Stephen M. Schenkel

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.

Communication in Emergency Medicine: Implications for Patient Safety1 This study was funded by a generous grant from the National Patient Safety Foundation.

Emergency medicine is largely a communicative activity, and medical mishaps that occur in this context are too often the result of vulnerable communication processes. In this year-long qualitative study of two academic emergency departments, an interdisciplinary research team identified four such processes: triage, testing and evaluation, handoffs, and admitting. In each case, we found that narrative rationality (the patients story) was consistently subjugated to technical rationality (actionable lists). Process changes are proposed to encourage caregivers to either reconsider their course of action or request additional contextual information. A heightened awareness of the bias for technical over narrative rationality and a better recognition of uncertainty in emergency medicine communication are important first steps toward anticipating potential failures and ensuring patient safety.

Resident Perceptions of Medical Errors in the Emergency Department

OBJECTIVES To evaluate resident experience and perceptions of medical error associated with emergency department (ED) care. METHODS Using a semistructured interview protocol, three researchers interviewed 26 randomly selected medical, surgical, and obstetrics residents regarding medical error. The authors chose a 16-case subset of incidents involving ED care for initial review. Interview transcripts were reviewed iteratively to draw out recurrent categories and themes. Two investigators separately analyzed all cases to ensure common understanding and agreement. RESULTS Most cases involved misdiagnosis, misread radiographs, or inappropriate disposition. Two thirds of the case patients died or experienced delays in care. Residents felt that the complexity of the patients, as well as the complexity of their own jobs, contributed to error. Attending supervision, nurse evaluation, and additional physician involvement all were noted to be important checks within the hospital system. Residents most often held the ED responsible for error. In addition, they deemed themselves, their teams, and their lack of training responsible. Though residents often discussed events with their admitting teams, follow-up with the ED or other associated individuals was uncommon. The findings revealed seven common themes that include factors contributing to errors, checks and adaptations, and follow-up of the event. CONCLUSIONS Residents are aware of medical error and able to recall events in detail. Whereas events are discussed among inpatient teams, little information finds its way back to the ED, potentially resulting in misunderstandings between departments and hindering learning from events. In-depth interviewing allows a nuanced and detailed approach to error analysis.

Foxy methoxy: A new drug of abuse

IntroductionIn 1999, a new synthetic tryptamine, 5-MeO-DIPT, became known as a street drug, with the street name of “Foxy” or “Foxy Methoxy”. By February 2003, the DEA reported law enforcement seizures and/or reports of abuse in 12 states. We report a case along with an analysis of poison center data on this new drug of abuse.Case reportA 19-year-old male was brought to the emergency department following ingestion of a larger than his usual dose of Foxy. Upon arrival, he had hallucinations, hypertension, tachycardia, mydriasis, and catalepsy. Symptoms resolved within two hours after administration of lorazepam and he recovered uneventfully.DiscussionThe AAPCC TESS database contained 41 exposures to “Foxy” between April, 2002 and June, 2003; 26 had moderate or major effects, indicating this drug has significant toxic potential. Given the expanding use of this and other club drugs, the spectrum of toxicity from this new agent will continue to be elucidated.

Effects of Vein Width and Depth on Ultrasound-Guided Peripheral Intravenous Success Rates

BACKGROUND Increasing numbers of operators are learning to use ultrasound to guide peripheral intravenous (i.v.) catheter insertion in patients with difficult access. Unfortunately, failed cutaneous punctures are common. Some veins seen on ultrasound may be better choices than others. OBJECTIVES To estimate the effects of vein width and depth on the probability of success in ultrasound-guided i.v. catheter insertion. METHODS We prospectively collected data from attempts at ultrasound-guided venous catheter insertion between the antecubital fossa and mid-humerus. Each ultrasound machines ruler function was used to determine depth from the skin to the closest vein edge and that veins largest diameter. Success was defined as being able to freely withdraw blood or inject saline after the first skin puncture, considering each encounter independently. We calculated relative success rates, confidence intervals, and p values using reference groups selected by histogram analysis. RESULTS Thirty-five operators recorded 180 encounters; 100 (56%) were successful on the first skin puncture, and 152 (84%) were eventually successful. Success rates were not linearly related to vein width or depth. Success rates were higher for veins with diameter > or = 0.4 cm vs. those < 0.4 cm (63% [78/124] vs. 39% [22/56], relative success 1.6 [95% confidence interval (CI) 1.1-2.3], p = 0.005) and for veins of depth 0.3-1.5 cm vs. veins of depth < 0.3 or > 1.5 cm (58% [96/165] vs. 27% [4/15], relative success 2.2 [95% CI 0.9-5.1], p = 0.04). CONCLUSION Success rates are higher in larger veins (> or = 0.4 cm) and veins at moderate depth (0.3-1.5 cm).

The unexpected challenges of accurate medication reconciliation.

Accurately and completely reconcile medications across the continuum of care. —The Joint Commission, 2008 National Patient Safety Goals, Hospital Program Your elderly patients are on medications you don’t know what they are, their other doctors don’t know what they are, they don’t know what they are, and the neighbor who provided them doesn’t know what they are. —Paraphrased from a lecture by John W. Rowe, MD, geriatrician, Harvard Medical School, circa 1995 In this issue of Annals, Miller et al present a detailed view of medication reconciliation as carried out in a large rural medical center. They selected admitted trauma patients and evaluated medication lists compiled by the trauma team, an admitting nurse, and a clinical pharmacist. Using the clinical pharmacistgenerated list as their criterion standard, the authors calculated that the lists created by the trauma team and admitting nurse were correct in all details only 15% of the time. The clinical pharmacist uncovered actual medication errors for 4% of patients, including one who experienced an adverse drug event. The authors conclude that medication histories obtained for these admitted trauma patients were “quite inaccurate.” Inaccurate medication lists can have significant repercussions. Essential medications may be missed. Unintended medications may be taken. Doses, routes, and timing may all be mistaken and potential pharmaceutical interactions may go unrecognized until too late. At the time of significant transitions, such as hospital admission or discharge, incorrect medications may find their way onto the list, and suddenly the patient is regularly taking a proton-pump inhibitor or a daily aspirin. Accurate medication reconciliation is clearly an appropriate goal. What is immediately striking from this study, though, is how remarkably difficult accurate and complete medication reconciliation turned out to be. This study evaluated 373 patients during 13 months. The authors excluded 299 subjects who were taking no prescription medications and who would typically be considered “reconciled,” skewing their results. Inclusion of these patients would have instantly lifted the

Incidence and types of non-ideal care events in an emergency department

Aim To identify and characterise hazardous conditions in an Emergency Department (ED) using active surveillance. Methods This study was conducted in an urban, academic, tertiary care medical centre ED with over 45 000 annual adult visits. Trained research assistants interviewed care givers at the discharge of a systematically sampled group of patient visits across all shifts and days of the week. Care givers were asked to describe any part of the patients care that they considered to be ‘not ideal.’ Reports were categorised by the segment of emergency care in which the event occurred and by a broad event category and specific event type. The occurrence of harm was also determined. Results Surveillance was conducted for 656 h with 487 visits sampled, representing 15% of total visits. A total of 1180 care giver interviews were completed (29 declines), generating 210 non-duplicative event reports for 153 visits. Thirty-two per cent of the visits had at least one non-ideal care event. Segments of care with the highest percentage of events were: Diagnostic Testing (29%), Disposition (21%), Evaluation (18%) and Treatment (14%). Process-related delays were the most frequently reported events within the categories of medication delivery (53%), laboratory testing (88%) and radiology testing (79%). Fourteen (7%) of the reported events were associated with patient harm. Conclusions A significant number of non-ideal care events occurred during ED visits and involved failures in medication delivery, radiology testing and laboratory testing processes, and resulted in delays and patient harm.

Ill, Itinerant, and Insured: The Top 20 Users of Emergency Departments in Baltimore City

The purpose of this study was to document the clinical and demographic characteristics of the 20 most frequent users of emergency departments (EDs) in one urban area. We reviewed administrative records from three EDs and two agencies providing services to homeless people in Baltimore City. The top 20 users accounted for 2,079 visits at the three EDs. Their mean age was 48, and median age was 51. Nineteen patients visited at least 2 EDs, 18 were homeless, and 13 had some form of public insurance. The vast majority of visits (86%) were triaged as moderate or high acuity. The five most frequent diagnoses were limb pain (n = 9), lack of housing (n = 6), alteration of consciousness (n = 6), infection with human immunodeficiency virus (HIV) (n = 5), and nausea/vomiting (n = 5). Hypertension, HIV infection, diabetes, substance abuse, and alcohol abuse were the most common chronic illnesses. The most frequent ED users were relatively young, accounted for a high number of visits, used multiple EDs, and often received high triage scores. Homelessness was the most common characteristic of this patient group, suggesting a relationship between this social factor and frequent ED use.

Emergency department medication history taking: current inefficiency and potential for a self-administered form.

BACKGROUND Emergency Departments (EDs) struggle with obtaining accurate medication information from patients. OBJECTIVE Our aim was to estimate the proportion of urban ED patients who are able to complete a self-administered medication form and record patient observations of the medication information process. METHODS In this cross-sectional study, we consecutively sampled ED patients during various shifts between 8 AM and 10 PM. We created a one-page medication questionnaire that included a list of 49 common medications, categorized by general indications. We asked patients to circle any medications they took and write the names of those not on the form in a dedicated area on the bottom of the page. After their visit, we asked patients to recall which providers had asked them about their medications. RESULTS Research staff approached 354 patients; median age was 45 years (interquartile range 29-53 years). Two hundred and forty-nine (70%) completed a form, 61 (17%) were too ill, 19 (5%) could not read it, and 25 (7%) refused to participate. Excluding refusals, 249 of 329 (76%; 95% confidence interval 70-80%) were able to complete the form. Of 209 patients recalling their visit, 180 (86%) indicated that multiple providers took a history, including 103 in which every provider did so, and 9 (4%) indicated that no provider took a medication history. CONCLUSIONS The process of ED medication information transfer often involves redundant efforts by the health care team. More than 70% of patients presenting for Emergency care were able to complete a self-administered medication information form.

Prospective, randomized controlled comparison of a flash-tip catheter and a traditional intravenous catheter in an urban emergency department:

Introduction: Safe and efficient intravenous access is paramount to the practice of emergency medicine. We compared the first-stick success rates and blood spillage of two peripheral intravenous catheters in a busy urban emergency department. Methods: In this randomized controlled trial, we assigned emergency department patients requiring peripheral intravenous access to use of either a flash-tip catheter (SurFlash Plus, Terumo Medical Corporation, Somerset, New Jersey) or a widely used control catheter (Insyte Autoguard; Becton, Dickinson and Company, Franklin Lakes, New Jersey). We compared frequency of first-stick success and blood contamination between catheters using chi-squared analysis. Results: We enrolled 600 patients, randomizing 309 to the flash-tip catheter and 291 to the control catheter. The first-stick success rate of each device was 79%. Blood contamination, defined as spillage of blood on the patient’s skin, bedding, or the inserter, occurred in 8 of 309 cases (2.6%) with the flash-tip catheter versus 92 of 291 cases (31.6%) for the control catheter. Conclusion: The two catheters tested in this study had comparable rates of first-stick success, but the flash-tip catheter was associated with significantly less blood contamination during insertion attempts.