Hospitalist Communication: Risks and Strategies

Published on: July 4, 2012

 “Ineffective care transition processes lead to: 

•  Adverse outcomes for patients, including medication errors, clinical progression of illness, lack of post-discharge follow up and avoidable emergency department visits; 
• Decreased patient and staff satisfaction;
• Inappropriate use of resources; and,
• Financial penalties through reduction in reimbursement from the Centers for Medicare & Medicaid Services (CMS) and other insurers.”

The Society of Hospital Medicine (SHM) 

Case Study 

 A 43–year–old married father of three was taken via ambulance to the ED with sudden onset of mid-sternal chest pain as well as numbness and pain radiating to his left arm. History obtained by paramedics included shortness of breath, diaphoresis, abnormal EKG and five similar episodes in the last two weeks. The patient’s serial cardiac enzymes, admitting EKG and chest x-ray were normal. The patient was admitted by Hospitalist A to the Telemetry Unit to rule out MI. The next day, the patient was feeling better and Hospitalist A ordered an exercise stress echo and noted “cardiology to see.” 

The stress echo was read by a cardiologist as showing no myocardial eschemia, frequent PVCs in recovery and excellent exercise tolerance; impression: normal. The cardiologist did not examine the patient, and it is disputed as to whether he was asked to perform a consultation or merely to interpret the stress echo, as there was no medical record documentation specifying the cardiologist’s role in the patient’s treatment. (Expert reviewers opined in retrospect that the stress echo was not normal.)  

On the third day of hospitalization, Hospitalist B was contacted by a nurse who reported the patient’s oxygen saturation was 90% on room air; a spirometry test was ordered and revealed severe obstruction and low vital capacity. Hospitalist B spoke with a cardiology physician assistant (PA) and requested a consultation and results of the echocardiogram. Again, the specifics of the conversation were not documented in the patient’s chart, and it was disputed at trial as to whether a consultation was requested or merely a reporting of the test results.  

Based on the normal echo results the cardiology PA discharged the patient with instructions to follow up with his PCP and continue Zantac and Lopressor. In her discharge summary, Hospitalist B did not address the spirometry results, nor did she specify a plan for follow-up.  

The patient saw his PCP two days after discharge and reported his recent hospitalization and negative cardiac studies. A spine film was ordered to rule out cervical radiculopathy and he was given a GI referral. On the next day, the patient called his doctor after experiencing three episodes of chest pain. He was advised to follow up with his GI consult. Nine days post discharge (before his appointment with gastroenterologist) the patient experienced chest pain and called an ambulance but expired en route to the hospital. Autopsy showed “critical coronary artery stenosis.”  

Claims of medical negligence were made against Hospitalist A, Hospitalist B, the cardiologist, the cardiology group, the cardiology PA, and the primary care physician. The case was settled on behalf of the cardiologist and cardiology group in the mid six-figure range and the case was settled on behalf of Hospitalist B in the low six figure range. Hospitalist A and the primary care physician were dismissed.  

This case illustrates how poor understanding of the division of responsibilities between the hospitalist and the cardiologist and poor communication between the hospitalists, cardiologist, and primary care physician resulted in the arguably unnecessary death of the patient. Essentially, no one took responsibility for the patient. It also illustrates that a lack of documentation of the treatment plan and disputed recollections hindered the defensibility of all of the defendant physicians. Although the bulk of the responsibility fell to the cardiologist, whom expert reviewers determined misinterpreted the stress echo, expert reviewers opined that Hospitalist B relied too heavily on the “normal” echo in determining that the patient was ready for discharge and failed in her duty to adequately address the spirometry results.  

Mnemonics and standardized hand-offs 

 Handoffs occur any time there is a transfer of responsibility for a patient from one caregiver to another. As we can see from the case example, it is vital to patient safety to establish role clarity amongst the treatment team members and goal clarity in the treatment plan.  

Regulatory bodies are aware of the dangers of ineffective hand-offs. Problems with handoff communication are listed as one of the root causes in up to 70% of adverse sentinel events compiled by The Joint Commission, and hospitals seeking accreditation are required to have a standardized method for hand-offs. According to several hospitalist groups surveyed by MIEC’s Patient Safety & Risk Management (PSRM) field staff, it is often routine for hospitalists to facilitate the hand-off via a telephone reporting system. The clinicians record a message for their colleagues summarizing a patient’s status. Unfortunately, the recorded message usually is not retained or memorialized in the chart by either the transferring or receiving hospitalist.   

Hospitalists can better protect themselves, their colleagues and their patients by documenting receipt of the message. Example language might be, “Reviewed chart, MAR, shift report from Dr. XX [hospitalist]; discussed case with cardiologist Dr. XX, and family. No significant changes since yesterday.” If there has been a significant change with the patient (positive or negative), the physicians should document the new information and any conversation between the two physicians.  

Several mnemonic tools have been developed to assist members of the health care team in accomplishing thorough, standardized hand-offs, including the FIVE-Ps (Patient, Plan, Purpose, Problems, Precautions), SBAR, I PASS the BATON, and more. For example, I PASS the BATON, which was developed by the Department of Defense’s Patient Safety Program, was designed to work in conjunction with opportunities to ask questions and clarify information:  

DE-PASS (a modification of I PASS) assists when transferring patients from the ED to the hospitalist inpatient service. As a handoff tool it helps the care team stratify patients as stable/urgent/emergent and defines communication requirements between providers. 

There is scant data available demonstrating the superiority of one standardized hand-off system versus another; the unique needs of each health care organization will likely determine which system is optimal. Regardless of which system you use, document the evaluation in the daily progress note. Electronically generate the notes (e.g., EMR, dictation/transcription) as these types of notes have proven to be more detailed than handwritten chart entries. It is also necessary to identify and correct systemic issues that prevent effective hand-offs, such as noise, interruptions, and unavailability of pertinent or pending test results and other data.  

Communication with primary care physicians 

In the case study, the patient’s primary care physician was falsely reassured by the patient’s recounting of the negative cardiac studies and did not consider MI when the patient called with additional complaints of chest pain. Had the primary care physician been aware of the spirometry results, might he have been more cautious about the patient’s reported symptoms? Primary care physicians are often hamstrung by a lack of information about their patient’s hospitalizations. Consider the following:  

• Researchers from Mt. Sinai School of Medicine in New York found that more than one-third of recommended outpatient work-ups following a patient’s hospitalization were not completed because the discharge summary didn’t include details of the work-up, or the summary wasn’t available to the primary doctor at the time of the patient’s follow-up visit. 
  

• A study published in the September 2009 edition of the Journal of General Internal Medicine found that while all patients in the study were waiting for test results at the time they left the hospital, only a quarter of discharge summaries mentioned any pending tests, and a scant 13% documented what those pending tests were. 
  

Effective discharge handoffs are receiving more attention and resources thanks to public reporting of readmission rates and decreased reimbursement for readmission within 30 days. The Society for Hospital Medicine launched its Better Outcomes by Optimizing Safe Transitions program (Project BOOST) in 2008. Since its launch in 2008, Project BOOST has assisted more than 180 hospitals and health systems enhance their care transition processes; the Project BOOST toolkit is available on the SHM website. 

In addition to discharge transitions, hospitalists must have effective communication channels with primary care physicians to address patients directly admitted by those PCPs. Both hospitalists and primary care physicians share the responsibility of ensuring adequate hand-off communication at admission and discharge.

MIEC recommends: 

• Speak with each other. Do not assume that the primary care physician received pertinent records regarding admissions;

• Review all pertinent tests and results, which specialists saw the patient, and what the follow-up plans are;

• Convey any lab or diagnostic results that were outstanding at discharge and clearly designate responsibility for following up on outstanding results(document understanding between providers);

• Ensure that it is hospital policy to forward discharge summaries to the PCP of record; and

• E-mail or fax a thorough, timely discharge summary.

Scheduling and group organizational techniques 

Traditionally, many hospitalist groups determine workflow and scheduling policies based on attempts to create equal work hours on a day-to-day basis. However, many groups are looking at innovative scheduling and assignment structures that aim to enhance communication, decrease disruptions, and enhance rapport with patients and primary care physicians. Would any of these strategies work for your group? 

• If possible, assign each hospitalist to designated primary care physicians (Hospitalist A always sees patients of Dr. Smith and Dr. Jones; Hospitalist B always sees patients of Dr. Johnson and Dr. Brown, etc.). This enables the hospitalist and primary care physician to get to know each other and to develop effective communication channels. Patients will likely welcome seeing a familiar face when admitted to the hospital.
  

• Do not assign new patients to a hospitalist the day before he or she is rotating off. Upon instituting this policy, one hospitalist group found that 71% of patients saw the same hospitalist throughout their stay, versus 57% under the previous policy which allowed assignment on the day before rotating off. This strategy also provides physicians rotating off with more time to have thorough discussions with patients, families and co-treaters, and to write notes. 
  

• Have separate admitters and rounders, so that rounders don’t have to drop what they’re doing to go to the ED to admit or rely on holding orders that they can’t be sure are appropriate without evaluating the patient. Your colleagues in the ED may benefit from this approach as well, and once again patient satisfaction may increase through timelier admission.

• Enlist the patient and patient’s family members as much as possible in hand-off processes. Educated, engaged patients can be terrific advocates for their own safety. Conduct hand-offs at bedside, involving the patient and the patient’s family. Clearly document patient and family understanding of the discussion.
  

• Conduct patient-centered, multi-disciplinary rounds, including any staff member or provider involved in the patient’s care (e.g., attending, resident, respiratory therapist, physical therapist, occupational therapist, social worker, pharmacist, charge nurse, individual patient’s nurse, and pastoral care provider). Focus on collaborative decision-making and goal clarity.

• To the extent possible, assign patients to wards geographically, similar to the ICU, to reduce time wasted in transit between patients located on several different floors.
  

Hospitalists face many challenges in ensuring safe transitions in care; some hurdles may only be addressed if hospitalists take a leadership role and work closely with PCPs, nurses, administration, the emergency department, specialists, and even the IT department to remove barriers to safe, effective hand-offs.  

Resources: 

“Avoiding Malpractice Risks in the Patient Handoff,” by Mark E. Crane for Medscape Business of Medicine, posted 05/10/2010 

Society of Hospital Medicine at www.hospitalmedicine.org 

“New handoff tool can improve safety,” by Suzanne Bopp for The Hospitalist, posted 2/21/2019