Monday, November 23, 2015
The Time of Highest Risk in Emergency Medicine
Medical care has always claimed that certain timeframes as critical to life and limb. Examples are 1) The “Golden Hour of Trauma,” 2) 90 minutes to PCI for a heart attack, 3) 90 minutes to receive TPA for strokes. The numerical value assigned for each of these times is subject to ongoing debate, and so the consensus changes periodically.
ED physicians generally agree that the interval of greatest risk for patients is during shift change, and its resulting turnover of care from one provider to another. This period of higher risk impacts nurses, physicians, techs, and all other providers. Indeed, the well being of the patient is highly dependent on the communication skills and the other established processes of a facility that transition their care from the old, departing, to the new, oncoming, teamThe article Handover in the emergency department: Deficiencies and adverse effects delineated the problem way back in 2007. The author’s state:
“Deficiencies in handover processes exist, especially in communication and disposition information. These affect doctors, the ED and patients adversely. Recommendations for improvement include guideline development to standardize handover processes, the greater use of information technology facilities, ongoing feedback to staff, and quality assurance and education activities.”Nevertheless, the “turnover problem” and its obvious risks still exist today, despite that fact that many EDs and some EHRs have tried to create processes to limit pitfalls and liability. Since the early 1990’s XpressTechnologies included a structured turnover note with its comprehensive set of templates.
The idea behind the turnover note was to facilitate systematic communication from a first provider that to the next provider, in that note was key information on the nature of the case, state of workup, and expected outcome for the most likely clinical course. The details included:
1. Pt name and location
2. Course so far: a) Initial presentation b) workup done c) communications made d) workup anticipated
3. Key tests awaited (needed for disposition).
4. Anticipated optimal clinical scenario for patient disposition, patient satisfaction, best outcome (repeat physical, see if patient improves, etc.)
5. Consultant names and contact numbers (primary physician, expected admitting physician, referral physicians, and consultants called or coming).
6. Cautions (what to watch out for, any risks to keep an eye upon)
The note was structured to allow brief, clear, few-word responses that could be seen at a glance. Still, the turnover process has historically not done a good job putting down key information was actually conveyed to the patient. For example:
1. Was the turnover done at the bedside? As a three-way discussion?
2. Was the patient (and the family) introduced to the next provider?
3. Was a game plan reiterated for all; to patient, family, and caregivers?
Top ED physicians know, perhaps a bit subconsciously, that going through these simple steps helps avoid disasters of the type that turnovers sometimes create. They know that avoiding abrupt hand-offs like: “if the tests are negative, discharge the patient,” helps avoid disasters and increases patient and family satisfaction. But is that avoidance always accomplished? When we are leaving, and convinced everything will be fine, do our wiser minds always rule?
Suggested safeguards are:
1. Have an organized plan that people adhere to.
2. Have turnovers rules. Include rules about how many turnovers are allowed, about types of patients allowed and disallowed, about expected time before the new doctor returns to check, and about what to do if unexpected problems arise (e.g. the family is at the nurses station complaining that the doctor has not been back in hours).
3. Providers should be realistic about the nature of emergency practice. We just do not always get to leave when the posted coverage schedule says we should. And so it is a bit dangerous (especially to the patient) to be obsessed with “leaving on time.” Compensation models can be adjusted to reward the most conscientious practitioners, and some practices find ways to avoid inadvertently encouraging providers to quit seeing new patients too early. A team approach can be created that so that reasonable turnovers are readily accepted. Doing so for others, and doing it safely, means the same can be done for you.
4. The bottom line is that high-risk turnovers can be transformed into low-risk patient and provider communication opportunities. Careful planning and appropriate rewards for those practicing this kind of safe medicine can really benefit patients, hospitals, and ED teams.