Updated: Feb 27
You are beginning a morning shift in the Emergency Department when the overnight physician comes up to you and asks “Hey, can I give you a few handovers?” Your colleague provides a brief verbal handover for three patients and then says “this fourth one is a slam dunk admit, I’ve called the hospitalist and they’ll come to see the patient sometime this morning. Don’t even worry about it.” A few hours later, a nurse comes to you and says “I’m worried about the patient consulted to the hospitalist, she’s delirious now. Can you assess her?” As you approach the patient you grab her chart and can’t decipher what the physician documented. Standing at the foot of the bed, you wish you had received abetter handover…
Transitions of care, also referred to as patient handoffs or handover, represent an area in medical care which has inherent risks to patient safety. Handovers can be defined as “the transfer of responsibility and accountability for some or all aspects of care for a patient or groups of patients, on a temporary or permanent basis” and are a relatively frequent occurrence in most areas of medical practice.(1) The Emergency Department (ED) specifically represents an area where transitions of care are frequent, both within its walls and to other clinical settings, such as transfers to the ward and to external care facilities. The Joint Commission has previously noted that poorly communicated transitions are the leading cause of sentinel events and lead to an estimated 80% of preventable medical errors.(23) In this post we will discuss the barriers and potential harms in transitions of care in the ED as well as ways to mitigate risk by using standardized tools.
The Canadian Medical Protective Association (CMPA) has identified several factors leading to ineffective transitions of care including time constraints and varying communication styles.(4) Specifically, providers having differing opinions on how transitions should occur and what information is required have both been implicated.(5,6) Other literature has described ED-specific domains such as technological factors (eg. electronic health records), team factors (i.e. peer relationships), local and institutional environmental factors (i.e. location, competing demands for attention) and caregiver factors (i.e. fatigue, inattention).(7) With this in mind, let us look at what can go wrong when transitions are ineffective.
What Could Go Wrong?
Critical information is communicated during transitions, such as pertinent investigative findings, treatments, advanced directives and expected clinical scenarios. In the presence of transition barriers, there is a risk of miscommunicated or omitted information. Previous studies have illustrated that abnormal vital signs or clinically important laboratory investigations are sometimes omitted.(8,9) As an example, failing to mention a fever or elevated lactate may delay initiation of antibiotics in a septic patient, leading to a worse outcome. Adverse events such as seizures or hyponatremia have also been reported due to inadequate communication surrounding medication changes.(10)
Mitigating the Risk to Patient Safety
In order to improve transitions of care, a variety of approaches can be adopted.One should look at their existing transition culture and identify the local barriers which exist. For example, if handover is taking place in a busy patient care area, the environment could be changed to a quieter setting such as an office, with consideration of bedside handovers for acutely ill or complex patients. Whether EDs use EMRs or written documentation, implementation of an accessible handover form or template will allow providers to legibly document essential information, for providers to legibly document essential information that can be incorporated into the formal patient record. This has been shown to improve the quality of information and reduce communication-related errors.(11–13)
The utilization of standardized approaches and mnemonics have been studied in various clinical environments.(14) SBAR (Situation, Background, Assessment and Recommendation), has been implemented and shown to cause a reduction in adverse events.(15) Similarly, IPASS (Illness severity, Patient summary, Action list, Synthesis by the receiver, Summary by the receiver) has also been previously well studied in the ED and inpatient settings with evidence that implementation can reduce the incidence of preventable adverse events by 30%.(16,17) Finally, various professional societies, such as ACEP and the Royal College, have created toolkits available aimed at setting standardized transitions for non-ED settings.
Mr Smith is having an acute exacerbation of COPD (S), he has previously required ICU admission (B), he is stable right now with bronchodilators via MDI (A), if he gets sleepy or has increased work of breathing, call RT for BiPAP (R).
Clinician 1: Ms. Green is an afebrile, hypotensive, tachycardic (I) 24y female with poorly managed insulin dependent diabetes and heavy THC use experiencing an episode DKA (P). She has received two fluid boluses and will require a recheck of her electrolytes and blood glucose in an hour to determine if potassium needs to be given prior to insulin infusion (A). Therapy should be initiated.
Clinician 2: Got it. Sick, 24y F, uncontrolled DM, in DKA – check lytes and BG shortly to determine need for K prior to starting insulin. Anything else? (S&S)
Transitions of Care Outside the ED
As the ED is interconnected with many different services, interventions aimed at improving transitions ought to involve all stakeholders (i.e. consultants, primary care providers, pre-hospital providers) from beyond its walls. Collaborative protocols should be created to improve bidirectional communication between referring providers, primary care providers and the ED. As an example, standardized referral forms have been utilized with great success with previous literature demonstrating substantial improvement of communicating Long Term Care patient advance directives after implementing this intervention.(18) We will next discuss possible ways to improve transitions out of the ED when patients are either admitted or discharged.
Transitions to Inpatient Services
As one can imagine, the opportunities for ineffective transitions of care become magnified when patients are admitted to inpatient services. Limited intra-group communication, crowding and unclear assignments of responsibility have been previously identified as a few of the challenges facing this process.(19) The aforementioned IPASS system merits consideration as it can significantly reduce the number of preventable adverse events and has been described as the “gold standard” for handovers by the Agency for Healthcare Research and Quality (AHRQ).(17,20) Other novel models of ED to inpatient have been previously suggested including the use of asynchronous electronic handovers and mobile applications.(21,22) Bedside handovers with consultants may provide a more patient-centred approach to these transitional periods and should also be considered.(23)
Transitions At Discharge
The AHRQ defines a high-quality ED discharge as one that incorporates the following 3 features:24
Inform/educate patients regarding tests/treatments in the ED, diagnosis, prognosis, treatment plan, expected course and indications to return to the ED;
Support patients in receiving post-ED care regarding medications (start, stop, avoid), care of injury/wounds, using devices/equipment, pending testing and follow-up with healthcare providers;
Coordinate care within greater health care system by assisting with arranging follow up and timely sharing of ED record when appropriate.
AHRQ conducted an environmental scan of the literature on the ED discharge process and found that in general, strategies involving improved discharge instructions, telephone follow-up and ED-made appointments were successful in reducing discharge failures.
Several of the above features have been incorporated into the patient, provider and caregiver co-designed Patient Oriented Discharge Summary (PODS) that has been applied successfully to many inpatient units across Ontario.25 The PODS design can be adapted to different settings, but fundamentally includes a description of the medical condition, a medication chart, follow-up appointments with phone numbers, normal expected symptoms as well as danger symptoms and what to do, when to resume activities, and applicable resources. It encourages a teach-back method and recommends that the process occur in the presence of family or a caregiver, that a copy be provided to the patient, and that the patient should be able to take additional notes on the PODS form. More information about how to use the PODS design can be found here.
In summary, transitions of care occur frequently in the ED and represent an area of threat to patient safety. Interventions aimed at improving transitions of care should focus on reducing identified barriers and implementing standardized tools.
Stay tuned for our next post where we discuss patient communication in the ED.
Senior Editor: Shawn Mondoux
Copyedited by: Paula Sneath
CMPA Good Practices Guide. What is a Handover. https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/communication/Handovers/what_is_a_handover-e.html. Accessed May 4, 2019.
Solet D, Norvell J, Rutan G, Frankel R. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80(12):1094-1099. https://www.ncbi.nlm.nih.gov/pubmed/16306279.
Transitions of Care Task Force Report. American College of Emergency Physicians. https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/administration/acep_toc_tf_report_sep2012_rev.pdf. Published September 2012. Accessed May 4, 2019.
CMPA Good Practices Guide. Barriers to Effective Handovers. https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/communication/Handovers/barriers_to_effective_handovers-e.html. Accessed February 25, 2019.
Griffiths D, Morphet J, Innes K, Crawford K, Williams A. Communication between residential aged care facilities and the emergency department: a review of the literature. Int J Nurs Stud. 2014;51(11):1517-1523. https://www.ncbi.nlm.nih.gov/pubmed/24996849.
Rider A, Kessler C, Schwarz W, et al. Transition of Care from the Emergency Department to the Outpatient Setting: A Mixed-Methods Analysis. West J Emerg Med. 2018;19(2):245-253. https://www.ncbi.nlm.nih.gov/pubmed/29560050.
Cheung D, Kelly J, Beach C, et al. Improving handoffs in the emergency department. Ann Emerg Med. 2010;55(2):171-180. https://www.ncbi.nlm.nih.gov/pubmed/19800711.
Venkatesh A, Curley D, Chang Y, Liu S. Communication of Vital Signs at Emergency Department Handoff: Opportunities for Improvement. Ann Emerg Med. 2015;66(2):125-130. https://www.ncbi.nlm.nih.gov/pubmed/25805116.
Maughan B, Lei L, Cydulka R. ED handoffs: observed practices and communication errors. Am J Emerg Med. 2011;29(5):502-511. https://www.ncbi.nlm.nih.gov/pubmed/20825820.
Boockvar K, Fishman E, Kyriacou C, Monias A, Gavi S, Cortes T. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med. 2004;164(5):545-550. https://www.ncbi.nlm.nih.gov/pubmed/15006832.
Kwok ESH, Clapham G, White S, Austin M, Calder L. LO25: The development and implementation of a standardized emergency department handover tool. CJEM. 2018;20(S1):S15-S15. doi:10.1017/cem.2018.87
Anderson J, Shroff D, Curtis A, et al. The Veterans Affairs shift change physician-to-physician handoff project. Jt Comm J Qual Patient Saf. 2010;36(2):62-71. https://www.ncbi.nlm.nih.gov/pubmed/20180438.
Petersen L, Orav E, Teich J, O’Neil A, Brennan T. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv. 1998;24(2):77-87. https://www.ncbi.nlm.nih.gov/pubmed/9547682.
Riesenberg L, Leitzsch J, Little B. Systematic review of handoff mnemonics literature. Am J Med Qual. 2009;24(3):196-204. https://www.ncbi.nlm.nih.gov/pubmed/19269930.
Haig K, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006;32(3):167-175. https://www.ncbi.nlm.nih.gov/pubmed/16617948.
Heilman J, Flanigan M, Nelson A, Johnson T, Yarris L. Adapting the I-PASS Handoff Program for Emergency Department Inter-Shift Handoffs. West J Emerg Med. 2016;17(6):756-761. https://www.ncbi.nlm.nih.gov/pubmed/27833685.
Starmer A, Landrigan C, I-PASS S. Changes in medical errors with a handoff program. N Engl J Med. 2015;372(5):490-491. https://www.ncbi.nlm.nih.gov/pubmed/25629753.
Zafirau W, Snyder S, Hazelett S, Bansal A, McMahon S. Improving transitions: efficacy of a transfer form to communicate patients’ wishes. Am J Med Qual. 2012;27(4):291-296. https://www.ncbi.nlm.nih.gov/pubmed/22327023.
Horwitz L, Meredith T, Schuur J, Shah N, Kulkarni R, Jenq G. Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med. 2009;53(6):701-10.e4. https://www.ncbi.nlm.nih.gov/pubmed/18555560.
Handoffs and Signouts. AHRQ Patient Safety Network. https://psnet.ahrq.gov/primers/primer/9/Handoffs-and-Signouts. Published March 14, 2019. Accessed May 4, 2019.
Sanchez L, Chiu D, Nathanson L, et al. A Model for Electronic Handoff Between the Emergency Department and Inpatient Units. J Emerg Med. 2017;53(1):142-150. https://www.ncbi.nlm.nih.gov/pubmed/28506546.
Fung R, Hyde J, Davis M. Oiling the gate: a mobile application to improve the admissions process from the emergency department to an academic community hospital inpatient medicine service. J Community Hosp Intern Med Perspect. 2018;8(1):1-5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5804721.
Lehmann LS, Brancati FL, Chen M-C, Roter D, Dobs AS. The Effect of Bedside Case Presentations on Patients’ Perceptions of Their Medical Care. N Engl J Med. 1997;336(16):1150-1156. doi:10.1056/nejm199704173361606
Boonyasai R, Doggett D, Bayram J, Connor C. Improving the Emergency Department Discharge Process: Environmental Scan Report. Agency for Healthcare Research and Quality. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/edenvironmentalscan/edenvironmentalscan.pdf. Published October 2014. Accessed March 14, 2019.
Hahn-Goldberg S, Okrainec K, Huynh T, Zahr N, Abrams H. Co-creating patient-oriented discharge instructions with patients, caregivers, and healthcare providers. J Hosp Med. 2015;10(12):804-807. https://www.ncbi.nlm.nih.gov/pubmed/26406116.