When Patient Handoffs Go Terribly Wrong

DOCTOR AND PATIENT
When Patient Handoffs Go Terribly Wrong
By PAULINE W. CHEN, M.D.
Published: September 3, 2009

I have always felt uneasy about patient handoffs, transferring my responsibility as a doctor to another physician. We cannot be on duty all the time, but I worry that I am playing some real-life medical version of the children’s game “Telephone” where the complexity of my patient’s care will be watered down, misinterpreted and possibly mangled with each re-telling. I wonder, too, if it is only a matter of time before the kind of mistake that happened to Joey (not his real name) might happen to one of my patients.

Two-year-old Joey had been healthy since birth. But a few weeks before I met him, his mother noticed that the left side of his face had started to swell. By the time he appeared in clinic, it looked as if a ping pong ball had been permanently lodged in his cheek.

Despite the senior surgeon’s years of experience, removing the mass from Joey’s cheek proved to be a challenge. It had insinuated itself into every possible crevice; and the nerve that innervated the muscles of his mouth and cheek — the nerve of facial expression — was embedded deep within.

The senior surgeon spent hours daintily picking away at the mass, sorting through strands of fibrous connective tissue, many of them neuronal doppelgangers, in order not to injure the buried nerve. After being nibbled at with surgical instruments for hours, the toddler’s flayed cheek looked more like a puppy’s well-worn chew toy than any recognizable set of anatomical structures. When the surgeon had at last cleaned the strand he believed was the nerve, he looped a slender yellow rubber tie around it. Then, without warning, the surgeon put down his instruments and looked up at the clock. He barked at the nurse to call for one of his colleagues, then stepped away from the table and ripped off his surgical mask and gown. “You take over,” he said when his colleague came into the room. “It’s mostly out, but I need to leave.” None of us knew if he had to attend to another urgent patient matter in the hospital or how long he might be gone.

The covering surgeon stepped up to the table, poked his finger around the remnants of the mass, then pulled on the rubber tie and the presumptive nerve. “What’s this?” he asked, reaching for a pair of scissors.

Without waiting for a response, he snipped the strand in two.

That night, I hovered outside of Joey’s room, waiting for him to wake up, laugh, cry or simply move his mouth. But it wasn’t until two days later, after we had removed all the gauze covering his incision, that I saw what I had feared I would. Joey grinned, but his left cheek remained frozen. His once symmetrical smile had been transformed into a contorted grimace.

Years later I am still haunted by the memory of Joey and that handoff which went terribly wrong. I don’t know what caused the first surgeon to suddenly leave. And because the operation was so difficult and the field of view so small, I’m not sure if the nerve might have been damaged or transected even before the second surgeon stepped in. But I do know that the surgeons never communicated clearly about what had been done when they traded places at the table. And I also know that transitions between physicians are now, more than ever, a routine and frequent part of health care.

Like many others among my professional peers, I find myself signing out and my patients being handed off more than I ever thought would happen. While older patients with multiple chronic conditions will see up to 16 doctors a year, some of the healthiest younger patients I see count not only a primary care physician among their doctors but also a handful of specialists. Hospitalized patients, no longer cared for by their primary care doctors but by teams of fully trained doctors, or hospitalists, in addition to groups of doctors-in-training, are passed between doctors an average of 15 times during a single five-day hospitalization. And young doctors, with increasing time pressures from work hours reforms, will sign over as many as 300 patients in a single month during their first year of training.

While these changes have led to improvements in certain aspects of quality of care and better rested physicians, it has also resulted in frank fragmentation. It’s hardly surprising, then, that according to two recent studies, the vast majority of hospitalized patients are unable to name their doctor, and an equally large percentage of their discharge summaries have no mention of tests and studies that are pending.

Over the last decade, medical researchers and educators turned their attention increasingly to this issue. I spoke recently to Dr. Vineet M. Arora, an assistant professor of medicine at the University of Chicago, who studies patient handoffs and the ways in which they might be improved.

Handoffs are supposed to mitigate any issues that arise when doctors pass the responsibility for patient care to a colleague. “But that requires investing time and effort,” Dr. Arora said, “and using handoffs as an opportunity to come together to see how patient care can be made safer.”

Most of the time, however, handoffs are fraught with misunderstanding and miscommunication. Physicians who are signing out may inadvertently omit information, such as the rationale for a certain antibiotic or a key piece of the patient’s surgical history. And doctors who are receiving the information may not assume the same level of responsibility for the care of that patient. “Handoffs are a two-way process,” Dr. Arora observed. “It’s a complex interplay.” Missed opportunities to impart important patient information result in more uncertainty for the incoming doctor. That uncertainty leads to indecision which can ultimately result in significant delays during critical medical decisions.

More recently, Dr. Arora pointed out, researchers have begun looking for new ways to approach patient handoffs, studying other high-stakes shift-oriented industries like aviation, transportation and nuclear power, as well as other groups of clinicians.

“We can borrow from the models of other health care practitioners,” Dr. Arora said. Nurses, for example, have long placed great importance on the process of handing off patients. “It’s pretty difficult to find and interrupt a nurse during shift change because they have made it a high priority,” Dr. Arora remarked. “There’s a dedicated time, a dedicated room, a culture that has developed around it. In contrast, physicians have historically emphasized continuity much more than handoffs. As a result, doctors’ signouts happen quickly, last-minute and on the fly.”

By incorporating more efficient methods of communication, the hope is that patient care transitions will eventually become seamless and less subject to errors. But even more important than teaching and learning those methods, Dr. Arora says, will be transforming physician attitudes.

“It’s critical that we invest the time and that our payment system eventually reflects how important that time is,” Dr. Arora said. “But we also need to change our profession’s thinking so that handoffs are a priority and not an afterthought. We need to be able to say that the ability to transition care well is an important metric by which you will be judged to be a good doctor.

“Good handoffs are about best practices, about being a good doctor. Investing time in them is the right thing to do.”
crédito: The New York Times and AHRQ