Handoffs and Consults: Who’s in charge? Part II

Part II: Handoffs
By Charles A. Pilcher MD FACEP
June, 2013

As introduced in the last issue of this newsletter, all too often the responsibility for a patient becomes unclear when an emergency physician requests a consult or transfers care to another doctor, resulting in potential catastrophe for the patient and physician.

In last month’s Perspective the consultant is that “person from whom one receives advice or with whom one exchanges views.” If on the other hand a physician [Editor’s Note: This article applies to nursing handoffs as well.] wishes to actually transfer responsibility for the care of a patient to another physician, that is known as a “handoff,” and is the topic of this month’s “Perspective.”

“Handoffs” are similar to “consults” in that there should be no question at the end of the process exactly who is responsible for that patient’s care. However, unlike the “consult” in which the physician requesting the consult generally retains responsibility for the patient, in a “handoff” the other physician becomes immediately responsible for the patient. In fact, the requesting physician may, if he/she continues to be involved in the patient’s care, subsequently assume the role of “consultant.”

As with a consultation, the patient should always be advised – in this case that primary responsibility for their care is actually being transferred to someone else.

In the Emergency Department but also during inpatient care, there are generally 6 situations that result in a handoff:

1. A patient is being discharged to outpatient care following an ED evaluation. Example 1: A simple ankle sprain may need follow-up before a high school football player can be cleared to return to play. Example 2: A 50 year old female with very low risk chest pain, no cardiac history, and a completely negative ED workup is advised to see a cardiologist “just to be sure.”
2. A patient requires treatment that is not within the skill set of the emergency physician, but can and should be accomplished during the ED visit. Example 1: An orthopedic surgeon is called to reduce a both-bone fracture of the forearm in the OR, after which a cast will be applied and the patient discharged. Example 2: Same situation, but the reduction and casting occurs in the ED.
3. Transfer: Examples: Following diagnosis and stabilization, a newborn with sepsis is being transferred to a children’s hospital where specialty expertise is available, or a diabetic is transferred to a nursing home following a hip replacement.
4. Patient is being admitted for inpatient medical care or surgery. Example 1: A 55 year old male with meningitis is being transferred from the ED to the ICU under the care of a hospitalist. Example 2: A patient with a small subdural hematoma from a motorcycle crash is being admitted to a neurosurgeon who will assume responsibility for monitoring him.
5. Shift change: Given the nature of emergency medicine, patient care often extends beyond the end of the initial ED physician’s shift. Example 1: A suicidal patient is being held in seclusion awaiting the arrival of – or disposition by – the county-designated mental health professional (CDMHP). Sometimes this can extend over several changes of shift. Example 2: A patient with a concussion has been evaluated and is likely to be discharged. A CT scan has not been ordered because the first treating physician believes that the injury is mild, and a couple hours of observation will make that clear.
6. Co-management: There remain situations where only part of a patient’s care is “handed off.” This can occur in both the ED and inpatient setting. Example 1: A patient with multiple injuries is simultaneously being resuscitated and treated in the ED by a general surgeon, an orthopedic surgeon and the ED physician while a decision is made about immediate versus delayed transfer to the OR. Example 2: An  elderly patient with a fracture of the hip and multiple medical problems is concurrently being cared for by both the inpatient hospitalist, an orthopedic surgeon, and 2 consultants.

Discussion:

1. Discharge from the ED: This situation contains an element of both patient and physician responsibility. It is usually accomplished via the “Discharge Instructions” provided to the patient. This has been previously covered in the Medical Malpractice Bulletin. While the care is being transferred to another physician, perhaps even the patient’s primary care physician, it is likely that the ED physician and the patient remain responsible until that takes place, and the patient should leave the ED with that being clearly understood.
2. Outpatient treatment by a specialist, either in the ED or in another part of the hospital: This one can get a bit tricky.
   1. If an orthopedic surgeon takes the patient to the OR, reduces a fracture, applies a cast, provides post-anesthesia care and discharges the patient, a “handoff” has occurred. However, while the patient remains in the ED, the ED physician retains some level of responsibility for the patient, if for no other reason than he/she has both immediate control of the patient as well as better “cultural familiarity” with the ED facilities, policies, and processes. Further, it will also be the ancillary staff in the ED, with whom he/she works on a daily basis, who will care for the patient until transfer.
   2. If the patient is treated in the ED, again almost always with the help of the same ancillary staff who would assist if the ED physician were providing the care, the ED physician retains some responsibility to the patient, family and specialist to assure a satisfactory outcome. He/she may even be involved in providing procedural sedation (i.e., co-management). In this situation, the ED staff might be seen as playing “host” to the specialist, who is now working on their turf as a “guest.” Too often, both the physician and nursing staff “check out” upon the arrival of the specialist. However, everything done to make the specialist feel welcome and to provide for his/her needs pays big dividends in both patient satisfaction, quality of care, and patient safety. This may include assisting the outside specialist in locating prescription pads, completing the EMR, assuring that specialist orders are carried out, and providing discharge instructions. Note that the specialist remains equally responsible to seek assistance if needed.
3. Transfer: In transfer situations, much of the detail is covered by EMTALA regulations. In particular, the EMTALA transfer form has a line item specifying exactly which physician – the transferring physician or the receiving facility – will retain responsibility for the patient during transfer. Whichever, the transferring ED retains control until the patient physically leaves the department. However, in some cases such as helicopter or other ALS transfers, a team of caregivers (perhaps even including a physician) may arrive at the transferring hospital and assume actual hands-on care of the patient before this occurs. In those cases, the care team will have a formal chain of responsibility to the receiving hospital, so a handoff may occur sooner. Transfers also occur at the time of discharge, for example to a rehab facility or nursing home. The EMTALA model of responsibility, though not necessarily required, is a model worthy of emulation.
4. Admission: The ED physician maintains responsibility for the safety and quality of the patient’s care until the patient actually leaves the department. Again, he/she is the one most familiar with the processes and staff in the department. Even if the physician assuming responsibility for inpatient care has personally evaluated the patient, that physician is less familiar with the ED than the ED doc. Until the patient has been moved to another part of the hospital, the ED physician must assure that any urgently needed care ordered by the specialist is carried out. This requires a high level of understanding and cooperation between the specialist and the ED physician. Again, since the ancillary staff continue to treat the patient before transfer, the ED physician cannot really “check out.”
5. Shift change: This is the classic handoff, and must be accomplished cleanly. It is best done at the patient’s bedside, at which time the oncoming physician is introduced to the patient/family by the off-going physician, and the patient’s situation, background, assessment to date, and recommendations (SBAR) should be clearly communicated. Because of its simplicity and clarity, SBAR has become the hospital standard for communicating changes in patient status, especially for  handoffs. Such handoffs need to be understood and documented, e.g., “patient’s care transferred to Dr. _____ at (time) using SBAR at the patient’s bedside.” A concurrent note by the receiving physician such as “accepted care of patient in transfer from Dr. ________ at (time)” is also helpful, with a brief summary of the care plan going forward. [Editor’s Note: This challenge also occurs when care is transferred between physicians covering hospitalized patients for colleagues. The latter is covered in a nice 2011 article in AMA News.]
6. Co-management: Occasionally there are situations such as major trauma and inpatient resuscitations where several physicians who may or may not have primary responsibility for a patient become a team. However, every team benefits from having a captain.
   1. In the ED, that role belongs to the ED physician – at least until primary responsibility is clearly “handed off” to another member of the team. In an inpatient resuscitation, the role initially belongs to the first arriving physician, but can quickly be handed off to another more familiar with the patient. Either way, the individual in charge must be apparent.
   2. In other parts of the hospital, responsibility for a complex medical patient needing a surgical procedure will likely be shared between a surgeon and an internist/hospitalist. In such situations, which may include conditions such as sepsis, where both an internist and an infectious disease doc are involved, clearcut spheres of authority must be established at the outset. Each specialist must be keenly aware of the limits of his/her role. For example, the “physician team” should understand who will order post-op pain and wound management versus who will manage the patient’s heart failure, diabetes, or pneumonia. This team must communicate well and often until the patient is transferred or discharged.

Bottom Line:

The fact should be apparent that in almost every one of these “handoffs” some level of responsibility is retained by the physician “passing the baton.” In each, there is some level of “time lag” between the perceived transfer of care and the actual assumption of care. The most comm0n mis-steps are those in which premature assumptions are made about who is in charge. In most cases, the transferring physician is likely to remain both legally and morally obligated to the patient during any time lag. In fact, much has been written about “abandonment,” and on a micro-scale, abandonment might be alleged if a handoff is mismanaged.

For further reading:

1. Advocates recommended for coordinating care of complex patients. Kaiser Health and the Washington Post report that “the failure of caregivers to collaborate is endemic, contributing to an estimated 44,000 to 98,000 deaths from medical errors each year.” They recommend that complex patients have an “advocate.”
2. ED Physicians recommend improved patient handoff protocol