Handoffs

One of the most dangerous times for a patient is during the transition, or "handoff," between providers. This is due to a number of reasons. First, the original provider(s) may not relay all the information he or she knows about the patient to the next provider(s). Second, the accepting team may take it for granted that everything is known about the patient, and therefore not take a complete history or perform an adequate physical examination. Third, if the patient initially looks good, the accepting providers may be lulled into a false sense of security, and not anticipate a deterioration in the patient's condition.

We know this problem to exist in the hospital setting. Survey of doctors-in-training suggests that handoffs may commonly lead to patient harm. Last year (2008) in September, there was a blog written by Elizabeth Cooney in the Boston Globe that stated, "a 2006 survey of resident physicians at Massachusetts General Hospital found that handoffs commonly lead to patient harm, according to an article in The Joint Commission Journal on Quality and Patient Safety." More than 50 percent "of the 161 medical or surgical residents who responded to the anonymous survey said they recalled at least one occasion in their last month-long rotation when a patient suffered from flawed handoffs." Approximately "one in nine said the harm that resulted was significant." The respondents said that "if the patient was coming from the emergency department or from another hospital, problematic handoffs were more likely."

This holds true in the field. Unless the new treatment team makes the assumption that they need to begin their assessment of the patient's condition from scratch, they are more likely to make a mistake. Obviously, such caution depends on the possible severity of the patient's condition and the rescue/environmental situation. If I can get a decent handle on a patient's condition, and there is little or no risk of me missing something, I will tailor my questioning and examination to suit the circumstances. However, I always start from the position that something has been hidden from me, of course not intentionally, and that the patient's initial assessment has underestimated the problem(s).

I cannot begin to tell you how many times I have found something that was missed, or have accepted the care of a patient just as he or she began to "crash." This is in no way a criticism of others, just a common fact of medical care. Previous rescuers may have been tired, the conditions may not have been conducive to a full examination, the patient may have been withholding information, or the situation may have just taken its natural course and worsened. Regardless, it's my responsibility to learn what I can as quickly as I can about my patient, so that nothing slips through the cracks.

Here are some simple rules to follow:

1. If the situation permits, ask your new patient to repeat his or her history. If they are reticent to engage in a long conversation, at least try to get them to relate current relevant events.
2. Repeat as much of the physical examination as you can. Explain to the patient that you have assumed their care, and that in order to do the best that you can on their behalf, it's important for you to understand their issues and to be able to monitor their progress based up the exam.
3. Assume that until you have talked to the patient or otherwise obtained a comprehensive history, and performed a physical examination with your own hands, eyes, and ears, that you do not know as much about your patient as you could.
4. If a patient is under your care for a prolonged time, or if you are managing a situation prone to rapid or undetected deterioration, interview and examine your patient as often as is necessary and practical. If you must be absent from a patient for a longer period than is prudent between examinations, delegate the responsibility to someone else.

image of leg splinting courtesy of www.princeton.edu

Tags: handoff, history, patient safety, wilderness medicine, outdoor medicine, healthline

Labels: examination, handoff, history, physical examination

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