The Joint Commission has made transitions of care one of its priorities for quality improvement, and the stakes are high. In its 2010 report on "Transitions of Care," the Joint Commission estimated that as much as 80 percent of all serious medical errors occur from miscommunication at transition points between medical providers. A follow-up report in 2013 focused specifically on "the need for collaboration across entire care continuum."
The authors of this article draw on a combined 30 years of leadership in two fields where direct patient hand-offs are extremely frequent and sometimes contentious: hospitalist medicine and emergency medicine. Because these two groups face near-opposite risks — the risk of mistakenly sending a patient home from the ED, and the risk of unnecessary admissions for hospitalists — disagreements about appropriate transitions of care are not uncommon.
Here we discuss three hot button scenarios between emergency physicians and hospitalists where better communication and strategic system changes can improve the continuity of care.
1. Should an ED patient be admitted to the hospital or sent home?
The situation: A young female patient has been stabilized in the ED but also complained of chest pain, so the emergency physician feels she is too high-risk to send home. He wants to send her up to the hospitalist service for observation. The hospitalist, however, wants the patient to remain in the ED for a "two-hour rule-out" for a heart attack, after which she should be sent home with instructions for follow-up with her primary care physician, or PCP.
Both physicians have the best interest of the patient in mind, but their additional professional pressures put them at odds. The emergency physician needs to understand that the hospitalist will be scrutinized during case management or utilization review for any unnecessary admissions (such as the patient not meeting observation criteria). And the hospitalist needs to grasp the liability and guilt facing the emergency physician if he sends the patient home and she becomes sicker — or worse.
Understanding, communication and collaboration are all necessary here. The emergency physician must understand the need to "justify the admission," and the hospitalist physician must address the risk of discharge in his recommendations. Most important to realize is that collaboration is necessary before the scenario hits late some night, when each physician's stress is already high.
Group leaders must establish clear protocols in advance that can guide the way out of tense debates over admissions. The most successful protocols will have been deliberated away from the pressures of the clinical space and established by true collaboration, with consideration of both group's opinions and concerns. (If one group dictates the specifics of admission criteria to the other, the so-called solution can end up worse than the problem.) Regardless of its details, a protocol that has been created collaboratively is the bedrock supporting smooth transitions of care.
2. Should a primary care-referred patient be seen in the ED or be admitted to the hospital directly?
The situation: A community PCP believes his patient needs to go the emergency room, but when he contacts the ED he is told admitting the patient directly is the better course; the hospitalist, however, agrees with the PCP's initial assessment and urges the PCP to try again with the emergency physician. To the PCP, this scenario seems more like "obstruction of care" than "transition of care."
Why were both the emergency physician and the hospitalist resistant to the PCP's wishes? Emergency physicians might be flattered at the answer from the hospitalist's side: only after the patient is examined in the ED does the hospitalist feel certain she knows exactly how sick a patient is, and the level of care required. For the emergency physician, the calculus seems simple: why waste precious resources of time, space and care on a patient who will need to be admitted anyway, and has been examined by another physician?
The basic solution to this issue is for both the hospital and the ED to develop and clearly state their admission and transfer protocols, which should be created with the active cooperation of the various services.
Creation of a transition unit near the ED can assist in resolving these conflicts. This space serves as a gateway to the appropriate disposition decision: referred patients go there to be assessed by a provider who can make the final decision about bed placement.
3. Should the ED patient be admitted to a surgeon, or sent to the hospitalist?
The situation: The patient has an issue the emergency physician knows could be appropriately managed by either a surgeon or a hospitalist. She calls the surgeon first, but the surgeon asserts that the patient should go to the hospitalist. The hospitalist believes the opposite, but nonetheless feels pressured to admit the patient.
Both the emergency physician and the hospitalist feel caught in the middle here. Cognizant of arrival-to-provider time, throughput and left-without-being-seen metrics, the emergency physician wants to get the patient where she needs to go as efficiently as possible. The hospitalist physician, too, feels stuck — he's being made to accept a patient he feels would be better managed by a specialist, and he also feels, in this context, that he has the least power of the three physicians.
Here, there are two answers. The first is an interpersonal reminder: "Don't shoot the messenger." At least in this scenario, both the emergency physician and the hospitalist physician are in a tough spot. Understanding the other's perspective and maintaining a positive exchange will help smooth the transition for the patient and avoid jeopardizing performance metrics unnecessarily.
The second is a systems issue: better protocols need to be in place so that individual judgment is not the only thing governing these choices. Together, these three stakeholder groups (the emergency physicians, hospitalists and specialty group) need to reach a consensus on, and then codify, who will take responsibility for which patients in various scenarios. Some examples:
- When a patient is expected to go to the operating room in the first 24 hours of admission, the trio agree that the patient should be admitted to the surgery service, with the hospitalist doing a consult;
- When a patient isn't expected to require prompt surgery, the trio might agree that the hospitalist will primarily admit the patient and the specialist will serve as the consultant.
- For specialty-specific protocols, the hospitalist, emergency physician and specialty surgeon could decide in advance which diagnoses should be admitted to the hospitalist service and which should be admitted into the specialty (e.g., neurosurgery). That specialty could further commit to do the consult within a specified time frame on any patient admitted to the hospitalist service.
Conclusion
Transitions of care require trust, communication and empathy — between the physician and the patient, of course, but also between physicians. Knowing which transitions are likely to disrupt professional rapport, medical directors and hospital leadership can create a roadmap for avoiding those pitfalls and keeping patients moving steadily toward more positive outcomes.