Article

Improving emergency department to hospital medicine transfer of care through electronic pass-off

2122 Correspondence / American Journal of Emergency Medicine 36 (2018) 21032128

skills to save patient lives [3]. SBE is a principle component of many patient safety and interprofessional education (IPE) paradigms [4]. Here, we propose the application of SBE to rapid response systems.

IPE consists of two main learning purposes. The first is to understand the importance and role of each professional, and the second is to be aware of what each professional is responsible for according to their specialty. The first learning purpose can be addressed through appropri- ate scenarios, debriefing, and feedback. Thus, educators can apply SBE to achieve the first goal irrespective of the learner’s specialty. In contrast, the second learning purpose requires an awareness of one’s specialty. Indeed, the learning purpose of professionals in clinical settings differs in various aspects. For example, the learning purpose for physicians might focus on leadership in advanced cardiac life support, the learning purpose for nurses might include family care, and the learning purpose for pharmacists may include additional resuscitation drug administration.

We are now developing simulation-based IPE training and found some effective principles to achieve these learning purposes. The combination of learning purposes of various professionals for rapid response systems is needed for establishing and achieving IPE. It is essential for educators to understand that rapid response IPE using SBE should incorporate the learning purpose of each specialty [5,6]. To achieve this, educators from various professions should collaborate to develop both common and individual learning purposes. Another important point is that learning purposes should be achieved step by step manner. From our experience, we propose the four processes, 1 performing appropriate resuscitation skill, 2 effective team develop- ment, 3 differential diagnosis and initial treatment, and 4 medical safety action.

IPE simulation Training for rapid response system should be developed with step by step process for multiple learning purposes.

Nobuyasu Komasawa Department of Anesthesiology, Osaka Medical College, Japan Corresponding author at: Department of Anesthesiology, Osaka Medical College, Daigaku-machi 2-7, Takatsuki, Osaka 569-8686, Japan.

E-mail address: [email protected].

Takahiro Ohashi Akemi Take Yoshiko Doi Tomotaro Dote Chiharu Akazawa

Department of Nursing, Osaka Medical College, Osaka Medical College,

Japan

Kaori Kadoyama

Department of Education and Research Center for Clinical Pharmacy, Osaka

University of Pharmaceutical Sciences, Japan

20 March 2018

https://doi.org/10.1016/j.ajem.2018.03.053

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    Improving emergency department to hospital medicine transfer of care through

    electronic pass-off?

    The transition of care from the Emergency Department (ED) to an inpatient service presents multiple challenges, including differences in specialty-specific communication and lack of preexisting relationships between providers [1,2]. Given increasing time constraints placed on inpatient and ED providers, those attempting to provide and receive pass-off are frequently forced to balance this with myriad other clinical and administrative tasks [3-5]. Traditionally, a verbal pass-off has been standard, sometimes involving multiple attempts at contact between providers. Delays in transfer associated with arranging pass-off may contribute to ED overcrowding and therefore affect both patient safety and ED financial and operational, financial, and patient experience outcomes [6-12]. This pilot quality improvement initiative aimed to evaluate whether the use of a standardized electronic pass-off tool could improve the pass-off time for patients admitted to Hospital Medicine (HM) from the ED.

    In a large, urban, academic hospital, a multidisciplinary group consisting of ED and HM providers met to discuss delays associated with ED to HM pass-off and to brainstorm potential solutions. Ulti- mately, a standardized electronic provider to provider “E-pass-off” tem- plate containing the information determined to be most important for safe patient care transition during pass-off was developed in the elec- tronic medical record (EMR, Epic Systems) (Fig. 1).

    During a two-week study period, ED providers were asked to com- plete the E-pass-off template, which the HM provider could review and either accept by page or call back by telephone for clarification. Data was collected to identify the percentages of patients with E-pass- off attempted by an ED provider and of patients with E-pass-off accepted by a HM provider as well as time from “ready bed” to pass- off. Outcome metrics including time from ready bed to pass-off comple- tion and proportion of these taking greater than 60 min were compared to a five month Baseline period. Non-parametric testing was utilized to assess for differences between successful, unsuccessful, and baseline pass-off times and Chi-square testing was used to assess for difference between the proportion of pass-offs greater than 60 min.

    Eighty-four patients were admitted from the ED to the HM service during the pilot period and forty-eight (57%) had E-pass-off was initiated by the ED provider; in 35 (72.9%) of these cases E-pass-off was accepted by the HM provider (Table 1). In 35 patients for whom E-pass-off was successful, mean time from ready bed to pass-off was

    52.0 min (13% decrease from baseline of 59.5 min), with a median of

    45.0 min (12% decrease from baseline of 51 min) and standard deviation of 25.7 min (49% decrease from baseline of 49.9 min). In contrast,

    ? All authors report no conflict of interest.

    This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

    Correspondence / American Journal of Emergency Medicine 36 (2018) 21032128 2123

    Fig. 1. E-pass-off template.

    In conclusion, initiatives such as E-pass-off may decrease ready bed to pass-off time for a subset of admitted patients, and thus decrease ED LOS and increase ED capacity. Future efforts should focus on studying the potential utility of electronic pass-off tools for patients admitted to all services, and formally studying the accuracy of communication in an electronic pass-off tool versus traditional verbal handoff.

    Jonathan D. Sonis, MD Ali S. Raja, MD, MPH, MBA

    Benjamin A. White, MD Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States Corresponding author at: Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, 5 Emerson Place,

    Room 170, Boston, MA 02114, United States.

    E-mail address: [email protected].

    David J. Lucier, MD, MBA, MPH

    Department of Medicine, Harvard Medical School, Massachusetts General

    Hospital, Boston, MA, United States

    Joan L. Strauss, MBA

    Center for Quality and Safety, Massachusetts General Hospital, Boston, MA,

    United States

    performance for the E-pass-off unsuccessful group (n = 49) was nearly the same as baseline, with a 1.2% difference in mean time (58.8 min vs 59.5 min), no difference in median (51.0 min for both), and a 6.8% difference in standard deviation (53.3 min vs 49.9 min). There was no statistically significant difference in the medians of all three groups,

    https://doi.org/10.1016/j.ajem.2018.03.059

    References

    13 March 2018

    although E-pass-off successful trended towards improvement. There was a statistically significant difference in the variance of E-pass-off successful compared to both unsuccessful and baseline (p = 0.001). Among the successful E-pass-offs, 25.7% (9 out of 35) took longer than 60 min, compared to 38.1% (391 out of 1026) of pass-offs at baseline.

    In this pilot test, use of a standardized electronic pass-off tool suc- cessfully reduced both mean and median pass-off times and variance in pass-off times. Given the expanding quality, safety, and capacity challenges for ED directors, our findings may have several potential important implications, including reducing delays in ED Patient throughput and improving the ED quality of care and patient experience [13-17]. Additionally, the potential reduction in variability and ambigu- ity in interdepartmental communication through use of a standardized pass-off tool may have important patient safety implications [4,18].

    Our pilot has several limitations. While it is possible that the signifi- cant decrease in ready bed to pass-off time variance observed during the study period was partially the result of external factors unrelated to the pass-off tool, no such factor was identified. That our pilot was limited to ED patients being admitted to one service in a single hospital reduces the generalizability of our findings. Finally, while our sample size was small, we expect that a more significant difference would have emerged with a larger data set.

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  6. Balhara KS, et al. Implementing standardized, inter-unit communication in an inter- national setting: handoff of patients from emergency medicine to internal medicine. Intern Emerg Med 2017. https://doi.org/10.1007/s11739-017-1615-y.
  7. Hilligoss B, Cohen MD. The unappreciated challenges of between-unit handoffs: negotiating and coordinating across boundaries. Ann Emerg Med 2013;61(2): 155-60.
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  10. Amarasingham R, et al. A rapid admission protocol to reduce emergency department Boarding times. Qual Saf Health Care 2010;19(3):200-4.
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    ented outcomes. Acad Emerg Med 2009;16(1):1-10.

    Falvo T, et al. The opportunity loss of boarding admitted patients in the emergency department. Acad Emerg Med 2007;14(4):332-7.

  12. Spaite DW, et al. Rapid process redesign in a university-based emergency depart- ment: decreasing waiting time intervals and improving patient satisfaction. Ann Emerg Med 2002;39(2):168-77.
  13. Boudreaux ED, O’Hea EL. Patient satisfaction in the emergency department: a review of the literature and implications for practice. J Emerg Med 2004;26(1):13-26.
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    literature. J Patient Exp 2018. https://doi.org/10.1177/2374373517731359.

    Table 1

    Time from ready bed to pass-off for successful and unsuccessful E-pass-off and baseline period

    N

    Mean (min)

    Median (min)

    Standard deviation (min)

    Sample variance (min)

    N greater than 60 min

    E-pass-off successful

    35

    52.0

    45.0

    25.7

    658.4

    9 (25.7%)

    E-pass-off not successful

    49

    58.8

    51.0

    53.3

    2845.8

    21 (42.3%)

    Baseline

    1026

    59.5

    51.0

    49.9

    2485.5

    391 (38.1%)

    2124 Correspondence / American Journal of Emergency Medicine 36 (2018) 21032128

    Pines JM. What U.S. emergency care value transformation can learn from Canadian efforts to improve emergency department throughput. Acad Emerg Med 2015;22 (6):750-1.

  15. Krall SP, Guardiola J, Richman PB. Increased door to admission time is associated with prolongED throughput for ED patients discharged home. Am J Emerg Med 2016;34(9):1783-7.
  16. Ramlakhan S, et al. The safety of emergency medicine. Emerg Med J 2016;33(4): 293-9.
  17. Singer AJ, et al. The association between length of emergency department boarding and mortality. Acad Emerg Med 2011;18(12):1324-9.
  18. Liu S, et al. The boarding experience from the patient perspective: the wait. Emerg Med J 2015;32(11):854-9.

    Impact of rapid response car system on ECMO in out-of-hospital cardiac arrest

    To the Editor,

    I read with great interest the recent article by Sato et al. [1]. The au- thors examined the effect of physician-based emergency medical ser- vices (P-EMS) that use a Rapid response car on the time from arrival to the implementation of extracorporeal membrane oxygenation (ECMO; door-to-ECMO). They concluded that the physician-based RRC system was associated with a shorter Door-to-ECMO time and that the combination of an RRC system with Extracorporeal life support (ECLS) may lead to better outcomes in patients with out-of-hospital cardiac ar- rest (OHCA). However, this conclusion is overstated, and several issues in this study need to be confirmed.

    First, the authors should clarify the reasons why the RRC system was

    not activated in the emergency medical service only group. Although the RRC system is activated by specific keywords such as “cardiac arrest” and “altered mental status”, more than half of the cases included in this study were not treated by the RRC system. This confounding factor could affect the outcomes. Second, the physician-based RRC system was associated with a shorter door-to-ECMO time but not with better clinical outcomes, such as reduced in-hospital mortality and favorable neurological outcomes, in this study. Therefore, the conclusion that the combination of the RRC system with ECLS may not be useful to im- prove clinical outcomes is accurate. Third, even if a shorter door-to- ECMO time is truly associated with better clinical outcomes [2,3], it is problematic that the combination of the RRC system with ECLS could not improve clinical outcomes, despite a shorter door-to-ECMO time. To investigate whether the physician-based RRC system was associated with worse clinical outcomes, multivariable analysis of predictive fac- tors of worse clinical outcomes should also be conducted. Finally, the in-hospital mortality and 30-day mortality in the two groups in Table 2 are incorrect. Mortality should be replaced with survival.

    Conflict of interest

    None.

    Source of support

    None.

    Acknowledgement

    None.

    Junpei Komagamine, MD Department of Internal Medicine, National Hospital Organization Tochigi Medical Center, 1-10-37, Nakatomatsuri, Utsunomiya, Tochigi 3208580,

    Japan E-mail address: [email protected].

    14 March 2018

    https://doi.org/10.1016/j.ajem.2018.03.062

    References

    Sato R, Kuriyama A, Nasu M, Gima S, Iwanaga W, Takada T, et al. Impact of rapid re- sponse car system on ECMO in out-of-hospital cardiac arrest: a retrospective cohort study. Am J Emerg Med 2018;36:442-5. https://doi.org/10.1016/j.ajem.2017.08.055.

  19. Leick J, Liebetrau C, Szardien S, Fischer-Rasokat U, Willmer M, van Linden A, et al. Door-to-implantation time of extracorporeal life support systems predicts mortality in patients with out-of-hospital cardiac arrest. Clin Res Cardiol 2013;102(9):661. https://doi.org/10.1007/s00392-013-0580-3.
  20. Han SJ, Kim HS, Choi HH, Hong GS, Lee WK, Lee SH, et al. Predictors of survival following extracorporeal cardiopulmonary resuscitation in patients with acute myocardial infarction-complicated refractory cardiac arrest in the emergency department: a retro- spective study. J Cardiothorac Surg 2015;10:23. https://doi.org/10.1186/s13019-015- 0212-2.

    Cardiopulmonary resuscitation on television:

    The TVMD study

    To the Editor:

    Television medical drama series (TVMD) present real and fictional clinical situations. In many of these series, cardiopulmonary resuscita- tion (CPR) is depicted [1]. Therefore, television is an important source of acquiring information about CPR [2]. Audience may acquire this infor- mation unintentionally, including Healthcare practitioners [3]. The clin- ical scenarios and outcomes presented in TVMD, may affect the public expectations about CPR-related outcomes [4]. We attempted to analyze TVMD portraying CPR, and comparing it to current guidelines for resus- citation as well as the outcome depicted after cardiac arrest.

    An instrument was created and validated to assess CPR performance and outcome in TVMD. One hundred episodes of 7 TVMD were scored by trained advanced cardiac life-support providers (see Table 1). Seventy-two instances of CPR were depicted in these episodes. In the 7 TVMD analyzed, males suffered cardiac arrest more frequently than females (72.2% [CI 61.2,81.5] vs. 27.8% [CI 18.5, 38.8]) (See Fig. 1). The

    most affected group found were those under 60 years of age, [CI 67, 86] followed by teenagers (13-19 years) at 10%, [CI 6, 22] children

    (4-12 years) [CI 2, 13] at 6%, seniors (60-75 years of age) at 3% [CI

    1,9] and babies (0-3 years) at 1% [CI 0,6] (See Fig. 2). Trauma was the leading cause of cardiac arrest in 54% of patients [CI 43, 65], followed by Cardiac origin in 21% [CI 13, 31], other causes reported 15% [CI 8,25], respiratory failure at 7% [CI 3,15] and drowning at 3% [CI 1,9]. Lo- cation of CPR was reported to be most frequently viewed in hospitals, when compared to out of hospitals performance (86% [CI 77,93] vs. 13% [CI 6,22]), being witnessed 83% [CI 74,91] of the time vs. 15% [CI 8,25] of unwitnessed cases. Physicians were the first to initiate CPR in all the TVMD reviewed, (81% [CI 70,88]), followed by nurses (8% [CI 4,16]), paramedics (6% [CI 2,13]), medical students (4% [CI 1,11]) and laypersons (1% [CI 0,6]). In most of these series, arm position was inad- equate. compression rates were inadequate in 62.5% [CI 51.0, 73.0]. CPR was interrupted in 54.4% of attempts [CI 42.7, 65.3]. An inappropriate position of hands was noted in 52.8% of the rescues [CI 41.3, 64.0]. Re- turn of spontaneous circulation (ROSC) in the TVMD series reviewed was reported in 70.8% with application of defibrillation in most patients. In the vast majority of TVMD, no medications were used while CPR was being performed. In most of the series, the patient survived.

    In our study, the portrayal of cardiac arrest, and the attempts of resus- citation may impact the expectations of the public. In almost all “self-re- specting” medical shows, there was a portrayal of dramatic resuscitations in most of the episodes. Although CPR performance looked realistic, it can be a source of misinformation. The epidemiology, the causes, the diag- nosis and even the treatment are questionable and even unrealistic. In ad- dition, based on current CPR guidelines, the techniques depicted in TVMD

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