Communicating in the "Gray Zone": Perceptions about Emergency Physician–hospitalist Handoffs and Patient Safety

Objectives: To identify the perceptions of emergency physicians (EPs) and hospitalists regarding interservice handoff communication as patients are transferred from the emergency department to the inpatient setting.
Methods: Investigators conducted individual interviews with 12 physicians (six EPs and six hospitalists). Data evaluation consisted of using the steps of constant comparative, thematic analysis.
Results: Physicians perceived handoff communication as a gray zone characterized by ambiguity about patients' conditions and treatment. Two major themes emerged regarding the handoff gray zone. The first theme, poor communication practices and conflicting communication expectations, presented barriers that exacerbated physicians' information ambiguity. Specifically, handoffs consisting of insufficient information, incomplete data, omissions, and faulty information flow exacerbated gray zone problems and may negatively affect patient outcomes. EPs and hospitalists had different expectations about handoffs, and those expectations influenced their interactions in ways that may result in communication breakdowns. The second theme illustrated how poor handoff communication contributes to boarding-related patient safety threats for boarders and emergency department patients alike. Those interviewed talked about the systemic failures that lead to patient boarding and how poor handoffs exacerbated system flaws.
Conclusions: Handoffs between EPs and hospitalists both reflect and contribute to the ambiguity inherent in emergency medicine. Poor handoffs, consisting of faulty communication behaviors and conflicting expectations for information, contribute to patient boarding conditions that can pose safety threats. Pragmatic conclusions are drawn regarding physician–physician communication in patient transfers, and recommendations are offered for medical education.     

The 2011 ACGME Standards: Impact Reported by Graduating Residents on the Working and Learning Environment

ObjectiveChanges in Accreditation Council for Graduate Medical Education (ACGME) requirements, including duty hours, were implemented in July 2011. This study examines graduating pediatrics residents' perception of the impact of these standards.MethodsA national, random sample survey of 1000 graduating pediatrics residents was performed in 2012; a total of 634 responded. Residents were asked whether 9 areas of their working and learning environments had changed with the 2011 standards. Three combined change scores were created for: 1) patient care, 2) senior residents, and 3) program effects, with scores ranging from −1 (worse) to 1 (improved). Respondents were also asked about hours slept and perceived change in hours slept.ResultsMost respondents felt that several areas had worsened, including continuity of care and senior resident workload, or not changed, including supervision and sleep. Mean change scores that included all study variables except those related to sleep all showed worsening: patient care (mean −0.37); senior residents (mean −0.36), and program effects (mean −0.06) (P < .01). Respondents reported a mean of 6.7 hours of sleep in a 24-hour period, with the majority (71%) reporting this amount of sleep has not changed with the 2011 standards.ConclusionsIn the year after implementation of the 2011 ACGME standards, graduating pediatrics residents report no changes or a worsening in multiple components of their working and learning environments, as well as no changes in the amount of sleep they receive each day.     

Systematic Training in Internal Medicine-Pediatrics End of Residency Handoffs: Residency Director Attitudes and Perceived Barriers

Background: It is unclear why systematic training in end-of-residency clinic handoffs is not universal. Purposes: We assessed Internal Medicine-Pediatrics (Med-Peds) residency program directors’ attitudes regarding end-of-residency clinic handoff systems and perceived barriers to their implementation. Methods: We surveyed all Med-Peds program directors in the United States about end-of-residency outpatient handoff systems. Results: Program directors rated systems as important (81.5%), but only 31 programs (46.3%) utilized them. Nearly all programs with (29/31 [93.5%]), and most programs without systems (24/33 [72.7%]) rated them as important. Programs were more likely to have a system if the program director rated it important (p = .049), and less likely if they cited a lack of faculty interest (p = .023) or difficulty identifying residents as primary providers (p = .04). Conclusions: Most program directors believe it important to formally hand off outpatients. Barriers to establishing handoff systems can be overcome with modest curricular and cultural changes.     

Unpacking the Complexity of Patient Handoffs Through the Lens of Cognitive Load Theory

Issue: The transfer of a patient from one clinician to another is a high-risk event. Errors are common and lead to patient harm. More effective methods for learning how to give and receive sign-out is an important public health priority. Evidence: Performing a handoff is a complex task. Trainees must simultaneously apply and integrate clinical, communication, and systems skills into one time-limited and highly constrained activity. The task demands can easily exceed the information-processing capacity of the trainee, resulting in impaired learning and performance. Appreciating the limits of working memory can help identify the challenges that instructional techniques and research must then address. Cognitive load theory (CLT) identifies three types of load that impact working memory: intrinsic (task-essential), extraneous (not essential to task), and germane (learning related). The authors generated a list of factors that affect a trainee's learning and performance of a handoff based on CLT. The list was revised based on feedback from experts in medical education and in handoffs. By consensus, the authors associated each factor with the type of cognitive load it primarily effects. The authors used this analysis to build a conceptual model of handoffs through the lens of CLT. Implications: The resulting conceptual model unpacks the complexity of handoffs and identifies testable hypotheses for educational research and instructional design. The model identifies features of a handoff that drive extraneous, intrinsic, and germane load for both the sender and the receiver. The model highlights the importance of reducing extraneous load, matching intrinsic load to the developmental stage of the learner and optimizing germane load. Specific CLT-informed instructional techniques for handoffs are explored. Intrinsic and germane load are especially important to address and include factors such as knowledge of the learner, number of patients, time constraints, clinical uncertainties, overall patient/panel complexity, interacting comorbidities or therapeutics, experience or specialty gradients between the sender and receiver, the maturity of the evidence base for the patient's disease, and the use of metacognitive techniques. Research that identifies which cognitive load factors most significantly affect the learning and performance of handoffs can lead to novel, contextually adapted instructional techniques and handoff protocols. The application of CLT to handoffs may also help with the further development of CLT as a learning theory.     

Factors Associated with Adverse Events Resulting From Medical Errors in the Emergency Department: Two Work Better Than One

Background

The Emergency Department (ED) is an environment at risk for medical errors.

Objective

Our aim was to determine the factors associated with the adverse events resulting from medical errors in the ED among patients who were admitted.

Methods

This was a prospective observational study. For a 1-month period, we included all ED patients who were subsequently admitted to the medical ward. Detection of medical errors was made by the admitting physician and then validated by two experts who reviewed all available data and medical charts pertaining to the patient’s hospital stay, including the first review from the ward physician. Related adverse events resulting from medical errors were then classified by type and severity. Adverse events were defined as medical errors that needed an intervention or caused harm to the patient. Univariate analysis examined relationships between characteristics of both patients and physicians and the risk of adverse events.

Results

From 197 analyzed patients, 130 errors were detected, of these, 34 were categorized as adverse events among 19 patients (10%). Seventy-six percent of these were categorized as proficiency errors. The only factors associated with a lower risk of adverse events were the transition of care involving a handoff within the ED (0% vs. 19%; p = 0.03) and the involvement of a resident (junior doctor) in addition to the senior physician (37% vs. 67%; p < 0.01).

Conclusions

In our study, the involvement of more than one physician was associated with a lower risk of adverse events.     

人工智能在眼科医疗管理过程中的应用:挑战与展望

人工智能(artificial intelligence,AI)为解决中国患者"看病难"问题提供了可行方案.眼科AI已实现为患者提供筛查、远程诊断及治疗建议等方面的服务,能显著减轻医疗资源不足的压力和患者的经济负担.而AI的应用过程中,给医疗管理带来的挑战应引起重视.本文从医疗管理的角度,总结分析AI在眼科医疗过程中,...     

The art of oral handovers: A participant observational study by undergraduate students in a hospital setting

Aims and objectives

To explore the conditions for oral handovers between shifts in a hospital setting, and how these impact patient safety and quality of care.

Background

Oral handovers transfer patient information and nursing responsibilities between shifts. Short written summaries of patients can complement an oral handover. How to find the balance between a standardised protocol for handovers and tailoring variations to specific patients and situations is debated in the literature. Oral handovers provide time for discussion, debriefing and problem solving, which can lead to increased team cohesiveness.

Design

This study used a participant observation design.

Method

Fifty‐two undergraduate nursing students conducted 1100 hr of participant observation in seven different units in a hospital in Western Norway from 2014–2015. Field notes were analysed using qualitative content analysis.

Results

Six themes emerged from the data: (i) content and structure of the handover, (ii) awareness of nurses’ attitudes during oral handover, (iii) verbal and nonverbal communication, (iv) distractions, (v) relaying key information accurately , (vi) ensuring quality through oral handovers.

Conclusion

Developing a familiar structure for oral handovers and minimising the use of abbreviations and unfamiliar medical terms promote clarity and understanding. Limiting disturbances during handovers helps nurses focus on the content of the report. Awareness of one's attitudes and the use of verbal and nonverbal communication can enhance the quality of a handover. Time allocated for an oral handover should allow for professional discussions and student supervision. Involving nurse leaders in promoting the quality of oral handovers can impact the quality of care.

Clinical implications

Oral handovers serve many purposes, such as the safe transfer of patient information between shifts and staff education and debriefing, which enhance team cohesiveness.