. Promote cross-training rotations in the ED for IM staff members.

Train hospitalists and house staff members to provide and receive sign-out consistently and more accurately. Emphasize higher-order content, such as the degree of certainty about the diagnosis, important pending information, and response to treatments initiated in the ED. De-emphasize factual content that is readily available from the chart or computer system. Design audit and feedback methods especially for trainees.

Make the ED personnel involved in failed transfers aware of this information immediately.

Be creative about workload. Consider taking on fewer admissions to limit the stress of on-call days. Overworked physicians can hand off work to underutilized physicians during the shift, and not after the shift is over. Replace numeric pagers with alphanumeric pagers and alphanumeric pagers with phones.

Prioritize discharge work earlier in the day to ease the burden on the ED.

Take responsibility for giving sign-out information to the new team member if a patient is rebooked from someone else on your team.

Remember long-term boarding patients. Pay particular attention to those likely to require continual intervention (e.g., asthmatics).

Distribute official policies about responsibility for boarding patients, pending data, etc.

Institute pager forwarding, team pagers, or computerized assignment of responsibility to all staff members.

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