Hospitalists: New Specialty and New Risks
Ineffective handoffs can lead to inappropriate treatment, delays in diagnosis, and potentially life-threatening adverse events.
All of these elements came into play in “Who’s in Charge?” a lesson from litigation by David B. Troxel, MD, medical director of The Doctors Company. Each of the hospitalists in the case study missed opportunities to diagnose the patient’s condition due to communication gaps and inattention to documentation among the members of the healthcare team:
- Hospitalist B did not review the medical record and did not communicate to hospitalist A that the patient fell.
- Neither hospitalist A nor B examined the patient following the fall, and the fall was not communicated to hospitalist C.
- Hospitalist C did not communicate with either A or B about the patient’s inability to stand.
- Hospitalist D failed to communicate the urgency of the MRI to the on-call neurologist.
In “Who’s in Charge?” there are many examples of communication and handoff breakdowns that led to the patient injury. Because the hospitalists involved in the case study didn’t use a standard set of critical elements to be communicated with each handoff or interaction, there were delays in diagnostic testing and treatment and failures in recognizing the patient’s neurological deficits, which resulted in the unfortunate outcome.
By understanding the problems that can occur during handoffs and planning effective communications, the hospitalists in this case could have minimized risk and enhanced patient safety.
The Shift Toward Hospitalists
Over the last decade there has been a dramatic shift away from primary care–directed hospital care toward a model in which hospital-based physicians—hospitalists—provide care to inpatients. In fact, the hospitalist field has now become the fastest-growing specialty in the history of American medicine, skyrocketing from 1,000 physicians nationally in the mid-1990s to more than 28,000 today.
Researchers at the University of Texas Medical Branch (UTMB) at Galveston have produced the first quantitative analysis of the increase in the number of hospitalists. In a paper appearing in the March 12, 2009, issue of the New England Journal of Medicine, UTMB Associate Professor Yong-Fang Kuo used Medicare data to calculate that the percentage of internal medicine physicians practicing as hospitalists jumped from 5.9 percent in 1995 to 19 percent in 2006.1
Hospitalists and Effective Communication
The goal of the hospitalist medicine model is to provide a coordinated approach to the care of inpatients. This requires the hospitalist to be skilled in effective communication between physicians and the rest of the hospital clinical team involved in the care of the patient. The processes and systems within the hospital environment create potential barriers to effective communication, in areas including:
- Key information unknown or not passed along
- Poorly defined roles of hospitalist, admitting physician, and specialist(s)
- High volume of information arising from a multitude of sources
- Lack of standardization of processes within the facility
In fact, studies have indicated that lack of communication is the single most common root cause that can lead to liability claims. However, all of the above concerns can be minimized with effective communication techniques and processes.
The primary objective of a handoff is to provide accurate information about a patient’s care, treatment, current condition, and any recent or anticipated changes. Handoffs are interactive communications allowing the opportunity for questioning between the provider and the recipient of patient information. For hospitals, the handoffs that occur during the time when a patient is moved to another unit, sent for a diagnostic test, or transferred to a new physician can create continuity of care issues.
Hospitalists can use the following tips to improve effective communication during handoffs.
Tips for Effective Handoff Communication
- Use standardized communication tools such as the mnemonic "HANDOFFS."2
- Allow interactive communication for questions/discussion and require repeat-back of the exchanged information.
- At a minimum, include the following during handoffs: diagnoses, current condition, recent changes in condition or treatment, anticipated changes, and warning signs of changes in the patient's condition.
- Limit interruptions during handoffs.
- Use the following questions for guidance in organizing communication during the handoff:
- What is important to communicate?
- Who needs to know what information?
- When should communication occur?
- How should the information be transmitted?
- How can I validate the communication was successful?
The hospitalist is responsible for the co-management of patients involving a wide range of physicians and other clinicians. It is critical for the hospitalist to communicate effectively with the healthcare team, the patient, and the patient’s family to limit risks and enhance patient safety.