BRIEF R EPO R T
Miriam Fischer, MD Robin R. Hemphill, MD, MPH Eva Rimler, MD
Patient Communication During Handovers Between Emergency Medicine and Internal Medicine Residents
Stephanie Marshall, MD Erica Brownfield, MD Philip Shayne, MD Lorenzo Di Francesco, MD Sally A. Santen, MD, PhD
Journal of Graduate Medical Education 2012.4:533-537. Downloaded from www.jgme.org by 37.9.47.139 on 01/23/19. For personal use only.
Abstract Background Communication failures are a key cause of medical errors and are particularly prevalent during handovers of patients between services. Objective To explore current perceptions of effectiveness in communicating critical patient information during admission handovers between emergency medicine (EM) residents and internal medicine (IM) residents. Methods Study design was a survey of IM and EM residents at a large urban hospital. Residents were surveyed about whether critical information was communicated during patient handovers. Measurements included comparisons between IM and EM residents about their perceptions of effective communication of key patient information and the quality of handovers. Results Ninety-three percent of EM residents (50 of 54) and 80% of IM residents (74 of 93) responded to the survey. The EM residents judged their handover
performance to be better than how their IM colleagues assessed them on most questions. The IM residents reported that one-half of the time, EM residents provided organized and clear information, whereas EM residents self-reported that they did so most of the time (80%–90%). The IM residents reported that 25% of handovers were suboptimal and resulted in admission to an inappropriate level of care, and 10% led to harm or delay in care. The EM residents reported suboptimal communication was less common (5%). On the global assessment of whether the admission handover provided the information needed for good patient care, IM residents rated the quality of the handover data lower than did responding EM residents. Conclusions There are gaps in communicating critical patient information during admission handovers as perceived by EM and IM residents. This information can form the basis for efforts to improve these handovers.
Introduction Miriam Fischer, MD, is Resident in Emergency Medicine at Emory School of Medicine and Attending in Emergency Medicine at BestPractices and Inova Fairfax Hospital; Robin R. Hemphill, MD, MPH, is Director of the National Center for Patient Safety and Associate Professor of Emergency Medicine at Emory School of Medicine; Eva Rimler, MD, is Clinical Instructor of Internal Medicine at Emory University; Stephanie Marshall, MD, is Resident in Emergency Medicine at Emory School of Medicine; Erica Brownfield, MD, is Associate Professor of Internal Medicine at Emory School of Medicine; Philip Shayne, MD, is Associate Professor of Emergency Medicine at Emory School of Medicine; Lorenzo Di Francesco, MD, is Associate Professor of Internal Medicine at Emory School of Medicine; and Sally A. Santen, MD, PhD, is Assistant Dean for Educational Research and Quality Improvement and Associate Chair and Associate Professor of Emergency Medicine at the University of Michigan Medical School, and Associate Professor of Emergency Medicine at Emory School of Medicine. Funding: The authors report no external funding source for this study. We would like to acknowledge Lydia Odenat for statistical review and the other resident members of the Patient Handover Task Force, Emory University School of Medicine: Taj Adams, MD; Kara Mould, MD; and Majid Shaifq, MD, for their input. Corresponding author: Sally A. Santen, MD, PhD, Department of Emergency Medicine, University of Michigan Medical School, 3960 Taubman Medical Library, 1135 Catherine Street, Ann Arbor, MI 48109-5726, 734.763.1297, [email protected] Received October 24, 2011; revisions received January 22, 2012, and June 16, 2012; accepted June 20, 2012. DOI: http://dx.doi.org/10.4300/JGME-D-11-00256.1
Despite improvements in patient care since the 1999 report of the Institute of Medicine,1 medical errors persist in the medical community. Root-cause analyses of adverse patient outcomes indicate that a common contributor is communication failure.2–6 Poor information transfer from one health care provider to another, particularly when each provider has a different focus, has generated many studies aimed at improving team training and health care provider effectiveness during patient handovers.2–4 Recently, there have been efforts to improve handovers among residents.7 These initiatives have included structured handoff programs and a handoff curriculum, including observations and evaluations of handoffs.8–14 There is a dearth of research on this process, particularly regarding handovers between specialties. One of the most common handovers, the admission handover, has the additional challenge of the perceived difference in focus and culture between the handover parties, such as between emergency Journal of Graduate Medical Education, December 2012 533
BRIEF R EPO R T
medicine (EM) and internal medicine (IM) residents. Our objective was to examine the perceptions of EM residents and IM residents on handovers of newly hospitalized patients. By identifying these differences, we hope to open lines of communication between specialties to improve communication during patient handovers through a collaborative process.
Methods
facilities, handovers are done almost exclusively by phone with the EM resident presenting to the IM resident. A transfer of care is made to a resident on the admitting team and not the IM ‘‘gatekeeper.’’ Emergency medicine admits approximately 40 patients per day to the internal medicine residency teaching service. Some of the data were not normally distributed or were ordinal and were thus analyzed using Mann-Whitney U tests to compare answers between IM and EM respondents (SPSS version 18.0).
Journal of Graduate Medical Education 2012.4:533-537. Downloaded from www.jgme.org by 37.9.47.139 on 01/23/19. For personal use only.
Survey Development We developed a survey through a review of the patient handover literature, specifically using the handover methods described by Riesenberg et al12 in ‘‘Systematic Review of Handoff Mnemonics Literature,’’ which highlights key items that should be communicated. A director of patient safety (R.R.H.) also provided input on the survey development, which enhanced content-validity evidence. The survey content for each resident group was identical but modified to reflect their respective specialty. For example, an IM resident survey question asked ‘‘How often did you feel the EM resident maintained professional conduct during the course of the handover?’’ The EM resident survey substituted ‘‘IM resident’’ for ‘‘EM resident’’ in the same item. The instrument was piloted with residents involved in a cross-residency quality-improvement project (3 IM and 3 EM residents, who were all excluded from the study population) to improve handovers and was revised using input from the pilot study. The survey was administered anonymously through Survey Monkey (Palo Alto, California) with multiple e-mailed reminders. This study was reviewed by Emory University’s Institutional Review Board and deemed exempt.
Results
Ninety-three percent of EM residents (50 of 54) and 80% of IM residents (74 of 93) responded to the survey, 124 total respondents (84%). The results are described in T A B L E 1 . For most questions concerning handovers, the EM residents perceived their own handovers to be better than did their IM counterparts evaluating the same handovers. The IM residents reported that, one-half of the time, the EM residents provided organized and clear information. In contrast, the EM residents reported they did so most of the time. The IM residents reported that 25% of handovers were suboptimal and resulted in admission to an inappropriate level of care, and 10% led to harm or delay in care. The EM residents reported these issues were less common. Both groups agreed that, most of the time, residents maintained a high level of professional conduct during the handover and that interruptions were infrequent. The final question was ‘‘How well do you think the process of patient handovers is in providing the information needed to take good care of the patients?’’ On this global question, the IM residents responded that the quality of the handovers was significantly worse than did the EM residents. T A B L E 2 contains a representative sample of free-text comments.
Study Setting and Population
Discussion
We surveyed postgraduate year (PGY)-1 through PGY-3 EM residents presenting to PGY-2 or PGY-3 IM residents admitting patients to the internal medicine floor, telemetry, and step-down units at Grady Memorial Hospital, an urban teaching hospital treating an underserved population. Residents were included if they had participated in patient care at the hospital in the past 6 months. The IM residents spend approximately 9 to 10 mo/y in inpatient care versus 1 mo/y of inpatient care and 4 mo/y of intensive care completed by the EM residents. The number of admitted patients varies by PGY level and the natural variation of the emergency department. In our
Our study demonstrates significant discrepancies in the perceptions of the effectiveness of handovers between EM and IM residents. The EM residents reported they were communicating key patient information well, whereas IM residents reported that there was often inadequate communication of information. A few studies3,15–17 have specifically examined the EMIM handovers and transitions in care, revealing that EM physicians and IM physicians view transitions differently. The EM physician is traditionally focused on acute interventions and admission criteria, whereas the IM physician is more concerned with a complete view of the
534 Journal of Graduate Medical Education, December 2012
B R IEF R EP O R T
TABLE 1
Perceptions of Emergency Medicine (EM) and Internal Medicine (IM) Residents About Handovers
EM, Median (Interquartile Range)
Journal of Graduate Medical Education 2012.4:533-537. Downloaded from www.jgme.org by 37.9.47.139 on 01/23/19. For personal use only.
Itemsa
IM, Median (Interquartile Range)
P Valueb
Approximately how long did an average handover discussion take, min
5 (3–5)
4 (3–5)
,.005
How often did you feel that you were able to deliver the handover in an organized manner, %
80 (75–90)
50 (50–75)
,.005
How often did you feel that you communicated the handover information clearly, %
90 (75–90)
50 (50–75)
,.005
How often did you feel that you failed to communicate key information (eg, a pertinent physical or laboratory finding, imaging, or intervention carried out in the ED, code status, etc), %
10 (5–25)
50 (25–75)
,.005
How often did you feel that you were able to give an accurate sense of the acuity of the patient’s illness, %
90 (80–95)
75 (50–75)
,.005
How often did you feel that a suboptimal handover possibly resulted in a patient being admitted to an inappropriate level of care (ie, telemetry when they needed step-down unit), %
5 (0–10)
25 (10–25)
,.005
How often do you feel that either harm or a dangerous delay in care occurred because of poor transmission of data during a handover from the EM to IM, %
5 (0–10)
10 (10–25)
,.005
How often did you feel that the IM resident maintained professional conduct during the course of the handover, %
90 (75–90)
90 (70–90)
NS
How often did you feel that you failed to complete an appropriate handover because of interruptions by the IM resident, %
10 (5–25)
10 (5–25)
NS
Based on your experience, how well do you think the process of patient handovers is in providing the information needed to take good care of the patients, 1 5 poor; 5 5 excellent
4 (3–4)
3 (3–4)
,.005
Abbreviations: ED, emergency department; NS, not significant. a b
Survey items are from the view point of the EM resident. Bonferoni correction for multiple tests used.
TABLE 2
Representative Comments on Handovers
From IM Residents on EM Resident Handovers &
‘‘I think that oftentimes the information that the EM people find most important does not always correlate with what the IM people feel is most important’’
&
‘‘Handovers from senior-level EM residents are generally excellent; PGY-1 and PGY-2 residents often leave out important information (either they forget to mention it or it was never obtained) and jump about in their presentation’’
&
‘‘I think that having a standardized process would be helpful.’’
&
‘‘Unless I am getting the sign-out from an upper-level ED resident, who is generally good, accurate, and well-known to me, I often cut off the person signing out as soon as I sense that they don’t know how to sign out and then I ask scripted questions’’
From EM Residents Regarding Handovers to IM Residents &
‘‘Maintaining professionalism, minimizing interruptions/criticism, standardization’’
&
‘‘It’s cool that the IM residents look at [the computerized medical record] while we present to them, but they look at it so closely sometimes that they stop listening to our presentations, and then they ask questions that we had already answered in our presentations because they weren’t listening originally’’
Abbreviations: ED, emergency department; EM, emergency medicine; IM, internal medicine; PGY, postgraduate year.
Journal of Graduate Medical Education, December 2012 535
Journal of Graduate Medical Education 2012.4:533-537. Downloaded from www.jgme.org by 37.9.47.139 on 01/23/19. For personal use only.
BRIEF R EPO R T
patient’s life-threatening or urgent problems.17 Through interviews with attending physicians from both EM and IM, the handover period has been shown to be a ‘‘gray zone,’’ resulting in confusion regarding patient condition, disposition, and emergency department admission.17 This confusion was believed secondary to differing expectations by the services regarding their roles and responsibilities related to those admitted patients. In our study, IM residents were less satisfied with the handover process than were the EM residents. Particularly concerning is that, in one-quarter of all encounters, the IM residents reported patients were admitted to an inappropriate level of care or that harm or delay in care might have occurred. This finding echoes a study18 of EM admissions to a pediatric hospital in which 25% of those giving and receiving handovers disagreed about the severity of that patient’s illness. Yet, our survey, unlike the prior study,18 shows this issue goes beyond disagreement regarding the severity of illness and the sometimes antagonistic, interpersonal relationships, indicating there is a clear problem in communication between the services. Even though residents reported the interaction was professional, there was still a breakdown in the communicating of important patient information when patients were admitted to the hospital. Few residents in either specialty believed professionalism was an issue during the admission handover process, which was encouraging and probably means failures in inpatient care are secondary to handovers and are more related to communication discrepancies than they are to interpersonal relationships between our institution’s IM and EM colleagues. In addition, time constraints were not the cause of the perceived discrepancies in patient handovers. The observed differences in perceptions of handovers are in areas where multidisciplinary, qualityimprovement projects should increase collaboration between residencies, which could lead to improved patient care.19–20 Our study has several limitations. First, there may be a response bias, with residents who are dissatisfied being more likely to respond. Second, we studied only 2 departments at a single teaching institution, limiting generalizability. Third, few residents piloted the instrument to improve response process validity, and it is likely that residents interpreted ‘‘harm’’ to patients variously because there was no operationalized definition in the survey. In addition, we did not observe the handovers or, for example, confirm incorrect placement of the patient or unprofessionalism. Therefore, all information is subject to recall bias and respondents’ interpretation of the questions on the survey. Future studies might seek more-objective 536 Journal of Graduate Medical Education, December 2012
documentation of communication by real-time observation of the admission handover.
Conclusion
Our single-site study found a large difference in perceptions during admission handovers between EM and IM residents. The EM residents reported that they communicated effectively more often than IM residents reported they were receiving the necessary and vital information. Our evidence points to miscommunication and misunderstanding as the core problems during the admission handover from EM to IM.
References 1 Blech S. Medical errors: five years after the IOM report. The Commonwealth Fund. http://www.commonwealthfund.org/Publications/ Issue-Briefs/2005/Jul/Medical-Errors-Five-Years-After-the-IOM-Report. aspx. Posted July 2005. Accessed January 15, 2011. 2 Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80(12):1094–1099. 3 Apker J, Mallak LA, Applegate EB III, Gibson SC, Ham JJ, Johnson NA, et al. Exploring emergency physician-hospitalist handoff interactions: development of the Handoff Communication Assessment. Ann Emerg Med. 2010;55(2):161–170. 4 Clancy CM. The importance of simulation: preventing the hand-off mistakes. AORN. 2008;88(4):625–627. 5 Cheung DS, Kelly JJ, Beach C, Berkeley RP, Bitterman RA, Broida RI, et al; Section of Quality Improvement and Patient Safety, American College of Emergency Physicians. Improving handoffs in the emergency department. Ann Emerg Med. 2010;55(2):171–180. 6 Parker J, Coiera E. Improving clinical communication: a view from psychology. J Am Med Inform Assoc. 2000;7(5):453–461. 7 [ACGME] Accreditation Council for Graduate Medical Education. Common Program Requirements. http://www.acgme.org/acwebsite/home/ Common_Program_Requirements_07012011.pdf. Effective July 1, 2011. Accessed January 15, 2011. 8 Kemp CD, Bath JM, Berger J, Bergsman A, Ellison T, Emery K, et al. The top 10 list for a safe and effective sign-out. Arch Surg. 2008;143(10):1008– 1010. 9 Gakhar B, Spencer, AL. Using direct observation, formal evaluation, and an interactive curriculum to improve the sign-out practices of internal medicine interns. Acad Med. 2010;85(7):1182–1188. 10 Chu ES, Reid M, Schultz T, Burden M, Mancini D, Ambardekar AV, et al. A structured handoff program for interns. Acad Med. 2009;84(3):347– 352. 11 Telem DA, Buch KE, Ellis B, Coakley B, Divino CM. Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results. Arch Surg. 2011;146(1):89–93. 12 Riesenberg LA, Leitzsch J, Massucci JL, Jaeger J, Rosenfeld JC, Patow C, et al. Residents’ and attending physicians’ handoffs: a systemic review of the literature. Acad Med. 2009;84(12):1775–1787. 13 Dhingra KR, Elms A, Hobgood C. Reducing error in the emergency department: a call for standardization of the sign-out process. Ann Emerg Med. 2010;56(6):637–642. 14 The Joint Commission. Accreditation Program: Hospital National Patient Safety Goals. http://www.jointcommission.org/assets/1/6/2011_NPSGs_ HAP.pdf. Effective January 1, 2011. Accessed January 15, 2011. 15 Horwitz LJ, Meredith T, Schuur JD, Shah NR, Kulkarni RG, Jenq GY. Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med. 2009;53(6): 701–710. 16 Gibson SC, Ham JJ, Apker J, Mallak LA, Johnson NA. Communication, communication, communication: the art of the handoff. Ann Emerg Med. 2010;55(2):181–182.
B R IEF R EP O R T 19 Varkey P, Reller MK, Smith A, Ponto J, Osborn M. An experiential interdisciplinary quality improvement education initiative. Am J Med Qual. 2006;21(5):317–322. 20 Daniel DM, Casey DE Jr, Levine JL, Kaye ST, Dardik RB, Varkey P, et al. Taking a unified approach to teaching and implementing quality improvements across multiple residency programs: the Atlantic Health experience. Acad Med. 2009;84(12):1788–1795.
Journal of Graduate Medical Education 2012.4:533-537. Downloaded from www.jgme.org by 37.9.47.139 on 01/23/19. For personal use only.
17 Apker J, Mallak LA, Gibson SC. Communicating in the ‘‘gray zone:’’ perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007;14(10):884–893. 18 Brannen ML, Cameron KA, Adler M, Goodman D, Holl JL. Admission handoff communications: clinician’s shared understanding of patient severity of illness and problems. J Patient Saf. 2009;5(4):237– 242.
Journal of Graduate Medical Education, December 2012 537
Miriam Fischer, MD Robin R. Hemphill, MD, MPH Eva Rimler, MD
Patient Communication During Handovers Between Emergency Medicine and Internal Medicine Residents
Stephanie Marshall, MD Erica Brownfield, MD Philip Shayne, MD Lorenzo Di Francesco, MD Sally A. Santen, MD, PhD
Journal of Graduate Medical Education 2012.4:533-537. Downloaded from www.jgme.org by 37.9.47.139 on 01/23/19. For personal use only.
Abstract Background Communication failures are a key cause of medical errors and are particularly prevalent during handovers of patients between services. Objective To explore current perceptions of effectiveness in communicating critical patient information during admission handovers between emergency medicine (EM) residents and internal medicine (IM) residents. Methods Study design was a survey of IM and EM residents at a large urban hospital. Residents were surveyed about whether critical information was communicated during patient handovers. Measurements included comparisons between IM and EM residents about their perceptions of effective communication of key patient information and the quality of handovers. Results Ninety-three percent of EM residents (50 of 54) and 80% of IM residents (74 of 93) responded to the survey. The EM residents judged their handover
performance to be better than how their IM colleagues assessed them on most questions. The IM residents reported that one-half of the time, EM residents provided organized and clear information, whereas EM residents self-reported that they did so most of the time (80%–90%). The IM residents reported that 25% of handovers were suboptimal and resulted in admission to an inappropriate level of care, and 10% led to harm or delay in care. The EM residents reported suboptimal communication was less common (5%). On the global assessment of whether the admission handover provided the information needed for good patient care, IM residents rated the quality of the handover data lower than did responding EM residents. Conclusions There are gaps in communicating critical patient information during admission handovers as perceived by EM and IM residents. This information can form the basis for efforts to improve these handovers.
Introduction Miriam Fischer, MD, is Resident in Emergency Medicine at Emory School of Medicine and Attending in Emergency Medicine at BestPractices and Inova Fairfax Hospital; Robin R. Hemphill, MD, MPH, is Director of the National Center for Patient Safety and Associate Professor of Emergency Medicine at Emory School of Medicine; Eva Rimler, MD, is Clinical Instructor of Internal Medicine at Emory University; Stephanie Marshall, MD, is Resident in Emergency Medicine at Emory School of Medicine; Erica Brownfield, MD, is Associate Professor of Internal Medicine at Emory School of Medicine; Philip Shayne, MD, is Associate Professor of Emergency Medicine at Emory School of Medicine; Lorenzo Di Francesco, MD, is Associate Professor of Internal Medicine at Emory School of Medicine; and Sally A. Santen, MD, PhD, is Assistant Dean for Educational Research and Quality Improvement and Associate Chair and Associate Professor of Emergency Medicine at the University of Michigan Medical School, and Associate Professor of Emergency Medicine at Emory School of Medicine. Funding: The authors report no external funding source for this study. We would like to acknowledge Lydia Odenat for statistical review and the other resident members of the Patient Handover Task Force, Emory University School of Medicine: Taj Adams, MD; Kara Mould, MD; and Majid Shaifq, MD, for their input. Corresponding author: Sally A. Santen, MD, PhD, Department of Emergency Medicine, University of Michigan Medical School, 3960 Taubman Medical Library, 1135 Catherine Street, Ann Arbor, MI 48109-5726, 734.763.1297, [email protected] Received October 24, 2011; revisions received January 22, 2012, and June 16, 2012; accepted June 20, 2012. DOI: http://dx.doi.org/10.4300/JGME-D-11-00256.1
Despite improvements in patient care since the 1999 report of the Institute of Medicine,1 medical errors persist in the medical community. Root-cause analyses of adverse patient outcomes indicate that a common contributor is communication failure.2–6 Poor information transfer from one health care provider to another, particularly when each provider has a different focus, has generated many studies aimed at improving team training and health care provider effectiveness during patient handovers.2–4 Recently, there have been efforts to improve handovers among residents.7 These initiatives have included structured handoff programs and a handoff curriculum, including observations and evaluations of handoffs.8–14 There is a dearth of research on this process, particularly regarding handovers between specialties. One of the most common handovers, the admission handover, has the additional challenge of the perceived difference in focus and culture between the handover parties, such as between emergency Journal of Graduate Medical Education, December 2012 533
BRIEF R EPO R T
medicine (EM) and internal medicine (IM) residents. Our objective was to examine the perceptions of EM residents and IM residents on handovers of newly hospitalized patients. By identifying these differences, we hope to open lines of communication between specialties to improve communication during patient handovers through a collaborative process.
Methods
facilities, handovers are done almost exclusively by phone with the EM resident presenting to the IM resident. A transfer of care is made to a resident on the admitting team and not the IM ‘‘gatekeeper.’’ Emergency medicine admits approximately 40 patients per day to the internal medicine residency teaching service. Some of the data were not normally distributed or were ordinal and were thus analyzed using Mann-Whitney U tests to compare answers between IM and EM respondents (SPSS version 18.0).
Journal of Graduate Medical Education 2012.4:533-537. Downloaded from www.jgme.org by 37.9.47.139 on 01/23/19. For personal use only.
Survey Development We developed a survey through a review of the patient handover literature, specifically using the handover methods described by Riesenberg et al12 in ‘‘Systematic Review of Handoff Mnemonics Literature,’’ which highlights key items that should be communicated. A director of patient safety (R.R.H.) also provided input on the survey development, which enhanced content-validity evidence. The survey content for each resident group was identical but modified to reflect their respective specialty. For example, an IM resident survey question asked ‘‘How often did you feel the EM resident maintained professional conduct during the course of the handover?’’ The EM resident survey substituted ‘‘IM resident’’ for ‘‘EM resident’’ in the same item. The instrument was piloted with residents involved in a cross-residency quality-improvement project (3 IM and 3 EM residents, who were all excluded from the study population) to improve handovers and was revised using input from the pilot study. The survey was administered anonymously through Survey Monkey (Palo Alto, California) with multiple e-mailed reminders. This study was reviewed by Emory University’s Institutional Review Board and deemed exempt.
Results
Ninety-three percent of EM residents (50 of 54) and 80% of IM residents (74 of 93) responded to the survey, 124 total respondents (84%). The results are described in T A B L E 1 . For most questions concerning handovers, the EM residents perceived their own handovers to be better than did their IM counterparts evaluating the same handovers. The IM residents reported that, one-half of the time, the EM residents provided organized and clear information. In contrast, the EM residents reported they did so most of the time. The IM residents reported that 25% of handovers were suboptimal and resulted in admission to an inappropriate level of care, and 10% led to harm or delay in care. The EM residents reported these issues were less common. Both groups agreed that, most of the time, residents maintained a high level of professional conduct during the handover and that interruptions were infrequent. The final question was ‘‘How well do you think the process of patient handovers is in providing the information needed to take good care of the patients?’’ On this global question, the IM residents responded that the quality of the handovers was significantly worse than did the EM residents. T A B L E 2 contains a representative sample of free-text comments.
Study Setting and Population
Discussion
We surveyed postgraduate year (PGY)-1 through PGY-3 EM residents presenting to PGY-2 or PGY-3 IM residents admitting patients to the internal medicine floor, telemetry, and step-down units at Grady Memorial Hospital, an urban teaching hospital treating an underserved population. Residents were included if they had participated in patient care at the hospital in the past 6 months. The IM residents spend approximately 9 to 10 mo/y in inpatient care versus 1 mo/y of inpatient care and 4 mo/y of intensive care completed by the EM residents. The number of admitted patients varies by PGY level and the natural variation of the emergency department. In our
Our study demonstrates significant discrepancies in the perceptions of the effectiveness of handovers between EM and IM residents. The EM residents reported they were communicating key patient information well, whereas IM residents reported that there was often inadequate communication of information. A few studies3,15–17 have specifically examined the EMIM handovers and transitions in care, revealing that EM physicians and IM physicians view transitions differently. The EM physician is traditionally focused on acute interventions and admission criteria, whereas the IM physician is more concerned with a complete view of the
534 Journal of Graduate Medical Education, December 2012
B R IEF R EP O R T
TABLE 1
Perceptions of Emergency Medicine (EM) and Internal Medicine (IM) Residents About Handovers
EM, Median (Interquartile Range)
Journal of Graduate Medical Education 2012.4:533-537. Downloaded from www.jgme.org by 37.9.47.139 on 01/23/19. For personal use only.
Itemsa
IM, Median (Interquartile Range)
P Valueb
Approximately how long did an average handover discussion take, min
5 (3–5)
4 (3–5)
,.005
How often did you feel that you were able to deliver the handover in an organized manner, %
80 (75–90)
50 (50–75)
,.005
How often did you feel that you communicated the handover information clearly, %
90 (75–90)
50 (50–75)
,.005
How often did you feel that you failed to communicate key information (eg, a pertinent physical or laboratory finding, imaging, or intervention carried out in the ED, code status, etc), %
10 (5–25)
50 (25–75)
,.005
How often did you feel that you were able to give an accurate sense of the acuity of the patient’s illness, %
90 (80–95)
75 (50–75)
,.005
How often did you feel that a suboptimal handover possibly resulted in a patient being admitted to an inappropriate level of care (ie, telemetry when they needed step-down unit), %
5 (0–10)
25 (10–25)
,.005
How often do you feel that either harm or a dangerous delay in care occurred because of poor transmission of data during a handover from the EM to IM, %
5 (0–10)
10 (10–25)
,.005
How often did you feel that the IM resident maintained professional conduct during the course of the handover, %
90 (75–90)
90 (70–90)
NS
How often did you feel that you failed to complete an appropriate handover because of interruptions by the IM resident, %
10 (5–25)
10 (5–25)
NS
Based on your experience, how well do you think the process of patient handovers is in providing the information needed to take good care of the patients, 1 5 poor; 5 5 excellent
4 (3–4)
3 (3–4)
,.005
Abbreviations: ED, emergency department; NS, not significant. a b
Survey items are from the view point of the EM resident. Bonferoni correction for multiple tests used.
TABLE 2
Representative Comments on Handovers
From IM Residents on EM Resident Handovers &
‘‘I think that oftentimes the information that the EM people find most important does not always correlate with what the IM people feel is most important’’
&
‘‘Handovers from senior-level EM residents are generally excellent; PGY-1 and PGY-2 residents often leave out important information (either they forget to mention it or it was never obtained) and jump about in their presentation’’
&
‘‘I think that having a standardized process would be helpful.’’
&
‘‘Unless I am getting the sign-out from an upper-level ED resident, who is generally good, accurate, and well-known to me, I often cut off the person signing out as soon as I sense that they don’t know how to sign out and then I ask scripted questions’’
From EM Residents Regarding Handovers to IM Residents &
‘‘Maintaining professionalism, minimizing interruptions/criticism, standardization’’
&
‘‘It’s cool that the IM residents look at [the computerized medical record] while we present to them, but they look at it so closely sometimes that they stop listening to our presentations, and then they ask questions that we had already answered in our presentations because they weren’t listening originally’’
Abbreviations: ED, emergency department; EM, emergency medicine; IM, internal medicine; PGY, postgraduate year.
Journal of Graduate Medical Education, December 2012 535
Journal of Graduate Medical Education 2012.4:533-537. Downloaded from www.jgme.org by 37.9.47.139 on 01/23/19. For personal use only.
BRIEF R EPO R T
patient’s life-threatening or urgent problems.17 Through interviews with attending physicians from both EM and IM, the handover period has been shown to be a ‘‘gray zone,’’ resulting in confusion regarding patient condition, disposition, and emergency department admission.17 This confusion was believed secondary to differing expectations by the services regarding their roles and responsibilities related to those admitted patients. In our study, IM residents were less satisfied with the handover process than were the EM residents. Particularly concerning is that, in one-quarter of all encounters, the IM residents reported patients were admitted to an inappropriate level of care or that harm or delay in care might have occurred. This finding echoes a study18 of EM admissions to a pediatric hospital in which 25% of those giving and receiving handovers disagreed about the severity of that patient’s illness. Yet, our survey, unlike the prior study,18 shows this issue goes beyond disagreement regarding the severity of illness and the sometimes antagonistic, interpersonal relationships, indicating there is a clear problem in communication between the services. Even though residents reported the interaction was professional, there was still a breakdown in the communicating of important patient information when patients were admitted to the hospital. Few residents in either specialty believed professionalism was an issue during the admission handover process, which was encouraging and probably means failures in inpatient care are secondary to handovers and are more related to communication discrepancies than they are to interpersonal relationships between our institution’s IM and EM colleagues. In addition, time constraints were not the cause of the perceived discrepancies in patient handovers. The observed differences in perceptions of handovers are in areas where multidisciplinary, qualityimprovement projects should increase collaboration between residencies, which could lead to improved patient care.19–20 Our study has several limitations. First, there may be a response bias, with residents who are dissatisfied being more likely to respond. Second, we studied only 2 departments at a single teaching institution, limiting generalizability. Third, few residents piloted the instrument to improve response process validity, and it is likely that residents interpreted ‘‘harm’’ to patients variously because there was no operationalized definition in the survey. In addition, we did not observe the handovers or, for example, confirm incorrect placement of the patient or unprofessionalism. Therefore, all information is subject to recall bias and respondents’ interpretation of the questions on the survey. Future studies might seek more-objective 536 Journal of Graduate Medical Education, December 2012
documentation of communication by real-time observation of the admission handover.
Conclusion
Our single-site study found a large difference in perceptions during admission handovers between EM and IM residents. The EM residents reported that they communicated effectively more often than IM residents reported they were receiving the necessary and vital information. Our evidence points to miscommunication and misunderstanding as the core problems during the admission handover from EM to IM.
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Journal of Graduate Medical Education 2012.4:533-537. Downloaded from www.jgme.org by 37.9.47.139 on 01/23/19. For personal use only.
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