If you were to map out a patient’s stay in a hospital you would find that there are numerous handovers. Some might be significant, such as a transition from an intensive care unit, to a regular ward bed. Or from the Emergency Room to an inpatient bed. Or from an inpatient status to home. Other transitions might not even seem like transitions because the patent doesn’t move, but instead it’s their information that gets passed from person to person. This might happen when one care goes home for the day or when one team signs off after a week on service. In each of these transitions, information is passed from one person to another, or from a care team to a patient (or a caregiver or a new care site that a patient has been transitioned to).
In my speciality of Emergency Medicine, a transition of care is recognized as a high risk time for a patient. I think the transitions we worry about the most are handoffs from one provider to the next. Sometimes a patient is just waiting for admission, other times they just need that “one last test” to come back prior to discharge. In these instances, the accepting provider may not feel the same ownership of the patient that they might if they had started with the patient. In instances that the provider hands off a patient for whom the evaluation has just begun, the accepting provider may understand that most of the work up is still pending and decisions about disposition will be entirely belong to that accepting provider. Errors in transition might be lower in these instances.
The recognition of care transitions has always been a part of emergency medicine, but increasingly the need to manage handoffs and transitions has made its way into other specialities. Hospital medicine providers now routinely work a shift schedule which means they hand off care to a night team. Many hospitalist teams work a single week at a time and then hand their entire service off to a new provider. Surgery services now do similar things. The goal may be to help with fatigue, long shifts and overly long periods of intense clinical time, but the result is an enormous number of care transitions and hand offs.
The risk of these transitions, whether they represent a physical change of environment for the patient (and admission, a discharge, a transfer from one unit to another) or a change in the provider caring for the patient (a handoff between two doctors as one leaves a shift and one comes on, or a change in the clinical team as one goes off service and another takes over) should be recognized as a high risk time for patients. Patients are complex, there is an enormous amount of information flowing around these patients, providers are busy and are attempting to multi-task at the same time that they have multiple interruptions in their work flow. The risk of lost information, a limited hand off that fails to recognize the history of a patient’s complex inpatient stay, confusion between various specialities, medication changes that one team knows about and another doesn’t, all can contribute to risks for patients. Those risks can cause harms to patients despite the best intentions of providers.
Next time we can begin to review ways to improve transitions of care.