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Brian Hiestand, MD, Sandy Tysinger, MSN, RN, PCCN, at Wake Forest Baptist Health and Jeremiah Underwood EMT-P, Stokes County EMS Training Officer present on Acute Care of Patient/Patient Transfer/Telemedicine/Paramedic.
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View Doctor Profile BRIAN C HIESTAND: Thank you all very much for coming out. Thanks for giving me the opportunity to speak. We're going to address communication, patient handoff. And as we can see, they're in the news. What's the huge thing in the news right now? It's Ebola in the United States. And fortunately or unfortunately, the case in Texas initially presented to an emergency department with nondescript viral symptoms, and there was an opportunity to identify this patient as an index case. The nurse at triage did the right thing. She asked, have you traveled? And the patient decided to be honest, and say, yes, indeed. I just came from West Africa. And that little piece of information was tucked somewhere in a section of the medical record and not escalated or taken any further. So the information that identified this patient as a key index visit was present and identified, but not transmitted to the care team taking care of the patient back in the emergency department. And therefore, the patient had nothing really going on from a clinical standpoint and was discharged, despite the fact that all of the information needed to identify as a high risk exposure, high risk individual. Because everybody's on high alert with Ebola, with international travelers. People from West Africa with viral symptoms, that's somebody that you need to pay attention. That data was all there, but it was not put in the right spot and not handed off appropriately to the right care team. And now we have CNN, and nobody wants CNN. So in terms of just financial disclosures, I have no relevant disclosures for this particular topic. What we're going to do today-- we're going to discuss the background of communication needs in urgent and emergent patient care. We're going to discuss some of the barriers in communication, and we're going to discuss some of the data elements most needed for provision of acute care and handoffs between different services in different arenas. A lot of my material comes from the American College of Emergency Physicians Transitions of Care Task Force Report. This is available on the web. The HTML is part of the handout there. And the scope of the issue. Of course, we can't always take care of the patient in one single care setting. Transitions of care are quite problematic when you get redundant information, or when the information at handoff focuses on irrelevant elements, or we miss key data such as travel history and someone with a virus syndrome. The scope of the issue is large. It's recognized as an issue by the World Health Organization, by the ACGME, which regulates residency and physician training. It's recognized as a problem by CMS, which is great. The feds are involved. And the Joint Commission, because that's even better. The problem is communication needs are not one size fits all. From different arenas of care, you have different-- one, you have different data available, and you have different data transmission needs. The things are different between EMS to emergency department, emergency department to emergency department transfers, the transfer service to the emergency department, and then from the ED to the inpatient arena of care. All of those have different amounts of data available and different communication needs. Verbal errors are common. I mean, that's why we do write down read back, right? If you try and remember what you hear, you might not always remember it five minutes later when you've been interrupted three times before actually executing the task that you were trying to concentrate on. Electronic systems are not always compatible. Say what you like about the epic monolith. I mean, it at least is making it easier to get data between health systems. The care everywhere thing has been quite advantageous for us, maybe not so much for the patient looking for that extra dose of Vicodin from one shop to the next. But at least as we get more and more information electronically, not relying on individuals to transport and transform data from one area to the other. Too much paper is a huge issue, and too little paper is an issue. I mean, sometimes you can drown somebody in transfer paperwork, or you don't have anything except some vital signs written on the back of a cocktail napkin. Either side of those doesn't get the job done. And so sometimes, the data is simply not there to be transmitted. And this is common early on in the course of events. I'd like to know the patient's medications. I'd like to know their family history. I'd like to know their surgical history, but they've got a breathing tube down, and they aren't able to give that information. And if I insist on that data before taking the patient in transfer, that's not good for the outside emergency department. That's not good for the patient care. So early on on things, you don't have all the data to handoff in the first place. Bias. Cognitive bias is when you focus on something and you stick with it, despite evidence to the contrary. There are different types of this. Triage cuing, so how the patient is initially presented to you. This is a big thing in academic medical centers where the resident comes up to me with a case and is like, yeah. They've got nothing. They've got a little knee pain, and I think we can get an x-ray and send them home. And then you go in and find that it's an artificial joint, and somebody with immunosuppression had a fever for three days. So if you anchor on how the case is initially presented to you-- even when the patient and when the person presenting the information to you has incomplete data-- if you stick with that presentation, you may anchor on the wrong diagnosis and stick with that. And this is a big thing. Phony data handoff is implicated in 25% of emergency department malpractice claims, and so huge impact there. This is not just an ED issue, however. Transition's of care, so who's responsible for the patient? Who is supposed to be following up on what lab result? Who is supposed to tell the resident that the potassium came back at 6.3? These are all issues in communication that affect medical malpractice and liability throughout the continuum of health care, both outpatient, inpatient, and emergent. So you think this is a huge issue, right? There's a lot of medical literature discussing-- and we could just go to the literature and they can tell us, OK, we've studied all this, and this is exactly the best way everybody needs to do it. No. Unfortunately not. Most of the literature supporting standardization of care, standardization of processes is from the non-medical industrial literature. And that data holds that decreasing variance is the gold standard. You want to do the same thing the same way every time. Unfortunately, assembly line care is not the same as medical care. Our patients are not standardized. Our disease processes are not standardized. Now, that's not an excuse. We should-- if there are elements in our care that we can standardize, template, checklist-- that we do almost the same every time, we should do that. The fact that the patients aren't standardized doesn't give you the excuse not to standardize what you can. But it should allow you to recognize that nonstandard issues are going to come up a lot more in medicine than they are in car assembly. So bottom line, no one size fits all template or communication method has enough data behind it in the medical arena to have an evidence-based recommendation. So does that mean we just wing it every single time? No. If you can prospectively tailor your communication plans to your mutual needs, this is going to be better care. Because if you try and wing it-- at four in the morning when I'm trying to talk to my hospitalist and give them a presentation to get the patient admitted-- four in the morning, I'm fatigued. They're fatigued. He's distracted. I'm distracted. And without a standard way of approaching things, that's a recipe for data loss, and not the best handoff, not the best outcome for the patient. So if you can come up with a plan, a mutually agreed upon perspective for your mutual needs, then that's going to be best for the patient. You want to do this collaboratively. I shouldn't be asking for information that the outside emergency department just is not going to have access to and is not going to have immediate impact on what I do. That leads to frustration on both ends and delays of care. If the outside ED thinks that I have to have every single data element ready to go before they can transfer this unstable patient to me, that's a problem. Having a standard template, a standard framework is advisable so that you can guide-- again, so not that you're on autopilot, but at least you know what elements you need to hit as you move through. But you need the flexibility to deviate because of data not available, or the patient is completely nonstandard, which happens a fair amount in emergency medicine. We get a lot of the nonstandard patients on the front end of things. This is the average emergency doctor's attention span. You get a lot of my attention at the front end, and then it just tailors off. So it needs-- the amount of information that you deliver to me, the longer you go on the less I listen to you. So you need to be able to deliver your high impact information up front. To my EMS colleagues, I ask them to make sure that they don't wait to mention the STEMI on the EKG, or the missing limbs on the trauma patient. Don't leave that to last. Let me know your immediate concerns right up front. And Sandy's going to talk about some formats that kind of address that information delivery. I need to know the complaint, the relevant patient characteristics, vitals, EKG, what you've done for the patient, and when are you going to get here. We recently had a case of a transfer of a burn patient that we anticipated would meet trauma criteria. And the patient was transferred and the trauma team was activated, and we waited, and we waited, and we waited, and we waited some more. And then the patient came driving up in their own private vehicle with a substantial quantity of burns. Because of a miscommunication between our facility and their facility, we assumed that with 20% total body surface area burns, that would usually be an EMS transfer. But that was an assumption on our part, and the patient was coming POV. Patient did fine. Absolutely no worries. But when you make assumptions on communication, then that's where things fall apart. For other EMS issues, we need to have the EMS record available for the ED encounter. And that with the new technology available for EMS records, a lot of times those are either immediately printed or downloadable directly straight to the electronic medical record. Now, when a patient is transferring from one emergency department to another, or from one emergency apartment to the inpatient, there's more information available. The patient has already been seen and evaluated in an emergency department. More data has been generated. Now a lot of times, we get the assumption on the radio that the patient-- all this data has already been communicated from the other emergency department to the receiving facility, and that can be a dangerous assumption sometimes. Well, the main thing I need to hear in route that I need to know about, are they a recent deterioration or recent improvement? Are the things that they're doing actually working? And what is actively ongoing? Do you have an airway in place? Do they need an airway in place, or are the airway completely fine all by themselves? And then where in the hospital are you planning to come? We have a fair amount of direct admissions at the Baptist, but we also have a fair amount that need to stop in the emergency department and get stabilized. So it's very key that-- where the EMS thinks they're going versus where they're actually going so that we can make sure that that is accurate, and make sure the patient's going to the right location for the right level of care. Now with all these, there's the potential for information overload. You're trying to drink from the fire hose. And unfortunately, that can lead to complete incomprehensibility, and can frankly be dangerous if you were trying to drink from a fire hose at the wrong time. When I'm talking about outside at emergency departments, it's key that I know the suspected diagnosis or concern right up front. Present what you're concerned about so that I know where we need to go from here. Brief background, critical relevant data-- and again, I emphasize on relevant. Sometimes what's relevant to one individual may not seem that important to the other, but as we saw with the Ebola case, sometimes the little things really do matter. And it's tough to get the little things right every single time. Who, if anyone else, knows that the patient's coming? It's one thing if the patient's coming straight to my emergency department with an aortic dissection, and cardiothoracic surgery is aware and ready to take that patient to the OR. It's another if that same patient is going to be a complete surprise to the folks that we're both expecting to crack the chest open. And how are they going to get there? Is this somebody who needs helicopter air and medical transport? Do they need ground transport? Or are they stable enough to get here via horse and buggy? So it all varies the acuity of the patient. So in conclusion, from the initial-- for global principles of transfer communication, there's no universal one right way to do it unfortunately. The collaborative planning is key so that you can set up how you're going to share information from one facility to the other, or one transport team to another, or one location in the hospital to another. And the key is you want to focus on getting everything that's important and nothing that's not. I appreciate your time and attention. I'm going to move on, transition.