- Email: [email protected]
In reply
Correspondence would be an excellent resource to review the case from a potentially different perspective, feeling free to critique care with no harm intended. Since each of us would be placed in the role of either the physician at the end of the shift or the one assuming takeover in care, no personal insult would be incurred and, in fact, new fresher feedback would be welcomed in order to enhance optimal patient care. We also have enlisted a standardized format for transfer of care, quite different from the typical SOAP (Subjective, Objective, Assessment, Plan) format, where very brief demographic information regarding the patient is shared, soon followed by a very important anchor of a presumed diagnosis and disposition, prior to any further necessary clinical details being shared. This assists the receiving physician in quickly incorporating the contextual aspect of the sign-out information and the trajectory of the patient disposition. Finally, we have an expectation that within approximately 1 hour of leaving the ED, the physician ending a shift will call back to make sure no loose ends have become obvious, requiring their input. This has also provided an unintended positive consequence of improving the knowledge base of the physician who has left a shift, easily providing them follow-up on pending tests and information that may have accrued since departure from the ED. Overall, I agree that sign-outs provide opportunities for patient care to suffer, and there are useful tactics and strategies that mitigate this risk. Douglas A. Propp, MD, MS Advocate Lutheran General Hospital Park Ridge, IL doi:10.1016/j.annemergmed.2010.03.038
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. 1. Cheung DS, Kelly JJ, Beach C, et al. Improving handoffs in the emergency department. Ann Emerg Med. 2010;55:171-180. 2. Gibson SC, Ham JJ, Apker J, et al. Communication, communication, communication: the art of the handoff. Ann Emerg Med. 2010;55:181-183.
patients headed down a perilous path. The Quality Improvement and Patient Safety Handoff Grant Team spent a considerable amount of time debating how best to provide this “opportunity to ask and respond to questions.” In the end, we decided— because published evidence is sorely lacking—that the handoff should be synchronous but not necessarily face to face. Your custom of having the departing physician call back an hour after departing his shift for any lingering questions certainly fits within this framework. This may be particularly effective for “closing the loop” as questions about patients sometimes do not become evident until the departing physician has left the building. How about a suggestion to improve on your already excellent practice? The only thing better than providing the option to ask and respond to questions is to allow for multiple opportunities. A contact number for the departing physician would allow addressing concerns at any time without delay. While we caution the use of overly rigid standardized formats, structured conversation encourages a rhythm for effective communication. What may work at your 58,000-visit suburban teaching emergency department (ED) may not be as effective in a 12,000-visit rural ED or a 130,000-visit county hospital ED. The key is fostering a culture of safety by breaking down barriers that may hinder an open discussion between parties. Different settings may find various ways of achieving this end, but as a specialty, we must move toward unifying this process. As we read your letter, the aspect that most intrigued us is how your group initially came to recognize that handoffs deserve the attention they received at your institution. The handoff interventions you deployed require considerable staff compliance. You and your group have already accomplished the most important step, that of moving the culture. Thank you again for sharing your specific suggestions. This exchange of ideas demonstrates the benefits of gathering, developing, and disseminating best handoff practices. Dickson S. Cheung, MD, MBA, MPH Sky Ridge Medical Center Carepoint P.C. Denver, CO Scott C. Gibson, MD Bronson Methodist Hospital Kalamazoo, MI doi:10.1016/j.annemergmed.2010.03.037
In reply: Thank you for sharing your experience in combating faulty handoffs. Kudos to you and your group for successfully improving this vital process. As mentioned in the “Improving Handoffs in the Emergency Department” article, your practice of having the arriving physician critique cases may allow for potential rescue of
Volume , . : August
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.
Annals of Emergency Medicine 205
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. 1. Cheung DS, Kelly JJ, Beach C, et al. Improving handoffs in the emergency department. Ann Emerg Med. 2010;55:171-180. 2. Gibson SC, Ham JJ, Apker J, et al. Communication, communication, communication: the art of the handoff. Ann Emerg Med. 2010;55:181-183.
patients headed down a perilous path. The Quality Improvement and Patient Safety Handoff Grant Team spent a considerable amount of time debating how best to provide this “opportunity to ask and respond to questions.” In the end, we decided— because published evidence is sorely lacking—that the handoff should be synchronous but not necessarily face to face. Your custom of having the departing physician call back an hour after departing his shift for any lingering questions certainly fits within this framework. This may be particularly effective for “closing the loop” as questions about patients sometimes do not become evident until the departing physician has left the building. How about a suggestion to improve on your already excellent practice? The only thing better than providing the option to ask and respond to questions is to allow for multiple opportunities. A contact number for the departing physician would allow addressing concerns at any time without delay. While we caution the use of overly rigid standardized formats, structured conversation encourages a rhythm for effective communication. What may work at your 58,000-visit suburban teaching emergency department (ED) may not be as effective in a 12,000-visit rural ED or a 130,000-visit county hospital ED. The key is fostering a culture of safety by breaking down barriers that may hinder an open discussion between parties. Different settings may find various ways of achieving this end, but as a specialty, we must move toward unifying this process. As we read your letter, the aspect that most intrigued us is how your group initially came to recognize that handoffs deserve the attention they received at your institution. The handoff interventions you deployed require considerable staff compliance. You and your group have already accomplished the most important step, that of moving the culture. Thank you again for sharing your specific suggestions. This exchange of ideas demonstrates the benefits of gathering, developing, and disseminating best handoff practices. Dickson S. Cheung, MD, MBA, MPH Sky Ridge Medical Center Carepoint P.C. Denver, CO Scott C. Gibson, MD Bronson Methodist Hospital Kalamazoo, MI doi:10.1016/j.annemergmed.2010.03.037
In reply: Thank you for sharing your experience in combating faulty handoffs. Kudos to you and your group for successfully improving this vital process. As mentioned in the “Improving Handoffs in the Emergency Department” article, your practice of having the arriving physician critique cases may allow for potential rescue of
Volume , . : August
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.
Annals of Emergency Medicine 205