290 The Impact of a Standardized Checklist on Transition of Care During Emergency Physician Change of Shift

Abstract Background The Accreditation Council for Graduate Medical Education requirements for systems-based practice state residents are expected to participate in identifying system errors and implementing potential systems solutions. The objective of this study was to determine the numbers of perceived errors occurring from patient pass offs between resident physicians in our emergency department. Methods Using a prospective observational study, we queried emergency medicine residents about perceived errors in the transition of care using trained research assistants and a standardized protocol. Transition of care was defined as the transfer of responsibility to evaluate and treat and disposition of a patient in the emergency department from 1 resident physician to a second oncoming emergency department resident physician. Mean resident-perceived errors per shift and per patient transfer of care were calculated. Additionally, the mean number of perceived errors impacting patients was calculated. Results Emergency medicine residents on 107 shifts reported receiving 713 patients in pass off with a mean of 7 patients per physician per shift, with 40% of patients passed off needing some intervention (mean of 2.8 patients per provider per shift). Nineteen of the 107 shifts (17.8%) during which a resident took patients from a prior provider had a perceived error in at least 1 patient signed off. Of the 713 patients transitioned, the receiving physician perceived an error related to the transition of care for 23. Two of the 23 errors were determined by reviewing emergency medicine attendings to not be errors, and for 9 the receiving physician perceived an impact on the patient. All were delays in care or disposition. Conclusion Our data suggest emergency medicine residents were able to perceive errors related to transitions of care, describe the types of pass-off errors, and, to a lesser degree, describe the impact these errors have on patients.

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The Impact of Emergency Physician Seniority on Clinical Efficiency, Emergency Department Resource Use, Patient Outcomes, and Disposition Accuracy

Medicine ◽

10.1097/md.0000000000002706 ◽

2016 ◽

Vol 95 (6) ◽

pp. e2706 ◽

Cited By ~ 15

Author(s):

Chao-Jui Li ◽

Yuan-Jhen Syue ◽

Tsung-Cheng Tsai ◽

Kuan-Han Wu ◽

Chien-Hung Lee ◽

...

Keyword(s):

Emergency Department ◽

Patient Outcomes ◽

Resource Use ◽

Emergency Physician ◽

Clinical Efficiency ◽

The Impact

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13.3 The Impact of Psychiatric Comorbidities in Transition of Care for Adolescents with Epilepsy

Journal of the American Academy of Child & Adolescent Psychiatry ◽

10.1016/j.jaac.2021.09.159 ◽

2021 ◽

Vol 60 (10) ◽

pp. S185-S186

Author(s):

Yang Cai ◽

Jane Timmons-Mitchell ◽

Elia Pestana-Knight ◽

Krystel Tossone ◽

Carrie Cuomo ◽

...

Keyword(s):

Transition Of Care ◽

Psychiatric Comorbidities ◽

The Impact

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The Impact of a Standardized Checklist on Transition of Care During Emergency Department Resident Physician Change of Shift

Western Journal of Emergency Medicine ◽

10.5811/westjem.2018.10.39020 ◽

2018 ◽

Vol 20 (1) ◽

pp. 29-34 ◽

Cited By ~ 2

Author(s):

Alyssa Milano ◽

Holly Stankewicz ◽

Jill Stoltzfus ◽

Philip Salen

Keyword(s):

Emergency Department ◽

Resident Physician ◽

Transition Of Care ◽

The Impact

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MP38: The impact of physician handoffs on the outcomes of emergency department patients: a medical administrative database retrospective cohort study

CJEM ◽

10.1017/cem.2020.186 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S56-S56

Author(s):

A. Mokhtari ◽

D. Simonyan ◽

A. Pineault ◽

M. Mallet ◽

S. Blais ◽

...

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Emergency Physician ◽

Retrospective Cohort ◽

Independent Predictor ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Emergency Physicians ◽

Icu Admission ◽

The Impact

Introduction: A physician handoff is the process through which physicians transfer the primary responsibility of a care unit. The emergency department (ED) is a fast-paced and crowded environment where the risk of information loss between shifts is significant. Yet, the impact of handoffs between emergency physicians on patient outcomes remains understudied. We performed a retrospective cohort study in the ED to determine if handed-off patients, when compared to non-handed-off patients, were at higher risk of negative outcomes. Methods: We included every adult patient first assessed by an emergency physician and subsequently admitted to hospital in one of the five sites of the CHU de Québec-Université Laval during fiscal year 2016-17. Data were extracted from the local hospital discharge database and the ED information system. Primary outcome was mortality. Secondary outcomes were incidence of ICU admission and surgery and hospital length of stay. We conducted multilevel multivariate regression analyses, accounting for patient and hospital clusters and adjusting for demographics, CTAS score, comorbidities, admitting department delay before evaluation by an emergency physician and by another specialty, emergency department crowding, initial ED orientation and handoff timing. We conducted sensitivity analyses excluding patients that had an ED length of stay > 24 hours or events that happened after 72 hours of hospitalization. Results: 21,136 ED visits and 17,150 unique individuals were included in the study. Median[Q1-Q3] age, Charlson index score, door-to-emergency-physician time and ED length of stay were 71[55-83] years old, 3[1-4], 48 [24,90] minutes, 20.8[9.9,32.7] hours, respectively. In multilevel multivariate analysis (OR handoff/no handoff [CI95%] or GMR[SE]), handoff status was not associated with mortality 0.89[0.77,1.02], surgery 0.95[0.85,1.07] or hospital length of stay (-0.02[0.03]). Non-handed-off patients had an increased risk of ICU admission (0.75[0.64,0.87]). ED occupancy rate was an independent predictor of mortality and ICU admission rate irrespectively of handoff status. Sensitivity and sub-group based analyses yielded no further information. Conclusion: Emergency physicians’ handoffs do not seem to increase the risk of severe in-hospital adverse events. ED occupancy rate is an independent predictor of mortality. Further studies are needed to explore the impact of ED handoffs on adverse events of low and moderate severity.

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P117: A multicenter analysis of an emergency physician lead on department flow and the provider experience

CJEM ◽

10.1017/cem.2020.323 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S107-S107

Author(s):

K. Crowder ◽

E. Domm ◽

R. Lipp ◽

O. Robinson ◽

S. Vatanpour ◽

...

Keyword(s):

Emergency Physician ◽

Strong Predictor ◽

Initial Assessment ◽

Leadership Roles ◽

Qualitative Feedback ◽

Left Without Being Seen ◽

Multicenter Analysis ◽

Provider Experience ◽

A Site ◽

The Impact

Introduction: Emergency department (ED) flow is a strong predictor of patient safety, quality of care and provider satisfaction. Throughput interventions have been shown to improve flow metrics, yet few studies have considered MD leadership roles and evaluated provider experience. Our objective was to evaluate the emergency physician lead (EPL) role, a novel MD staffing initiative. Methods: This mixed-method observational time series analysis evaluated ED metrics at two tertiary EDs including ED length of stay (LOS), EMS Park LOS and physician initial assessment (PIA) time as well as 72-hour readmit and left without being seen (LWBS) rates. Data was collected from the ED information system database for control (Dec 6, 2017-Feb 28, 2018 SITE1 and Mar 1–May 31, 2018 SITE2), pre (Sept 3-Nov 30, 2018 SITE 1 and Dec 3, 2018-Feb 28, 2019 SITE2) and post (Dec 3, 2018 –Feb 28, 2019 SITE1, Mar 1- May 31, 2019 SITE2) periods for adult patients presenting to each site. Site data was analyzed independently using descriptive and inferential statistics to calculate differences in means, and means were compared using t-tests. A survey elicited provider feedback from ED physicians, nurses, and EMS professionals on the effect of the EPL on throughput, timeliness of admissions and discharges, provider workload, and the EPL as a resource to other professionals. Results: The number of ED visits at SITE1 were 13136 (Ctrl), 13236 (Pre) and 13137 (Post), and at SITE2 were 14371(Ctrl), 13866 (Pre) and 14962 (Post). Mean ED LOS was decreased by 17 min in post vs control and 20 min vs pre at SITE1 (p < 0.01). SITE2 saw an increase in ED LOS by 7 min vs control and 8 min vs pre (p < 0.01). EMS LOS at SITE1 was decreased by 21 min vs control and 22 min vs pre (p < 0.01), but was increased at SITE2 by 2 min vs control (p = 0.09) and 14 min vs pre (p < 0.01). PIA time at SITE1 was decreased by 15 min vs control (p < 0.01) and 13 min vs pre and increased by 5 min vs control and 12 min vs pre at SITE2 (p < 0.01). 72 hour readmit and LWBS rates were unchanged at both sites. Qualitative feedback from ED providers highlighted the early provision of treatments and investigations by the EPL, and many felt the EPL was an important resource. Conclusion: The inclusion of both quantitative and qualitative data in this study provided a robust analysis of the impact of the EPL role and demonstrated modest but important improvements. A site-dependent, carefully considered implementation of the EPL role may improve ED metrics and provider experiences.

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The impact of electronic health record implementation on emergency physician efficiency and patient throughput

Healthcare ◽

10.1016/j.hjdsi.2014.06.003 ◽

2014 ◽

Vol 2 (3) ◽

pp. 201-204 ◽

Cited By ~ 2

Author(s):

Nicholas Risko ◽

David Anderson ◽

Bruce Golden ◽

Edward Wasil ◽

Fermin Barrueto ◽

...

Keyword(s):

Electronic Health Record ◽

Emergency Physician ◽

Health Record ◽

Patient Throughput ◽

Electronic Health ◽

The Impact

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MP02: The impact of adoption of an electronic health record on emergency physician work: a time motion study

CJEM ◽

10.1017/cem.2020.150 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S42-S43

Author(s):

S. Calder-Sprackman ◽

G. Clapham ◽

T. Kandiah ◽

J. Choo-Foo ◽

S. Aggarwal ◽

...

Keyword(s):

Electronic Health Record ◽

Patient Care ◽

Emergency Physician ◽

Chart Review ◽

Direct Patient Care ◽

Health Record ◽

Physical Movement ◽

Time Motion ◽

Motion Study ◽

The Impact

Introduction: Adoption of a new Electronic Health Record (EHR) can introduce radical changes in task allocation, work processes, and efficiency for providers. In June 2019, The Ottawa Hospital transitioned from a primarily paper based EHR to a comprehensive EHR (Epic) using a “big bang” approach. The objective of this study was to assess the impact of the transition to Epic on Emergency Physician (EP) work activities in a tertiary care academic Emergency Department (ED). Methods: We conducted a time motion study of EPs on shift in low acuity areas of our ED (CTAS 3-5). Fifteen EPs representing a spectrum of pre-Epic baseline workflow efficiencies were directly observed in real-time during two 4-hour sessions prior to EHR implementation (May 2019) and again in go live (August 2019). Trained observers performed continuous observation and measured times for the following EP tasks: chart review, direct patient care, documentation, physical movement, communication, teaching, handover, and other (including breaks). We compared time spent on tasks pre Epic and during go live and report mean times for the EP tasks per patient and per shift using two tailed t-test for comparison. Results: All physicians had a 17% decrease in patients seen after Epic implementation (2.72/hr vs 2.24/hr, p < 0.01). EPs spent the same amount of time per patient on direct patient care and chart review (direct patient care: 9min06sec/pt pre vs 8min56sec/pt go live, p = 0.77; chart review: 2min47sec/pt pre vs 2min50sec/pt go live, p = 0.88), however, documentation time increased (5min28sec/pt pre vs 7min12sec/pt go live, p < 0.01). Time spent on shift teaching learners increased but did not reach statistical significance (31min26sec/shift pre vs 36min21sec/shift go live, p = 0.39), and time spent on non-patient-specific activities – physical movement, handover, team communication, and other – did not change (50min49sec/shift pre vs 50min53sec/shift go live, p = 0.99). Conclusion: Implementation of Epic did not affect EP time with individual patients - there was no change in direct patient care or chart review. Documentation time increased and EP efficiency (patients seen per hr on shift) decreased after go live. Patient volumes cannot be adjusted in the ED therefore anticipating the EHR impact on EP workflow is critical for successful implementation. EDs may consider up staffing 20% during go live. Findings from this study can inform how to best support EDs nationally through transition to EHR.

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Internal Medicine Residents’ Views About Care Transitions: Results of an Educational Intervention

Journal of Medical Education and Curricular Development ◽

10.1177/2382120520988590 ◽

2021 ◽

Vol 8 ◽

pp. 238212052098859

Author(s):

Fatima Sheikh ◽

Evelyn Gathecha ◽

Alicia I Arbaje ◽

Colleen Christmas

Keyword(s):

Internal Medicine ◽

Qualitative Analysis ◽

Continuity Of Care ◽

Transitional Care ◽

Care Transitions ◽

Reflective Writing ◽

Patient Specific ◽

Transition Of Care ◽

Internal Medicine Residents ◽

The Impact

Problem: Suboptimal care transitions can lead to re-hospitalizations. Intervention: We developed a 2-week “Transitions of Care Curriculum” to train first-year internal medicine residents to improve their knowledge and skills to deliver optimal transitional care. Our objective was to use reflective writing essays to evaluate the impact of the curriculum on the residents. Methods: The rotation included: Transition of Care Teaching modules, Transition Audit, Transitional Care Site Visits, and Transition of Care Conference. Residents performed the above elements of care transitions during the curriculum and wrote reflective essays about their experiences. These essays were analyzed to assess for the overall impact of the curriculum on the residents. Qualitative analysis of reflective essays was used to evaluate the impact of the curriculum. Of the 20 residents who completed the rotation, 18 reflective essays were available for qualitative analysis. Results: Five major themes identified in the reflective essays for improvement were: discharge planning, patient-centered care, continuity of care, goals of care discussions, and patient safety. The most discussed theme was continuity of care, with following subthemes: fragmentation of the healthcare system, disjointed care to the patients, patient specific factors contributing to lack of continuity of care, lack of primary care provider role as a coordinator of care, and challenges during discharge process. Residents also identified system-based gaps and suggested solutions to overcome these gaps. Conclusions: This experiential learning and use of reflective writing enhanced the residents’ self-identified awareness of gaps in care transitions and prompted them to generate ideas for systems improvement and personal actions to improve their practice during care transitions.

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