Improving handoffs from the ED

Just because disagreement between hospitalists and emergency physicians is natural, it's not necessarily unavoidable.

Conflict between emergency department (ED) and hospitalist physicians seems almost inevitable, according to Dickson Cheung, MD, an emergency physician at Sky Ridge Medical Center in Lone Tree, Colo. “The emergency physician and the internist are wired a little differently. It gets to basic innate personalities and workflows and work habits,” he said.

But just because disagreement is natural, it's not necessarily unavoidable. Dr. Cheung and colleagues from both emergency medicine and hospital medicine are working to smooth relations between the specialties, with the aim of improving the hospital experience for both patients and clinicians.

Photo by Thinkstock
Photo by Thinkstock.

“Everybody would like to work in a place where there's great teamwork and collegiality, and there's shared decision making. It definitely affects patient care as well,” he said.

Source of the problem

The conflict starts back in residency, according to emergency physician Liam Yore, MD, of North Sound Emergency Medicine in Washington state. “In training programs, [medicine] residents often adopt a blocking approach to admissions. It's not surprising since many residents are grossly overworked and simply adapt to blocking as a survival strategy,” he said.

ED and hospitalist physicians are also trained to have differing priorities. “The emergency physician is usually thinking about what's immediate,” said Dr. Cheung. “Hospitalists are usually trained to come up with a definitive diagnosis. They're detail-oriented and comprehensive, but maybe a little slower.”

Communication expert Julie Apker, PhD, found that these differences were maintained in practice, and even increased, when she studied handoffs between attendings in an emergency department and medical service in Michigan. “In the emergency department, there are constant interruptions. It can be a chaotic and loud environment. Often the goal is to make sure that the patient is stable or ready for transfer to the next level of care. Their communication might be more concise,” she said.

Hospitalists, on the other hand, want more details, specifically, “What's the information that I need to know to help me over the next 24 to 48 hours while this patient is going to be under my responsibility?” Dr. Apker said.

“So sometimes the [hospitalist] physicians would report feeling frustrated: ‘I would have liked more dialogue about long-term circumstances', or ‘There wasn't a whole lot of give-and-take in helping me make a decision,’” she said. Handoff conversations typically aren't long enough to include much dialogue, lasting only one to three minutes, according to her study in the February 2010 Annals of Emergency Medicine.

Emergency physicians have their own worries and frustrations about the interaction, noted Dr. Yore. “We are relentlessly punished when we miss something,” he said. “The result is that ER docs often take a conservative approach to admissions, especially in patients who do not have evidence of active disease, but who have the potential to have disease.”

To hospitalists, these admissions can feel like unnecessary extra work, especially if the emergency physician doesn't clearly explain his reasoning. “If it's a social admit, but the doc bends over backwards to try to make it seem like a medical admission, it generates reasonable skepticism from the hospitalist,” said Dr. Yore.

The result of the failed communication is mistrust. “The emergency physician will want to admit a patient but the hospitalist will feel that they don't know if the patient has been appropriately worked up and so they're not sure the patient is ready to be admitted. At the same time, the emergency physician will want to write holding orders, but they're not sure that the hospitalist will see the patient in a reasonable period of time,” said Prentice Tom, MD, an emergency physician and president of Galen Inpatient Physicians, a California-based hospitalist company.

Bridging the divide

Both hospitalists and emergency physicians agreed that the consequences of their conflicts and misunderstandings are frustrated physicians and worse patient care. But how to fix the problem is an open question. Dr. Cheung is currently working with a group of emergency physicians, hospitalists and communication experts on a white paper offering some potential solutions.

In the meantime, he and other experts shared some ideas about fixes, beginning with more frequent interaction between the specialties. “Something as simple as social functions—just get to know each other as people,” he said.

Social contact is helpful but insufficient, countered Robert Fielder, principal of Hospital Practice Consultants in Dallas. “They may talk about sports or what was on the television the night before, but in terms of trying to fix something that's really problematic, there just doesn't seem to be a lot of time spent,” he said.

His solution is to have physicians spend some time seeing how the other half works. “It's the old ‘walk a mile in someone else's shoes.’ To be down there and look around and see what's going on would lend itself to a much better understanding,” Mr. Fielder said.

More formal meetings between the groups can also help. “One of the things we do is require our hospitalist and emergency department medical directors to get together on a very regular basis,” said Dr. Tom. “It surprised me when we first started developing our hospitalist program that most of the hospitalists do not participate in the emergency department meetings and it is rare for the emergency department physicians to participate in the hospitalist meetings.”

Such meetings can give physicians an opportunity to look at the big picture instead of their immediate priorities, said Dr. Tom, offering the example of a patient who is being admitted through the ED and needs a CT scan.

“The emergency physician might say, ‘I don't need that CT to know the patient needs to be admitted.’…Now the CT is not done for a number of hours. That delays a consult. Now the hospitalist has this patient for an entire extra day….Two days later the emergency department is backed up because somebody didn't order a test that would have sped up overall patient care by a day,” Dr. Tom said.

When they meet, hospitalists and emergency physicians can agree on protocols that are conducive to overall patient flow. Physicians working for Galen review their hospitals' top seven to 10 diagnoses and define standard emergency department evaluations that will provide hospitalists with the information they need. “We have some templates we try to work with, but we allow each hospital to define what each group wants,” said Dr. Tom.

Need to know

Another issue to discuss at these meetings is the appropriate information to include in the handoff conversation. “Work with the emergency department staff—not just the docs but the nurses—and say what elements are critical. It might vary depending on the people involved and whether the hospital has an electronic health record [EHR],” said Kevin O’Leary, FACP, a hospitalist at Northwestern University in Chicago and a member of the white-paper group.

His hospitalist service found that acquisition of electronic records significantly changed what information was needed from the ED. “It's the stuff that we don't have in the EHR—for example, the gestalt of the physician on whether the patient's improving or not,” said Dr. O’Leary.

“We have to get away from reciting a litany of facts,” agreed Dr. Cheung. “We have to get more toward synthesizing data.”

Key information may include the emergency physician's confidence in the working diagnosis. “We might be treating them for pneumonia but we're still not sure whether they might have something else. That sort of thing is not in a discrete field in the EHR,” said Dr. O’Leary.

Based on her research, Dr. Apker also had some suggestions about what should be included in the handoff conversation: “Could we set up a protocol where after I give the history of the patient, there's a prompt that says ‘Do you have any questions about what I said?’” Her study found that, despite hospitalists' expressed desire for greater dialogue, they asked few questions during handoffs. “Just having that solicitation by the emergency physician could prompt somebody. It gives that conversational break,” she said.

Hospitalists could also contribute to the clarity of the exchange by providing “readback” at the end of the conversation, Dr. Apker recommended. “Here's what I've understood that you've told me about the patient. I want to give you a brief recap to make sure that I have heard everything you've told me,” she said.

Her study found very little use of readback, as well as few instances where the hospitalist clearly accepted the patient. “Out of our 15, there were two or three at most,” said Dr. Apker. “It was more hospitalists saying, ‘What room is the patient in?’ Our emergency physicians did say they wished they could get complete closure: ‘I'll take the patient.’”

It might be easier to have these thorough conversations if handoffs were timed to be convenient for both physicians. That isn't always possible, noted Dr. O’Leary. “If the ER is getting killed and I have a few minutes to listen to a good handoff, but the emergency physician doesn't have the time to listen to all my questions, that creates disagreement,” he said.

But unawareness of each other's schedules may make that disagreement more common than it has to be. “They don't consider when the hospitalist changes shifts, and the hospitalists don't consider when the emergency physicians change shifts,” said Dr. Tom.

A hospital's protocol could address this issue, for example, by specifying whether a handoff should be delayed if the hospitalist service is about to have a shift change or completed when an emergency doctor is leaving the hospital. “Would they prefer to talk to me since I have seen the patient for the last several hours or should I hand off the patient to the incoming ER physician and let them hand off the patient when all the test results are back?” asked Dr. O’Leary. “There needs to be some flexibility, but it's something that each group of physicians in each hospital should have a discussion about.”

Spread the word

Once the protocol is set, it's necessary information for everyone involved in the handoff process. “It probably should be part of our training for students and residents to be able to give and receive a handoff that covers the essential elements in a succinct manner,” said Dr. O’Leary.

Training about the functions and needs of their colleagues could potentially overcome young physicians' tendency to see the other department as an adversary. “When a new resident graduates into a hospitalist program, sometimes this blocking attitude persists,” said Dr. Yore.

He recommended that physicians be encouraged to conduct handoffs in person. “It's too easy to misuse, abuse or lie to a voice on the phone,” Dr. Yore said. “The face-to-face experience develops the sense that we are all on the same team rather than opposing squads.”

That's a lesson that older physicians may want to keep in mind as well. “The simplest thing for any of us as human beings to do when we are seemingly thwarted in our efforts by someone else is to demonize that area or department or person. If instead we would assume a positive intent—there's a reason this is going on—we would all do a whole lot better,” said Mr. Fielder.