Wednesday, November 19, 2008

The rift between ER docs and hospitalists

---may have adverse consequences for patient care.

A survey published in the Annals of Emergency Medicine documented numerous handoff errors between ER physicians and hospitalists resulting in near misses and, in some cases, patient harm. Why?

…analysis of responses identified numerous contributors to error: inaccurate or incomplete information, particularly of vital signs; cultural and professional conflicts; crowding; high workload; difficulty in accessing key information such as vital signs, pending data, ED notes, ED orders, and identity of responsible physician; nonlinear patient flow; “boarding” in the ED; and ambiguous responsibility for sign-out or follow-up.

Today’s Hospitalist interviewed one of the study authors:

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.

Anyone who’s worked long in this environment knows what’s going on. There tends to be a cultural divide between emergency medicine and hospital medicine. Expectations are mismatched and workflows are misunderstood. There’s no easy fix to the problem but communication is key. Hospitalist groups should meet with their emergency medicine colleagues regularly to discuss cases, offer feedback and improve professional relationships.

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