Overcrowding compounds mistrust and mismatched expectations by Paula S. Katz
Published in the November 2008 issue of Today’s Hospitalist
“No sign-out was given on the patient. When nursing staff called me to evaluate, patient was tachypneic and tachycardic. Patient was transferred to CCU with acute coronary syndrome. ED stated that this was an error secondary to being very busy with crowding in ED.”
Sound familiar? Given all the communication problems between ED physicians and hospitalists, it’s no wonder that both groups stereotype the other: Hospitalists complain that ED staff lack professionalism and judgment. Hospitalists, counter the ED doctors, expect too much.
Researchers who looked at transfers between the ED and the medical service
“There’s clearly a level of frustration.”
–Leora I. Horwitz, MD, MHS Yale-New Haven Hospital
in an urban academic center were surprised to find that problems went far beyond inaccurate or incomplete vital-sign information. Instead, they say it’s more often about system flaws—overcrowding, high workload and lagging technology—that intensify the pressure.
In a study titled “Dropping the Baton”, published online in June by Annals of Emergency Medicine, 40 respondents described 36 specific incidents of errors in diagnosis, treatment and disposition that caused patients harm or a near miss.
“It’s not that patients are dying left and right,” says Leora I. Horwitz, MD, MHS, lead author and assistant professor of medicine at Yale University School of Medicine who works with the Center for Outcomes Research and Evaluation at Yale-New Haven Hospital in New Haven, Conn. “But it’s interesting how many people observed problems.”
Dr. Horwitz talked to Today’s Hospitalist about who—if anyone—is to blame, and what strategies can ease the mutual frustration.
Why are there so many communication problems?
There’s lots of mistrust that contributes to misunderstanding. One respondent said the ED doctor didn’t talk to his patients if he could get away with it. I have no doubt the ED doctor talked to patients, but some things get miscommunicated and hospitalists attribute that to ED incompetence. I don’t think that’s necessarily true, but there’s clearly a level of frustration.
There’s frustration in the ED as well. It takes forever to get a call back, hospitalists give them a hard time about accepting a patient, or hospitalists ask for the patient to go somewhere else or for more tests. I don’t think people deliberately behave nonprofessionally, but they’re busy and stressed.
What’s behind the miscommunication?
For one thing, ED physicians and hospitalists just think differently. When a patient comes into the ED, the ED doctor first asks a few basic questions: How sick is this patient? What do I need to do to stabilize the patient right now?
After that, there’s triage to figure out where a patient belongs. Hospitalists take that for granted. What they want to know instead is: Does this patient with shortness of breath have pneumonia or heart failure?
There’s a fundamental disconnect of expectations. The hospitalist pushes, and ED doctors feel pressure to make a diagnosis, which could turn out to be wrong. Plus, hospitalists ask for more diagnostic tests or procedures to be done than the ED has time for because hospitalists know that results come faster that way.
As a result, people aren’t sure who is responsible for following up on tests that a hospitalist wants but the ED doctor orders. It’s not that hospitalists shouldn’t ask for those, but it is one more reason results fall through the cracks.
How many problems relate to questions of who is responsible for which aspects of care?
There’s definitely a lot of ambiguity about who’s responsible for patients who are already signed out to the admitting team or who go to dialysis before going to the floor, or who are reassigned after sign-out to a new team.
Most hospitalists say that if the patient is in the ED, the ED doctor is responsible. But the reality is that if the patient is signed out, the ED doctor is mentally finished with that patient and moves on. If his shift ends before the patient goes up to the floor, it’s even worse.
Often, all the next ED doctor is told is, “This is Ms. X, who’s been admitted with pneumonia and could disappear in the next 10 minutes.” With most patients that‘s OK, but not all, like acute asthmatics or diabetics who need hourly monitoring of their insulin drips.
Can technology help?
One frequent comment we heard about our ED is that information like vital signs is available only on paper, so hospitalists have to rely on the sign-out. Technology can help with issues like that.
But technology is by no means a silver bullet. For example, the ED is moving so fast that it’s actually harder to enter orders on the computer than to take two seconds to use the preprinted form. As a result, we’ve been scanning the ED paperwork, but the timing of that— and physician handwriting—isn’t always perfect.
The study puts a lot of the blame on systems issues.
EDs are bursting at the seams. Nationally, volume is up 1.5% per year, while the number of EDs has dropped 10% in the past decade. At same time, length of stay is declining and turnover is immense, so doctors on the floor are admitting and discharging faster and faster.
The problem isn’t really about communicating vital signs. It’s about environment, information technology, patient flow and responsibility.
That’s a lot to fix. Where should we start?
For individual hospitalists, communication is the most fixable area, so that’s the place to begin. Ask questions and give feedback when there’s a problem. Point out every time you don’t get a sign-out instead of complaining to one another. Also, understand the priorities and mindset of ED doctors, and be sympathetic to their needs and workflow.
We need to rethink how frontline clinicians participate in quality of care. When I was in the ED as a resident, I would follow up and find out when I had goofed or misdiagnosed a patient. I considered it part of my obligation.
But ED doctors are busy and may not always have the time to follow up on every patient themselves. In our study, virtually no ED doctors had any stories to tell about transfer-related errors because they never heard about them! The point is not to embarrass someone, but to teach and offer constructive dialogue.
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.