Making transitions of care saferMaking transitions of care safer(a biased perspective)(a biased perspective)
Pat Croskerry MD, PhDPat Croskerry MD, PhD
SMACC Chicago June 23-26 2015SMACC Chicago June 23-26 2015
‘ ‘ the transfer of professional the transfer of professional responsibility and accountability responsibility and accountability for some or all aspects of care for some or all aspects of care for a patient, or group of for a patient, or group of patients, to another person or patients, to another person or professional group on a professional group on a temporary or permanent basistemporary or permanent basis’.
BMA 2005
Transitions in Emergency CareFirst responder
EMTs/ParamedicsED Triage
_____________________ED Nurses
ED PhysiciansConsultants
Vertical
Vertical ++ Horizontal
What makes transitions unsafe? Lack of standardization Discontinuity of care Time constraints Vulnerabilities of communication Uncertainty Degradation of information Fatigue and sleep deprivation Cognitive and affective biases
Standardized approach Embed in departmental and hospital cultureEmbed in departmental and hospital culture Provide training in handover and communicationProvide training in handover and communication Tailor to local needsTailor to local needs Recognise as a multiprofessional team activityRecognise as a multiprofessional team activity Define who should be presentDefine who should be present Designated time and locationDesignated time and location Determine clear plan for ongoing care of patientDetermine clear plan for ongoing care of patient
RCP UK 2011RCP UK 2011
Co-OrientationCo-Orientation
SharedSharedMentalMentalModelsModels
Communication
Perry, Patient Safety EM, 2009
Failures in transmission processFailures in transmission process
Transfer of poor information Poor transfer of information
Transfer of poor information Unwarranted opinions Stereotyping Stigmatization Gratuitous comments Over-confidence Other biases
Poor transfer of information
Unstructured/casual setting Rushed/fatigued Interruptions/distractions Limited or no input from others Verbal only Degradation of narrative skills
Where there is uncertainty there is an Where there is uncertainty there is an increased liklihood of heuristics and increased liklihood of heuristics and
biasesbiases
Kahneman, 2011Kahneman, 2011
Categorization of certainty?
Handover Categorization
Status Diagnosis Comments/Critical Information1 Unknown Unknown Initial work-up started.
Needs to be seen.
2 Stable Uncertain Needs complete reassessment
3 May require transfer and admission
Uncertain Waiting for:(a) further bloodwork to rule out/check level/etc(c) awaiting consult from....
4 Probably doesn't need transfer/admission
Fairly certain Waiting for…
5 Does not need transfer/admission
Certain Waiting for…
6A Awaiting transfer/admission
Known or not Patient is stable and no involvement anticipated
6B
_______6C
Awaiting transfer/admission___________________Awaiting transfer/admission
Known or not___________Known
Patient may not remain stable/you may be called_______________________________________Patient is DNR or DNI
MemoryMemory
Memory predictably fails us
Forcing functions are a good way to Forcing functions are a good way to overcome memory and other biases overcome memory and other biases
ChecklistsMnemonics
MnemonicsMnemonics
SBARI Pass The BATON
SIGNOUTI-PASS
Starmer et al, 2012
Biases at TransitionBiases at Transition
Serial position effects Content biasesContent biases
People were asked about a person described as:People were asked about a person described as: (a) (a) envious, stubborn, critical, impulsive, industrious and intelligentenvious, stubborn, critical, impulsive, industrious and intelligent.. or or(b) (b) intelligent, industrious, impulsive, critical, stubborn and envious. intelligent, industrious, impulsive, critical, stubborn and envious.
(b) was rated more highly than (a) (b) was rated more highly than (a)
Asch 1946Asch 1946
Primacy effect
Recency effect
We tend to remember the last few things more than those in the middle. We also
tend to assume that items at the end of the list are of greater importance or
significance.
Biases at transitions of careBiases at transitions of careFraming
Premature diagnostic closureDiagnosis momentum
Order effects: Primacy/RecencyFundamental attribution error
FramingFraming
An elderly female presented at triage with shoulder sprain. She was mowing her lawn and as she pushed the mower around a corner, felt pain in her left shoulder.She was triaged to the fast track area of the ED. She was seen and examined by an emergency physician who ordered a shoulder X-ray which shows mild osteoarthritis. She was prescribed an anti-inflammatory and discharged.
She returns later the same day having an inferior infarct.
Fundamental attribution errorFundamental attribution error
An ED physician was transferring a series of patients at the end of a busy shift. Two had serious conditions, and another has DNR staus and the family are present. After completion of the handover, the offgoing physician returned to tell his colleague of a patient he forgot at the back of the ED.He was a middle aged male, a ‘frequent flyer’, who typically presented acutely intoxicated. He was presently getting fluids IV and ‘can go when he wakes up’.After several hours, he is reassessed, subsequently diagnosed with acute pancreatitis and admitted.
.
Primacy? Search Satisficing? Primacy? Search Satisficing? A 48 year old male presented to the emergency department c/o
of lower anterior chest pain. He was seen and assessed by the ED physician doing the night shift, diagnosed as an unstable angina and heparinized pending a cardiology consult. The following morning he was transferred to the oncoming physician at 0700hrs. At the time of transfer, the offgoing physician appeared ill-humoured, fatigued, and cursory. With concerns about the quality of transfer the oncoming physician re-assessed the patient. His EKG and cardiac enzymes were normal, however, his history was significant for alcoholism. He had been having upper abdominal pain with black bowel movements for 2 weeks; rectal exam revealed black stool positive for occult blood. He was admitted with alcoholic gastritis and consulted to GI.
.
Red flags at handoverRed flags at handover
Transfer process is not standardized Transfer process is rushed Off-going physician fatigued, sleep deprived, dysphoric Dismissive or judgmental comments about patient Signs of cognitive or affective bias Department is excessively busy Patient has been handed over more than once