Spotlight Case

1. Spotlight Case All in the History

2. Source and Credits • This presentation is based on the February/March 2009 AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Christopher Fee, MD, University of California, San Francisco • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Bradley A. Sharpe, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Describe EMTALA and understand that it does not apply to transfers to emergency departments from non-acute facilities (e.g., nursing homes) • State interventions to improve communication between referring facilities (such as nursing homes or clinics) and emergency departments • Describe what critical information should be conveyed during transitions in patient care in the emergency department • Appreciate how emergency physicians and inpatient physicians differ in their approach to patient diagnoses

4. Case: All in the History A fatigued emergency department (ED) physician was coming to the end of a long shift when he was informed of a patient referral from an area nursing home. On the phone, the nursing home physician started to explain, “I’m sending you a 68-year-old man with a history of interstitial lung disease who has been having some shortness of breath…” At that moment, the call was interrupted when a senior nurse grabbed the ED physician and said, “We need you in code room one now!” The paramedics had just arrived in the ED with a critically ill patient.

5. Case: All in the History (2) In the code room, the physician found an elderly man with no pulse, no blood pressure, and very low oxygen saturation. The physician began advanced life support—the patient was intubated and placed on mechanical ventilation, and given intravenous fluids, epinephrine, and atropine to treat his pulseless arrest. The patient regained a pulse and blood pressure after a few minutes but remained critically ill. Once the patient was somewhat stabilized, the ED physician searched for further information about the patient. The paramedics who had delivered the patient had left without speaking with him and did not leave any paperwork or documentation.

6. Case: All in the History (3) The physician managed to find some papers with the patient that identified him as a 68-year-old nursing home resident with shortness of breath and included scant notes about medications, but no further information on past medical history. Only many hours later did the ED physician realize that this patient was the 68-year-old man the nursing home physician had tried to sign out initially. Because of the interrupted signout and inadequate handoff from the paramedics, the ED physician had no choice but to proceed with the evaluation and treatment of this patient despite minimal information.

7. Emergency Department (ED) Referrals • Some patients “referred” to EDs from other EDs, hospitals, nursing homes, or clinics • Emergency Medical Treatment and Labor Act (EMTALA) regulates referrals from other EDs or other hospitals • EMTALA does not apply to non-acute care facilities such as nursing homes or clinics See Notes for reference.

8. ED Referrals (cont.) • Although not law, it is professional courtesy to contact EDs ahead of time about patients referred from nursing homes or clinics • This communication should follow the handoff guidelines described by the Joint Commission See Notes for references.

9. Joint Commission Effective Handoffs • Interactive communication allowing for questions between giver and receiver of patient information • Up-to-date information about patient condition, care, treatment, medications, services, and recent or anticipated changes • Methods to verify received information, including repeat-back or read-back techniques • Opportunities for the receiver to review relevant patient historical data, which may include previous care, treatment, or services • Limited interruptions to minimize the possibility that information fails to be conveyed or is forgotten See Notes for references.

10. Nursing Home or Clinic Referrals • Three simple interventions to improve handoff • Use checklists to gather crucial information (see Figure next slide) • Dedicate one ED physician to handle referrals • Task non-physician personnel with gathering demographic and non-clinical data

11. UCSF ED Referral Template**Reproduced with permission.

12. Emergency Medical Services (EMS) Handoff • This case highlights potential for lost information at the EMS-to-ED transition • Many systems require EMS providers to radio/call the receiving ED prior to arrival • These “ringdowns” are necessarily limited in amount of information and often complicated by poor reception

13. EMS-to-ED handoffs • Formal face-to-face verbal report on the patient should be required of EMS providers • This verbal report should include the patient’s history, pertinent examination findings (including vitals), and any response to pre-hospital treatment

14. EMS-to-ED handoffs • EMS providers required to complete a written (paper or electronic) report for each patient (a “runsheet”) • These runsheets may contain essential information that is not conveyed verbally • In one ED, EMS personnel relayed verbally only 44% of pertinent data from their runsheets • EDs should require their physicians to sign runsheets to document receipt of the information See Notes for reference.

15. Case (cont.): All in the History (4) A stat chest radiograph revealed infiltrates in the left lung. Based on the minimal information at hand (the history of shortness of breath, the low oxygen levels, the cardiac arrest, and the chest x-ray), the ED physician made a presumed diagnosis of aspiration pneumonia with respiratory arrest and septic shock. The patient was given intravenous antibiotics, fluids, and vasopressors for blood pressure support.

16. Case (cont.): All in the History (5) The ED physician contacted the team that would be managing the patient in the ICU. He remained busy with this patient (and others in the ED) and could only give a brief signout: “The patient is a 68-year old man with a possible history of lung disease, with probable aspiration pneumonia. He’s intubated, on pressors, and already got antibiotics. He needs to get up to the ICU.” At that moment, another patient was crashing and the physician had to hang up.

17. Case (cont.): All in the History (6) The admitting ICU team evaluated the patient and agreed with the initial assessment (although they were bothered at the limited information available). The patient was taken to the ICU. Three hours later, the patient had another arrest, becoming pulseless without a blood pressure. After being treated with aggressive fluids and three vasopressor medications, his blood pressure remained low.

18. Case (cont.): All in the History (7) At this point, the admitting team remained puzzled and contacted the nursing home physician. Further history revealed the patient’s shortness of breath had been very acute in onset, had been associated with chest pain, and the patient had stated at the time he “felt faint and like he was going to die.” Based on this vital information, the team became concerned that a pulmonary embolism (blood clot to the lungs) was the cause for his critical illness.

19. Case (cont.): All in the History (8) The patient was treated with thrombolytics (clot-busters) for presumed massive pulmonary embolism 5 hours after he arrived at the hospital. The patient immediately responded to treatment, with improvements in his oxygen level and blood pressure. He continued to improve and, after a prolonged hospitalization, ultimately returned to the nursing home.

20. ED-to-Inpatient Handoff • ED-to-inpatient handoff is another care transition that can lead to medical errors • This transfer should also follow Joint Commission Patient Safety guidelines • ED-to-inpatient provider signout should be brief but thorough and include the following items (see next slide) See Notes for reference.

21. Presenting complaint and history of present illness Pertinent past medical history, pertinent medications, allergies Pertinent social/family history Presenting vital signs and pertinent physical exam findings Pertinent lab, radiographic, electrocardiographic data Therapeutic interventions and response to therapy Most recent vital signs Working diagnoses (including differential) Pending studies Code status (if known) Contact information for referring providers or primary physician, if available Information to Include in ED-to-Inpatient Handoff

22. Errors during the ED-to-Inpatient Handoff • In survey, 29% of emergency and internal medicine providers reported that a patient had adverse event or near miss after an ED-to-inpatient transfer • These events were most often errors in diagnosis, treatment, or disposition See Notes for reference.

23. Factors Contributing to Handoff Errors • Inaccurate or incomplete information (particularly vital signs) • ED crowding and high provider workload • Difficulty for inpatient providers to access key information (vitals, ED notes, ED orders, pending data, etc.) • Patients “boarded” in the ED • Ambiguous responsibility for signout or follow-up See Notes for reference.

24. Potential Solutions to Improve Transition • Improved electronic access to key information • Vital signs, ED notes and orders, laboratory and radiology studies, and pending studies • Signout checklists

25. Different Approach to Diagnoses • Recent survey and this case also highlight different path that ED and inpatient providers take to determining diagnoses • Many ED physicians feel their role is to stabilize and determine appropriate disposition and not to achieve a final diagnosis • ED diagnoses are necessarily uncertain at best; this uncertainty is not always appreciated by admitting providers See Notes for reference.

26. Hazards of Premature Closure • Tendency to stop considering other possible diagnoses after a diagnosis is reached • As a result, inpatient providers may trust too strongly (or “anchor”) on the ED diagnosis See Notes for reference.

27. Preventing Premature Closure • ED physicians can help by acknowledging diagnostic uncertainty, by referring to the patient’s complaint as the final ED diagnosis, and by suggesting a differential: • “Respiratory failure of unclear etiology, possible aspiration vs. pneumonia vs. pulmonary embolism” • Inpatient providers should consciously ask themselves over time, “What alternatives should be considered?”

28. Take-Home Points • Transitions of care in the emergency department should follow Joint Commission standardized guidelines for effective handoff communications • Emergency departments should employ checklists (either paper or digital) to improve transitions of care from referring facilities • Emergency medical services personnel should be required to provide a direct verbal signout to ED providers as well as a written report (“runsheet”)

29. Take-Home Points (2) • The handoff between the ED and inpatient teams should be brief but standardized to include the pertinent clinical information • Emergency physicians and inpatient services approach final diagnoses in different ways, and this cultural divide can lead to errors and poor patient outcomes. Both groups should strive to understand and appreciate the other’s perspective