Christopher Beach

Improving Handoffs in the Emergency Department

Patient handoffs at shift change are a ubiquitous and potentially hazardous process in emergency care. As crowding and lengthy evaluations become the standard for an increasing proportion of emergency departments (EDs), the number of patients handed off will likely increase. It is critical now more than ever before to ensure that handoffs supply valid and useful shared understandings between providers at transitions of care. The purpose of this article is to provide the most up-to-date evidence and collective thinking about the process and safety of handoffs between physicians in the ED. It offers perspectives from other disciplines, provides a conceptual framework for handoffs, and categorizes models of existing practices. Legal and risk management issues are also addressed. A proposal for the development of handoff quality measures is outlined. Practical strategies are suggested to improve ED handoffs. Finally, a research agenda is proposed to provide a roadmap to future work that may increase knowledge in this area.

Shift Changes among Emergency Physicians: Best of Times, Worst of Times

The need for 24-hour emergency care requires emergency department (ED) staff to work in shifts. Shift changes have long been viewed as risky times, for failures in the transfer of information, authority, or responsibility care can result in adverse events. We observed shift transitions in the ED as part of a study on safety in emergency care. We found that, in addition to being an expected point of failure, transitions were also, unexpectedly, associated with recovery from failure. We report two illustrative case studies, and examine implications for strategies aimed at reducing the number of and volume of transitions.

Improving Interunit Transitions of Care Between Emergency Physicians and Hospital Medicine Physicians: A Conceptual Approach

Patient care transitions across specialties involve more complexity than those within the same specialty, yet the unique social and technical features remain underexplored. Further, little consensus exists among researchers and practitioners about strategies to improve interspecialty communication. This concept article addresses these gaps by focusing on the hand-off process between emergency and hospital medicine physicians. Sensitivity to cultural and operational differences and a common set of expectations pertaining to hand-off content will more effectively prepare the next provider to act safely and efficiently when caring for the patient. Through a consensus decision-making process of experienced and published authorities in health care transitions, including physicians in both specialties as well as in communication studies, the authors propose content and style principles clinicians may use to improve transition communication. With representation from both community and academic settings, similarities and differences between emergency medicine and internal medicine are highlighted to heighten appreciation of the values, attitudes, and goals of each specialty, particularly pertaining to communication. The authors also examine different communication media, social and cultural behaviors, and tools that practitioners use to share patient care information. Quality measures are proposed within the structure, process, and outcome framework for institutions seeking to evaluate and monitor improvement strategies in hand-off performance. Validation studies to determine if these suggested improvements in transition communication will result in improved patient outcomes will be necessary. By exploring the dynamics of transition communication between specialties and suggesting best practices, the authors hope to strengthen hand-off skills and contribute to improved continuity of care.

A Comparison of Manual and Electronic Status Boards in the Emergency Department: What's Gained and What's Lost?

Emergency departments (EDs) are complex, high tempo, high risk work environments that require dynamic sharing of information across a group of caregivers. EDs commonly use status boards as tools to facilitate this sharing. Manual status boards have been replaced in some institutions by electronic ones, for a variety of reasons. We contrast the use of manual and electronic status boards in 4 different EDs to assess the gains and losses for workers.

Transitions in Care: Signovers in the Emergency Department:

The need for 24-hour emergency care requires emergency department (ED) staff to work in shifts. We observed shift transitions in 5 EDs as part of a study on safety in emergency care. We found the observable characteristics of shift transitions to be highly variable across institutions and dynamically variable within shift change episodes. However, across all sites, turnovers were interactional rather than transactional, and were highly tailored to the immediate context. The high degree of situatedness in the turnovers suggest they are not likely to be adapted to a standardized tool or protocol.

Clinical operations in academic emergency medicine.

The operations of an emergency department are increasingly being recognized as vital to the provision of safe, efficient, quality care. The numerous and highly variable processes that characterize our system must be closely examined and investigated to identify those which are effective and those which are not. Original research in this field should be promoted and embraced by our society for both our patients and our profession. Effective operational processes should ultimately be seen as those which preserve and enhance the patient-physician relationship.

The Taxonomy of Emergency Department Consultations—Results of an Expert Consensus Panel

INTRODUCTION AND NECESSITY FOR TAXONOMY OF CONSULTATIONS The basis of all consultations is communication between clinicians. Consultation is a “service type provided by a physician whose opinion or advice regarding evaluation or management of a specific problem is requested by another physician or other appropriate source.” Patient safety is a major concern in physician-to-physician communication, with evidence showing that transitions of care, specifically during consultations, are high-risk periods. Effective interpersonal communication is fundamental to safe patient care. It lies at the core of the continuum of care from clinician to clinician, shift to shift, between departments and between hospitals. In the emergency department (ED), there is a high frequency of consultations on a wide spectrum of disease processes and medical conditions facing emergency physicians. Additionally, with the increasing scrutiny of resource use and transfers of care, including consultants in crowded EDs, improving safety during consultations grows increasingly important. Consultations may have a place early in what often becomes a transfer of responsibility for patients, yet they are distinct from handoffs or transfers of care. Like transfers in care, there is no current agreement on the definition of a “standard” consultation between an emergency physician and the wide variety of specialists with whom they regularly consult (M. Cohen, B. Hilligoss, unpublished data, 2010). Consultations vary in type and content within and across EDs. They range from questions to requests for procedural assistance, can occur in person or by telephone, and are performed by various types of providers. According to the National Hospital Ambulatory Medical Care Survey, there were 117 million ED visits in 2007. A recent review found that 20% to 40% of patients admitted from the ED received at least 1 specialist consultation during their ED course. In addition, a recent study showed a 94% increase in the probability that an ED’s patient visit would result in a consultation or referral to a specialist between 1999 and 2009. (

HANDOFF COMMUNICATION AND ELECTRONIC HEALTH RECORDS: EXPLORING TRANSITIONS IN CARE BETWEEN EMERGENCY PHYSICIANS AND INTERNAL MEDICINE/HOSPITALIST PHYSICIANS

When transferring patient care responsibilities across the healthcare continuum, clinicians strive to communicate safely and effectively, but communication failures exist that threaten patient safety. Although researchers are making great strides in understanding and solving intraservice handoff problems, inter-service transition communication remains underexplored. Further, electronic health records (EHRs) figure prominently in healthcare delivery, but less is known about how EHRs contribute to inter-service handoffs. This descriptive, qualitative study uses Sensemaking Theory to explore EHR-facilitated, inter-service handoffs occurring between emergency medicine and internal/hospitalist medicine physicians. The researchers conducted six focus groups with 16 attending physicians and medical residents at a major Midwestern academic hospital. Findings suggest clinicians hold varied expectations for information content and relational communication/style. Their expectations contribute to making sense of uncertain handoff situations and communication best practices. Participants generally perceive EHRs as tools that, when used appropriately, can enhance handoffs and patient care continuity. Ideas for practical applications are offered based on study results.

Conceptual Framework for Studying Shift Changes and other Transitions in Care

In healthcare systems, division of labor and the need for continuous, 24 hour care subjects patients to multiple transitions in care. These transitions, or turnovers, are potential points of failure but have not been intensively studied. We observed care transitions in 5 EDs as part of a study on safety in emergency care and found that very different sorts of handovers occur in different settings. Based on these observations, we propose a conceptual framework for characterizing turnover events. The ability to characterize certain types of transitions may help clarify future studies and assist in crafting interventions to the context of work.

Exploring role dialectics in inter-service admission handoffs: a qualitative analysis of physician communication

ABSTRACT Admission handoffs between emergency physicians (EPs) and internal medicine/hospitalist physicians (IMHPs), a frequently occurring form of patient transfer, remain understudied despite their importance to care continuity. Handoffs function as more than simple information transfer; they require a repertoire of interpersonal skills to accomplish tasks and develop professional relationships. Relational Dialectics Theory (RDT), a perspective that asserts social life consists of oppositional and unified discourses present in personal relationships, frames the current study. We use role dialectics to more fully understand the contradictions that emerge from the competing discourses of physician roles. Data were collected from six focus groups consisting of residents and attending physicians working at a large, urban, academic medical center in the Midwest United States. Using a grounded, constant-comparative approach, analysis of transcripts reveals that these physicians encounter two key role dialectics during handoffs: autonomy–collaboration and uncertainty–certainty. Interventions for physicians and hospital decision-makers are recommended.