Assignment
Scenario: Handoffs in Patient Care
Midwest University Medical Center (MUMC) is a highly specialized tertiary referral and trauma center affiliated with a major university in the Midwest. The main hospital is a 600-bed acute care facility that receives roughly 45,000 patient admissions each year, more than half of which come through the emergency department (ED).
When physicians in the ED decide to admit a patient, they initiate an admission form in the electronic medical record (EMR), designating the service to which the patient is to be admitted. They also send a page to the admitting physician on that service. The admitting physician then calls the ED physician and takes a handoff over the telephone. During this handoff, the ED physician presents the patient's case, including some relevant medical history, information about the chief complaint, and how the patient has responded to care in the ED.
To a certain extent, the handoff signifies the transfer of responsibility for the patient from the ED to the inpatient service; however, this transfer can involve considerable ambiguity at times. Sometimes physicians on the inpatient services feel a patient would be better served by a different service. In such cases, they may redirect the admission to another service, and the ED physician must then make a handoff to that service.
Boarding in the ED
Patients must often remain in the ED for some period after the handoff- a process known as "boarding" - until an inpatient bed is available and a transport tech can move the patient to the inpatient ward. Consequently, a kind of gray zone exists in which patients may receive less attention as staff incorrectly assume that someone else is looking after them.
This problem is exacerbated by the fact that boarded patients may be physically out of sight. After the handoff conversation has occurred, ED staff often move these patients into the hallways of the ED to make room for incoming patients. ED nurses and physicians, going about their duties caring for new, incoming patients, are physically removed from the hallways where the boarded patients wait. Meanwhile, the inpatient staff are even farther away. The MUMC ED is in the basement of the hospital, and most of the inpatient wards are in the tower on floors 4 through 11.
Because MUMC tends to operate at or near capacity, boarding is frequent, and patients often remain in the ED for six or more hours after the handoff. When shift changes occur in the ED or inpatient services during these times of boarding, the risk of a patient falling ofT someone's radar increases.
A "New" Patient?
At 8:35 a.m. on a bleak February morning, Dr. Anita Henderson, a hospitalist, received an urgent page from a nurse. "Orders needed for Saunders. STAT. Nausea. In pain." Dr. Henderson was perplexed: She knew of no patient by the name of Saunders. She double•checked the paper list of patients she carried in her white coat. No Saunders. She looked at the whiteboard where her service lists the names of expected new patients. No Saunders. She asked several of her colleagues--other general internal medicine physicians on the hospitalist service if they had a patient by the name of Saunders, but no one recognized the name.
Dr. Henderson had just begun her seven-day rotation on the hospitalist service that morning. Dr. Chris Clark had rotated off the service the prior afternoon, and now his patients were her responsibility. When she arrived at 7:00 am, Dr. Henderson had taken handoffs from the night float residents who had been cross-covering the patients during the night. They had reported two new admissions, but neither was named Saunders.
Whose Patient is This?
Dr. Henderson picked up the phone and called the nurse who had sent the page. The nurse reported that Mr. Saunders was a 61 year-old male with a history of smoking, emphysema, and diabetes. He had been admitted to the ED for shortness of breath and had just recently arrived on the general medicine floor. The nurse said that Mr. Saunders was complaining of pain and feeling nauseated. Dr. Henderson asked who was listed as the patient's attending physician. The nurse responded, " Dr. Chris Clark."
Hearing the nurse's concern regarding the patient's condition, Dr.Henderson laid aside for the time being any further questions about how this patient came to be on her service without her knowing or receiving some kind of handoff from another physician. She went to see the patient for herself.
After examining and interviewing Mr. Saunders, Dr. Henderson concluded that he had missed at least one dose or each of his several home medications because of his stay in the ED. He was somewhat dehydrated, his emphysema was flaring up, and he was clearly short of breath. He was also complaining of a "funny feeling in his heart." Dr. Henderson also learned that he had been down in the ED since the previous rooming and had spent much of the afternoon and all of the night in a bed in a crowded hallway. She offered an apology to soothe the clearly irritated patient and wrote orders for his medications and for fluids.
Later, Dr. Henderson sat down and looked closely at the patient's electronic medical record. She found the name of the ED resident who had issued the admission orders the previous day and sent him a page asking him to call her. Twenty minutes later, Dr. Calvin Lee , a third-year resident in the MUMC ED, called Dr. Henderson.
Dr. Henderson: This is Anita Henderson.
Dr. Lee: Hi, Anita . It's Calvin Lee returning your page.
Dr. Henderson: Hi, Calvin. Thanks for calling me back. I wanted to ask you about a patient by the name of Saunders. Did you admit him yesterday?
Dr. Lee: Saunders? Sounds familiar. We see so many.
Dr. Henderson: He says he came in yesterday morning with shortness of breath and maybe an irregular heartbeat . Hc has a history of smoking and emphysema.
Dr. Lee: Oh, my gosh! Yes! Did he end up on your service?
Dr. Henderson: Yes. He just arrived, and he's not doing well. I think he missed his medications and is dehydrated . Sounds like he was boarded overnight in the ED.
Dr. Lee: Could be . We were overflowing yesterday. Still super busy down here today. So, how can I help>
Dr. Henderson: Well I just got a page from the floor nurse saying he was on my service and needed attention, but that was the first I heard of him. I'm trying to learn more about him and also find out where the ball got dropped.
Dr. Lee:: Wow, nobody handed him off to you? And he is just getting to the floor now?
Dr. Henderson: Yes.
Dr. Lee: Well, that was a big mess yesterday. His EKG showed an irregular heart rhythm, so I called pulmonary because I thought the abnormal rhythm might be. due to his emphysema. But pulmonary said, "Oh, no, no. We think they're two separate issues. Admit to cardiology to get the heart rate under control and we'll consult." But then, when I called cardiology, and they heard about the emphysema, they were like, "No, no, no. This is a pulmonary problem, and the heart is just a side victim. This has nothing to do with us, and what are we going to do with this? And he's going to be on our service for four days recovering from emphysema, and this is ridiculous and this is not what we do." Oh my gosh! They went back and forth and had me call the hospitalist service-Dr. Clark, I think. I can't even remember how many phone calls there were. I finally told them to work it out and then call me back. But I guess they never did. WhenI left at 3:00 p.m., I handed the pager off to my colleague
Handoffs Within the ED
As the conversation continued, Dr. Henderson realized that the patient had been handed off several times in the ED--first when Dr. Lee's shift ended at 3:00 pm, and then again at the subsequent shift changes at 1:00 pm and 7:00 am. From experience, Dr. Henderson knew the details about patient cases tend to get lost with multiple handoffs, particularly when patients have already been officially admitted and are being boarded in the ED.
Dr. Henderson learned that Dr. Lee had listed the hospitalist service as the admitting service in the EMR because, at the point when he issued the admission order, neither the pulmonary service nor the cardiology service seemed likely to take him as a patient, meaning the hospitalist service would have to take him. Dr. Henderson knew that the EMR system requires an admitting service to be selected to start the admissions process. She also knew that because Dr. Clark was responsible for the admissions pager for the hospitalist service yesterday, the EMR system would have designated him as the attending by default.
Dr. Lee also said that when he handed the patient off to his colleague at the end of the shift, he had instructed her to update the EMR once the final decision on placement had been made and to update the involved services.
Epilogue
Dr. Henderson cared for Mr. Saunders with consultations from physicians in the pulmonary and cardiology services and discharged him home after several days. When Dr. Clark returned to work a few days later, Dr. Henderson asked him about the patient's case. Dr. Clark told her that, when he had left that evening, the issue about where the patient would go had not been settled, as the other services were waiting for results from additional tests. Dr. Clark said he notified the night night resident about Mr. Saunders and that the ED would call if the patient were going to be admitted to the hospitalist service.
Task
A. Multiple factors contributed to the problem. Identify as many distinct factors as possible.
B. Using the list of contributing factors from question A, develop some strategies to reduce the likelihood of a recurrence.
C. Identify all of the stakeholders (see Ex.1.3) who were affected by this situation and describe how they were affected.
D. Was this an example of "excellent" care? Use the SEPTEE criteria (Ex. 1.1) as a guide when answering.
E. As a hospital administrator, what would one should do if this case had occurred in your hospital?