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