I remember a bad hand-off once, long ago. It was the classic admitted patient, long forgotten two shifts after a bed had been ordered, but hanging out in the ER waiting for the assigned bed to be vacated and cleaned. It was a chest pain admission, a "low-risk rule-out," meaning that the patient was to get a blood tests to rule out a heart attack and then a stress test. Turns out the diagnosis was quite wrong: it was an aortic dissection, and when the patient crashed, there was chaos because nobody remembered why the patient was there and who was responsible for him.
In that case, there were other problems: the nurses in the ED had been quite content to ignore the patient while he slept. No vital signs were obtained, at one point the cardiac monitoring had been discontinued for the patient to go to the bathroom, and the schedule of blood tests designed to detect an evolving heart attack were not drawn.
The outcome was bad, and we as an organization learned a lot from it.
Doctor RW writes about this topic today, linking to an interesting article in Today's Hospitalist. RW's recommendation is good, but does not go far enough:
Hospitalist groups should meet with their emergency medicine colleagues regularly to discuss cases, offer feedback and improve professional relationships.To be sure, this is necessary and I won't disagree with it. But the fact is this: if the patient is physically in your ED after "admission," they remain your responsibility, and as a department, you must have procedures in place to ensure the patient will continue to receive excellent care during the transition.
Key points which such procedures must address include:
- There must be an ED physician who is the designated responsible provider and who is aware of the patient. This is pretty standard and is easily accomplished with most patient tracking system, be they simple grease boards or sophisticated EMRs.
- Transfer of care to the hospitalist does not take place until the patient has either left the ED or until the hospitalist has physically seen the patient in the ED.
- The ED doc must perform interval assessments of the "boarding" patients in the ED, regardless of whether the hospitalist has seen them. If they're in the ED, they're still your responsibility. Generally, stable patients don't take much attention, but sicker patients, ICU admits, etc will require this assessment. If nothing else, it can add to your critical care time!
- Once the hospitalist has seen the "boarded" patient, they are the primary caregiver, and simple questions or non-urgent issues can be directed to them. But the ED doc must remain available for urgent issues and to keep tabs on the patient's condition.
- Inpatient admitting orders should be written at the time the patient is designated as "admitted." The ED nursing staff need to follow these orders as if the patient were in their inpatient bed, especially if the patient will be boarding more than a couple of hours.
- If you are in the enviable position of sending patients upstairs before the admitting doc has seen them, you need to write adequate holding orders.
My opinion is that by writing good holding orders, the ER docs improve patient care, help the hospitalists, and reduce everybody's risk. The key is that these orders do not need to be comprehensive, but they do need to be adequate. In my opinion, the minimum acceptable holding order set includes:
- The name of the responsible admitting doc.
- A clear statement that for problems, questions, or changes in condition, the admitting doc should be promptly notified.
- A defined time during which your holding orders are valid (i.e. an expiration time for your orders, by which time the admitting doc needs to have seen the patient).
- Any critical patient safety information (ie allergies, NPO, fall precautions, etc)
- Any scheduled tests or treatments which will forseeably be needed before the patient may be seen (serial enzymes, nebs, pain meds, blood sugars, e.g.)
- Parameters to notify the admitting doc (vitals, test results, etc)
This is a pretty important topic. Change of shift is the most dangerous time in any ER, and the transfer of care is fraught with risk. It's curious, now that I think about it, that this has received so little attention in the evolving culture of patient safety and the Quality measures being developed. Look for this to gain prominence in coming years.