Spotlight Case

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Spotlight Case

• All in the History

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Source and Credits

• This presentation is based on the February/March
  2009 AHRQ WebMM Spotlight Case
• See the full article at http//webmm.ahrq.gov
• CME credit is available
• Commentary by Christopher Fee, MD, University of
  California, San Francisco
• Editor, AHRQ WebMM Robert Wachter, MD
• Spotlight Editor Bradley A. Sharpe, MD
• Managing Editor Erin Hartman, MS

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Objectives

• At the conclusion of this educational activity,
  participants should be able to
• Describe EMTALA and understand that it does not
  apply to transfers to emergency departments from
  non-acute facilities (e.g., nursing homes)
• State interventions to improve communication
  between referring facilities (such as nursing
  homes or clinics) and emergency departments
• Describe what critical information should be
  conveyed during transitions in patient care in
  the emergency department
• Appreciate how emergency physicians and inpatient
  physicians differ in their approach to patient
  diagnoses

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Case All in the History

• A fatigued emergency department (ED) physician
  was coming to the end of a long shift when he was
  informed of a patient referral from an area
  nursing home. On the phone, the nursing home
  physician started to explain, Im sending you a
  68-year-old man with a history of interstitial
  lung disease who has been having some shortness
  of breath At that moment, the call was
  interrupted when a senior nurse grabbed the ED
  physician and said, We need you in code room one
  now! The paramedics had just arrived in the ED
  with a critically ill patient.

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Case All in the History (2)

• In the code room, the physician found an elderly
  man with no pulse, no blood pressure, and very
  low oxygen saturation. The physician began
  advanced life supportthe patient was intubated
  and placed on mechanical ventilation, and given
  intravenous fluids, epinephrine, and atropine to
  treat his pulseless arrest. The patient regained
  a pulse and blood pressure after a few minutes
  but remained critically ill. Once the patient was
  somewhat stabilized, the ED physician searched
  for further information about the patient. The
  paramedics who had delivered the patient had left
  without speaking with him and did not leave any
  paperwork or documentation.

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Case All in the History (3)

• The physician managed to find some papers with
  the patient that identified him as a 68-year-old
  nursing home resident with shortness of breath
  and included scant notes about medications, but
  no further information on past medical history.
  Only many hours later did the ED physician
  realize that this patient was the 68-year-old man
  the nursing home physician had tried to sign out
  initially. Because of the interrupted signout and
  inadequate handoff from the paramedics, the ED
  physician had no choice but to proceed with the
  evaluation and treatment of this patient despite
  minimal information.

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Emergency Department (ED) Referrals

• Some patients referred to EDs from other EDs,
  hospitals, nursing homes, or clinics
• Emergency Medical Treatment and Labor Act
  (EMTALA) regulates referrals from other EDs or
  other hospitals
• EMTALA does not apply to non-acute care
  facilities such as nursing homes or clinics

See Notes for reference.
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ED Referrals (cont.)

• Although not law, it is professional courtesy to
  contact EDs ahead of time about patients referred
  from nursing homes or clinics
• This communication should follow the handoff
  guidelines described by the Joint Commission

See Notes for references.
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Joint Commission Effective Handoffs

• Interactive communication allowing for questions
  between giver and receiver of patient information
• Up-to-date information about patient condition,
  care, treatment, medications, services, and
  recent or anticipated changes
• Methods to verify received information, including
  repeat-back or read-back techniques
• Opportunities for the receiver to review relevant
  patient historical data, which may include
  previous care, treatment, or services
• Limited interruptions to minimize the possibility
  that information fails to be conveyed or is
  forgotten

See Notes for references.
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Nursing Home or Clinic Referrals

• Three simple interventions to improve handoff
• Use checklists to gather crucial information (see
  Figure next slide)
• Dedicate one ED physician to handle referrals
• Task non-physician personnel with gathering
  demographic and non-clinical data

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UCSF ED Referral TemplateReproduced with
permission.
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Emergency Medical Services (EMS) Handoff

• This case highlights potential for lost
  information at the EMS-to-ED transition
• Many systems require EMS providers to radio/call
  the receiving ED prior to arrival
• These ringdowns are necessarily limited in
  amount of information and often complicated by
  poor reception

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EMS-to-ED handoffs

• Formal face-to-face verbal report on the patient
  should be required of EMS providers
• This verbal report should include the patients
  history, pertinent examination findings
  (including vitals), and any response to
  pre-hospital treatment

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EMS-to-ED handoffs

• EMS providers required to complete a written
  (paper or electronic) report for each patient (a
  runsheet)
• These runsheets may contain essential information
  that is not conveyed verbally
• In one ED, EMS personnel relayed verbally only
  44 of pertinent data from their runsheets
• EDs should require their physicians to sign
  runsheets to document receipt of the information

See Notes for reference.
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Case (cont.) All in the History (4)

• A stat chest radiograph revealed infiltrates in
  the left lung. Based on the minimal information
  at hand (the history of shortness of breath, the
  low oxygen levels, the cardiac arrest, and the
  chest x-ray), the ED physician made a presumed
  diagnosis of aspiration pneumonia with
  respiratory arrest and septic shock. The patient
  was given intravenous antibiotics, fluids, and
  vasopressors for blood pressure support.

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Case (cont.) All in the History (5)

• The ED physician contacted the team that would be
  managing the patient in the ICU. He remained busy
  with this patient (and others in the ED) and
  could only give a brief signout The patient is
  a 68-year old man with a possible history of lung
  disease, with probable aspiration pneumonia. Hes
  intubated, on pressors, and already got
  antibiotics. He needs to get up to the ICU. At
  that moment, another patient was crashing and the
  physician had to hang up.

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Case (cont.) All in the History (6)

• The admitting ICU team evaluated the patient and
  agreed with the initial assessment (although they
  were bothered at the limited information
  available). The patient was taken to the ICU.
  Three hours later, the patient had another
  arrest, becoming pulseless without a blood
  pressure. After being treated with aggressive
  fluids and three vasopressor medications, his
  blood pressure remained low.

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Case (cont.) All in the History (7)

• At this point, the admitting team remained
  puzzled and contacted the nursing home physician.
  Further history revealed the patients shortness
  of breath had been very acute in onset, had been
  associated with chest pain, and the patient had
  stated at the time he felt faint and like he was
  going to die. Based on this vital information,
  the team became concerned that a pulmonary
  embolism (blood clot to the lungs) was the cause
  for his critical illness.

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Case (cont.) All in the History (8)

• The patient was treated with thrombolytics
  (clot-busters) for presumed massive pulmonary
  embolism 5 hours after he arrived at the
  hospital. The patient immediately responded to
  treatment, with improvements in his oxygen level
  and blood pressure. He continued to improve and,
  after a prolonged hospitalization, ultimately
  returned to the nursing home.

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ED-to-Inpatient Handoff

• ED-to-inpatient handoff is another care
  transition that can lead to medical errors
• This transfer should also follow Joint Commission
  Patient Safety guidelines
• ED-to-inpatient provider signout should be brief
  but thorough and include the following items (see
  next slide)

See Notes for reference.
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Information to Include in ED-to-Inpatient Handoff

• Presenting complaint and history of present
  illness
• Pertinent past medical history, pertinent
  medications, allergies
• Pertinent social/family history
• Presenting vital signs and pertinent physical
  exam findings
• Pertinent lab, radiographic, electrocardiographic
  data

• Therapeutic interventions and response to therapy
• Most recent vital signs
• Working diagnoses (including differential)
• Pending studies
• Code status (if known)
• Contact information for referring providers or
  primary physician, if available

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Errors during the ED-to-Inpatient Handoff

• In survey, 29 of emergency and internal medicine
  providers reported that a patient had adverse
  event or near miss after an ED-to-inpatient
  transfer
• These events were most often errors in
  diagnosis, treatment, or disposition

See Notes for reference.
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Factors Contributing to Handoff Errors

• Inaccurate or incomplete information
  (particularly vital signs)
• ED crowding and high provider workload
• Difficulty for inpatient providers to access key
  information (vitals, ED notes, ED orders, pending
  data, etc.)
• Patients boarded in the ED
• Ambiguous responsibility for signout or follow-up

See Notes for reference.
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Potential Solutions to Improve Transition

• Improved electronic access to key information
• Vital signs, ED notes and orders, laboratory and
  radiology studies, and pending studies
• Signout checklists

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Different Approach to Diagnoses

• Recent survey and this case also highlight
  different path that ED and inpatient providers
  take to determining diagnoses
• Many ED physicians feel their role is to
  stabilize and determine appropriate disposition
  and not to achieve a final diagnosis
• ED diagnoses are necessarily uncertain at best
  this uncertainty is not always appreciated by
  admitting providers

See Notes for reference.
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Hazards of Premature Closure

• Tendency to stop considering other possible
  diagnoses after a diagnosis is reached
• As a result, inpatient providers may trust too
  strongly (or anchor) on the ED diagnosis

See Notes for reference.
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Preventing Premature Closure

• ED physicians can help by acknowledging
  diagnostic uncertainty, by referring to the
  patients complaint as the final ED diagnosis,
  and by suggesting a differential
• Respiratory failure of unclear etiology,
  possible aspiration vs. pneumonia vs. pulmonary
  embolism
• Inpatient providers should consciously ask
  themselves over time, What alternatives should
  be considered?

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Take-Home Points

• Transitions of care in the emergency department
  should follow Joint Commission standardized
  guidelines for effective handoff communications
• Emergency departments should employ checklists
  (either paper or digital) to improve transitions
  of care from referring facilities
• Emergency medical services personnel should be
  required to provide a direct verbal signout to ED
  providers as well as a written report (runsheet)

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Take-Home Points (2)

• The handoff between the ED and inpatient teams
  should be brief but standardized to include the
  pertinent clinical information
• Emergency physicians and inpatient services
  approach final diagnoses in different ways, and
  this cultural divide can lead to errors and poor
  patient outcomes. Both groups should strive to
  understand and appreciate the others perspective