Dickson S. Cheung

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.

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.

Assessment of Medicare's imaging efficiency measure for emergency department patients with atraumatic headache.

STUDY OBJECTIVE Computed tomography (CT) use has increased rapidly, raising concerns about radiation exposure and cost. The Centers for Medicare & Medicaid Services (CMS) developed an imaging efficiency measure (Outpatient Measure 15 [OP-15]) to evaluate the use of brain CT in the emergency department (ED) for atraumatic headache. We aim to determine the reliability, validity, and accuracy of OP-15. METHODS This was a retrospective record review at 21 US EDs. We identified 769 patient visits that CMS labeled as including an inappropriate brain CT to identify clinical indications for CT and reviewed the 748 visits with available records. The primary outcome was the reliability of OP-15 as determined by CMS from administrative data compared with medical record review. Secondary outcomes were the measures validity and accuracy. Outcome measures were defined according to the testing protocol of the American Medical Associations Physician Consortium for Performance Improvement. RESULTS On record review, 489 of 748 ED brain CTs identified as inappropriate by CMS had a measure exclusion documented that was not identified by administrative data; the measure was 34.6% reliable (95% confidence interval [CI] 31.2% to 38.0%). Among the 259 patient visits without measure exclusions documented in the record, the measures validity was 47.5% (95% CI 41.4% to 53.6%), according to a consensus list of indications for brain CT. Overall, 623 of the 748 ED visits had either a measure exclusion or a consensus indication for CT; the measures accuracy was 16.7% (95% CI 14% to 19.4%). Hospital performance as reported by CMS did not correlate with the proportion of CTs with a documented clinical indication (r=-0.11; P=.63). CONCLUSION The CMS imaging efficiency measure for brain CTs (OP-15) is not reliable, valid, or accurate and may produce misleading information about hospital ED performance.

Data-driven process and operational improvement in the emergency department: the ED Dashboard and Reporting Application.

EXECUTIVE SUMMARY Emergency departments (EDs) in the United States are expected to provide consistent, high‐quality care to patients. Unfortunately, EDs are encumbered by problems associated with the demand for services and the limitations of current resources, such as overcrowding, long wait times, and operational inefficiencies. While increasing the effectiveness and efficiency of emergency care would improve both access and quality of patient care, coordinated improvement efforts have been hindered by a lack of timely access to data. The ED Dashboard and Reporting Application was developed to support datadriven process improvement projects. It incorporated standard definitions of metrics, a data repository, and near real‐time analysis capabilities. This helped acute care hospitals in a large healthcare system evaluate and target individual improvement projects in accordance with corporate goals. Subsequently, there was a decrease in “arrival to greet” time—the time from patient arrival to physician contact—from an average of 51 minutes in 2007 to the goal level of less than 35 minutes by 2010. The ED Dashboard and Reporting Application has also contributed to datadriven improvements in length of stay and other measures of ED efficiency and care quality. Between January 2007 and December 2010, overall length of stay decreased 10.5 percent while annual visit volume increased 13.6 percent. Thus, investing in the development and implementation of a system for ED data capture, storage, and analysis has supported operational management decisions, gains in ED efficiency, and ultimately improvements in patient care.

Evaluation of the patient with closed head trauma : An evidence based approach

This article approaches the subject of closed head trauma from the time-sensitive vantage point of the emergency physician. As the clinical scenario unfolds, he or she constantly evaluates the need for diagnostic tests as information is received from paramedics, nurses, and the history and physical examination. This article provides a synopsis and a critique of original clinical trials to aid the emergency physician in making an evidence based decision.

Measuring Patient Safety in the Emergency Department

As a safety net for the health care system, quality and safety performance in emergency medicine (EM) is important for policy makers, insurers, researchers, health care providers, and patients. Developing performance indicators that are relevant, valid, feasible, and easy to measure has proven difficult. To monitor progress, patient safety should be measured objectively. Although conceptual frameworks and error taxonomies have been proposed, a practical scorecard for measuring patient safety over time in EM has been lacking. This article proposes a framework that measures safety through 4 major domains: (1) how often patients are harmed, (2) how often appropriate interventions are delivered, (3) how well errors in the system are identified and corrected, and (4) emergency department (ED) safety culture. Examples of specific measures for each of these domains are provided, but the EM community should reach consensus on what measures are important for the ED environment and patients.

Strategies for improving communication in the emergency department: Mediums and messages in a noisy environment

Alarge body of research provides strong evidence that hospitals are loud environments with noise levels far exceeding those recommended by the World Health Organization (WHO). WHO guidelines specify 35 decibels (dB) for continuous background noise in patient rooms, with nighttime peaks not to exceed 40 dB. Hospital background noise exceeds those levels, and peaks frequently exceed 90 dB. Staff voices and medical equipment typically produce noise at 70–75 dB levels. Other sources of noise include alarms, bedrails, telephones, ice machines, paging systems, and pneumatic tube systems. The noise from portable x-ray machines can exceed 90 dB, analogous to walking next to a highway when a large truck passes. 39) Noise is good for neither patients nor health care providers. High levels of ambient noise in patient care areas have been associated with increases in blood pressure and heart rate and poor sleep patterns. Noise in nurseries has been associated with higher oxygen-support therapy needs. Hagerman et al. reported an increase in readmissions at a coronary care unit following discharge for patients who had poor room acoustics and noisy hospital stays. The emergency department (ED) can be a particularly noisy environment—and noise elevates stress in patients. Weiland et al. found that ED patients listening to a digital audio recording of nature sounds, a soothing beat, or acoustical music demonstrated less anxiety than control subjects listening to a recording of ED noise. The prospects for health care workers in terms of health and hearing loss are just as grim. Work in settings with high levels of ambient noise has been associated with hypertension and coronary artery disease. Noise-induced stress has been identified as a predictor of burnout in critical care nurses. In the ED, noise levels have been identified as stressful and interfering with communication and teaching. High noise levels in a hospital setting have been associated with hearing loss. In the last two decades, there has been much interest in improving communication, including a substantial review of research on communication during patient handoffs in hospitals. Yet little attention has been given to the potential opportunities and challenges associated with technology-based communication, particularly with respect to its use in environments with high levels of ambient noise, such as the ED. Nevertheless, Lund et al. reported that text messaging was a “practical and feasible tool” in mass casualty events, during which background ambient noise levels are inordinately high. 2) In this article, we (1) review the effects of noise on patients and providers; (2) analyze the modes, mediums, and affordances of the prevalent communication mechanisms in the ED; and (3) suggest strategies to reduce ambient noise and improve communication in the ED and ways to evaluate the impact of these strategies.

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.