Complex Patient Handoffs: Communication Issues Impacting Patient Satisfaction
While the profession of medicine has embraced the concept of separating outpatient and inpatient care, patients have not been so quick to do so. The geometric expansion of medical technology and knowledge has made it almost impossible for the same physician to master both areas…especially in the primary care specialties.
So, why the problem? And, why are patients troubled by these changes? The answer comes down to one word: communication.
Patients are most comfortable and most compliant when they feel there is a continuum of care. They would like to think that any physician involved in their care knows their health history and has a comfort level with their therapy. The answer to this dilemma can be stated simply: appropriate and adequate hand offs from provider to provider and from beginning to end of an episode of care. The problem is, it’s complex to achieve.
Mind-boggling number of handoffs
If one reflects on a 65-year-old patient being admitted to the hospital through the emergency department, sent there by their primary care physician, the number of handoffs is mind boggling.
For example, let’s say that Mrs. S is admitted for a severe pneumonia found by her primary care provider (PCP) during an exam, chest x-ray (CXR) and decreased blood oxygenation.
And the train leaves the station!
Along the journey of handoffs, the following care transitions will take place.
- Primary care physician to ED triage to ED physician with the possibility of and extra doctor with shift change.
- ED physician to Intensivist, again with extra handoffs for shift changes and team changes if the length of stay (LOS) extends over the weekend or is longer than the average LOS.
- ICU to a step down unit or to a floor bed. Again, there is a strong possibility that there will be additional transitions as noted above.
- Floor hospitalist to skilled nursing, rehab, or primary care provider.
Complexity of the handoff process
A complex patient, where communication is vitally important, could easily experience a dozen handoffs in a relatively short stay (likely even more). This number doesn’t even include physicians involved in specialty consultation, which is a topic for discussion in and of itself.
The handoff process has become very complex:
- It takes many forms
- Face-to-face communication is rare
- Cut and paste becomes imbedded in the process
So where does this process lead us? It often leads to patient dissatisfaction, family frustration, and unfortunately, increased litigation.
You as the physician may have thousands of patients. But for each patient, their interaction with you is one important event. Each patient wants to be heard and to feel that their “event” is very important to you. If a patient gets the sense that you haven’t taken the time to learn where they are in their health care event, they will feel disrespected, let down and dissatisfied.
You as the physician may have thousands of patients. But for each patient, their interaction with you is one important event.
Communication gaps lead to mistakes
What happens if that dissatisfied patient has something that doesn’t go quite right? In every law suit I have ever reviewed, a communication gap has played some role.
Having good care transitions does not require a lengthy presentation, or a 3-page note. There are, however, elements which should be included in every handoff.
Ensuring appropriate info is available.
On admission, the accepting physician should make every effort to gather past medical information if it is not readily available at the time of admission. This is a good place to have physician extenders become involved, although that requires an additional handoff. If this initial information is not correct, it follows the patient through the admission, leading to omissions and redundancies and increased cost….and possibly errors in care.
The admitting hospitalist should speak directly with the ED physician to exchange important information. If necessary, to fill in the gaps there should be communication with the primary care physician and other physicians whose care is relevant to the admission.
During the stay, the hospitalist is tasked with coordinating the overall care of the patient, engaging specialists as needed, communicating with them including the coordination of order writing and, very importantly, keeping the patient and family informed of who is seeing the patient and for what reason.
If there is a transfer of care or transition to a higher or lower level of care, the hospitalist must communicate with the receiving service, and equally importantly with the patient and family that this is happening and why. There are few events more daunting than having a family arrive to visit only to find an empty room with the bed made!
In all of these processes there must be a succinct but informative sign out to a nocturnist with priorities and “what to do if” information.
Finally, at the time of discharge, the attending physician must assure appropriate follow up. This includes appointments with the primary care physician and specialists as needed. Treatments and labs necessary for continued care should be ordered and all abnormal tests discussed with the patient and family as appropriate. This communication should be face-to-face and in writing in a document that the patient can take with him. It should also be immediately available electronically to the primary care physician and/or the next physician providing care.
Measuring and improving
While many hospitalist groups have policies in place to guide patient handoffs, they are only as good as the paper they are on without a method of measuring the process and monitoring compliance. Additionally, a query to the patient done very soon after discharge can be used to measure outcomes, patient satisfaction and to improve adherence and change behavior.
Transitions to different providers providing care in both the inpatient and outpatient settings are numerous. They are also becoming the norm. Failure of transition communication leads to inadequate care and patient dissatisfaction. This action places both the patient and the physician at risk for adverse events and could result in accusations of negligence for the physician.