Exploring emergency physician-hospitalist handoff interactions: development of the Handoff Communication Assessment.

STUDY OBJECTIVE: We develop and evaluate the Handoff Communication Assessment, using actual handoffs of patient transfers from emergency department to inpatient care. METHODS: This was an observational qualitative study. We derived a Handoff Communication Assessment tool, using categories from discourse coding described in physician-patient communication, previous handoff research in medicine, health communication, and health systems engineering and pilot data from 3 physician-hospitalist handoffs. The resulting tool consists of 2 typologies, content and language form. We applied the tool to a convenience sample of 15 emergency physician-to-hospitalist handoffs occurring at a community teaching hospital. Using discourse analysis, we assigned utterances into categories and determined the frequency of utterances in each category and by physician role. RESULTS: The tool contains 11 content categories reflecting topics of patient presentation, assessment, and professional environment and 11 language form categories representing information-seeking, information-giving, and information-verifying behaviors. The Handoff Communication Assessment showed good interrater reliability for content (kappa=0.71) and language form (kappa=0.84). We analyzed 742 utterances, which provided the following preliminary findings: emergency physicians talked more during handoffs (67.7% of all utterances) compared with hospitalists (32.3% of all utterances). Content focused on patient presentation (43.6%), professional environment (36%), and assessment (20.3%). Form was mostly information-giving (90.7%) with periodic information-seeking utterances (8.8%) and rarely information-verifying utterances (0.4%). Questions accounted for less than 10% of all utterances. CONCLUSION: We were able to develop and use the Handoff Communication Assessment to analyze content and structure of handoff communication between emergency physicians and hospitalists at a single center. In this preliminary application of the tool, we found that emergency physician-to-hospitalist handoffs primarily consist of information giving and are not geared toward question-and-answer events. This critical exchange may benefit from ongoing analysis and reformulation.

The endocrine response to critical illness: update and implications for emergency medicine.

This review will provide an updated overview of the neuroendocrine response to critical illness. Specifically, the current evidence for "stress steroid" administration will be examined, as well as interventional glucose control during critical illness. The emergency physician will also find relevance in the alterations of thyroid hormones that occur in the face of severe illness or trauma.

Communicating in the "gray zone": perceptions about emergency physician hospitalist handoffs and patient safety.

OBJECTIVES: To identify the perceptions of emergency physicians (EPs) and hospitalists regarding interservice handoff communication as patients are transferred from the emergency department to the inpatient setting. METHODS: Investigators conducted individual interviews with 12 physicians (six EPs and six hospitalists). Data evaluation consisted of using the steps of constant comparative, thematic analysis. RESULTS: Physicians perceived handoff communication as a gray zone characterized by ambiguity about patients' conditions and treatment. Two major themes emerged regarding the handoff gray zone. The first theme, poor communication practices and conflicting communication expectations, presented barriers that exacerbated physicians' information ambiguity. Specifically, handoffs consisting of insufficient information, incomplete data, omissions, and faulty information flow exacerbated gray zone problems and may negatively affect patient outcomes. EPs and hospitalists had different expectations about handoffs, and those expectations influenced their interactions in ways that may result in communication breakdowns. The second theme illustrated how poor handoff communication contributes to boarding-related patient safety threats for boarders and emergency department patients alike. Those interviewed talked about the systemic failures that lead to patient boarding and how poor handoffs exacerbated system flaws. CONCLUSIONS: Handoffs between EPs and hospitalists both reflect and contribute to the ambiguity inherent in emergency medicine. Poor handoffs, consisting of faulty communication behaviors and conflicting expectations for information, contribute to patient boarding conditions that can pose safety threats. Pragmatic conclusions are drawn regarding physician-physician communication in patient transfers, and recommendations are offered for medical education.