Wednesday, April 8, 2009

Case for Improving Communications

A story on AHRQ’s Morbidity & Mortality website makes a strong case for better communication between non-acute care facilities and emergency departments. The case commentary was provided by Christopher Fee, M.D. Assistant Clinical Professor of Emergency Medicine at UCSF Medical Center.

The case highlights the communication failures that can and have occurred between nursing homes and the emergency departments as well as between emergency medical services personnel and emergency departments.

How do failures occur while transporting a patient? In one situation, paramedics delivered a patient to the emergency department and left without speaking with the doctor plus the paramedics did not leave any paperwork or documentation.

The physician managed to find some papers with the patient that identified him as a 68 year old nursing home resident with shortness of breath and some scant notes about his medications but there wasn’t any further information on the patient’s past medical history. Because of the inadequate handoff from the paramedics, the ED physician had no choice but to proceed with the evaluation and treatment of the patient despite only having minimal information.

Although the majority of patients seen in EDs present directly or are brought by ambulance, many are referred from outside facilities such as other EDs, nursing homes, or local clinics. These patients are frequently quite ill and may have received significant medical evaluation or treatment prior to transfer.

Unfortunately, the Emergency Medical Treatment and Active Labor Act (EMTALA) only applies to the transfer of patients to the ED from another ED, hospital, or medical center and does not apply to patients from non-acute facilities.

In a perfect world, the 2008 Joint Commission guidelines would be communicated when bringing the patient into the ED. However, there may be confusion in the emergency department when the patient arrives, the ED physician does not always have the opportunity to ask questions, and in some cases the physician may be overwhelmed with multitasking.

The most important step to take is to use checklists so that the receiving facility and provider can obtain crucial patient information before or on arrival in the ED. These checklists can be on paper but much better if they are part of an electronic record.

Another weak link is the transfer of care between EMS and ED. Many healthcare systems require EMS providers to radio ahead to the ED prior to arriving. However, the information is brief and out of necessity usually the only information given is the patient’s age and gender and very often the radio reception can be faulty when talking to the ED.

In a recent survey of emergency and internal medicine providers from a large academic medical center, 29 percent of the respondents reported that one of their patients had experienced an adverse event or near miss after ED to inpatient transfer.

The case describes a number of pitfalls in communicating information whether from a nursing facility to an ED, EMS to ED, or ED to an admitting team but when lives are at stake, the system has to meet the needs of the patient and provide for safe transfers.

To read the entire case, go to