Bouncebacks – Advanced Practice Clinicians
Mike Weinstock MD, Tim Scanlon, Shonna Riedlinger PA, Jennifer Stankus MD,JD
Take Home Points
▪ Handoffs of patient care between providers are high risk for error. Taking ownership of the patient can decrease the likelihood of error.
▪ Critical lab values should be called to the provider while confirmatory testing is in progress, not after results are available.
▪ If the midlevel provider feels the case is outside their scope of practice or level of expertise, the physician should take over the case without hesitation.
● Scanlon reported for his shift at 11pm and assumed care of a patient assigned to the physician leaving at 1am. The patient was a 28 year old male presenting with abdominal pain. He was diaphoretic, tachycardic and slightly confused. Scanlon was concerned that the patient would not be wrapped up before the physician left so he approached the overnight doctor to see if they would assume care of the patient. She was unable to help and referred Scanlon to the departing physician.
● What did Scanlon see? The patient was in obvious distress with a complaint of abdominal pain. He had nausea and vomiting. He was restless, diaphoretic and a poor historian. He had a concerned mother at the bedside. She was very impatient with questioning and evasive with some questions.
● What was the differential diagnosis? Kidney stones, gallbladder disease, pancreatitis and perforated bowel. He considered toxic ingestion. The patient had previously had an appendectomy.
● This was a difficult patient and the diagnosis was unclear. The CO2 was 19.
● Midlevel providers need to know what they know and when to ask for help. The first physician left and Scanlon discussed the case again with the overnight physician.
● The patient’s mental status continued to deteriorate. The patient accidentally removed his IV several times. The patient had a low grade fever, leukocytosis and altered mental status. They considered the possibility of a CNS infection and decided to obtain a head CT. They ordered a drug screen and considered toxidromes. Scanlon wished for more oversight by the physician.
● “You’ve got this, right? When everything results, let’s get him admitted.” The sign-out between the physicians was minimal.
● How can we make handoffs positive?
o A study by Horwitz looked at the development of a handoff evaluation tool for shift to shift physician handoffs. They came up with certain elements that were important to convey to the receiving physician; identifying information, problem list, medication list, anticipatory guidance and a to-do list.
▪ Horwitz, LI et al. Development of a handoff evaluation tool for shift-to-shift physician handoffs: the Handoff CEX. J Hosp Med. 2013 Apr;8(4):191-200. PMID: 23559502
o Another study looked at potential errors of handoffs such as a high signal to noise ratio, not having a standard approach, having an ambiguous moment of transition of care and cognitive bias.
o Incentive based models may encourage or discourage handoffs, which could affect patient safety.
o Cheung found some solutions. Reduce unnecessary handoffs. Limit interruptions and disruptions. Provide succinct overview of the case. Communicate outstanding tasks with a clear plan. Have information available for direct review. Encourage questioning by the receiving party. Have a clear moment of transition of care.
● Cheung, DS et al. Improving handoffs in the emergency department. Ann Emerg Med. 2010 Feb;55(2):171-80. PMID: 19800711
o Apker, J et al. Exploring emergency physician-hospitalist handoff interactions: development of the Handoff Communication Assessment. Annals of Emergency Medicine 2010 Feb;55(2):161-70. PMID: 19944486
▪ They looked at handoffs between emergency physicians and hospitalists. They found the power differential between the physicians can decrease openness and the amount of accurate information conveyed.
● Handoffs are high risk. However, it is also high risk for a provider to avoid seeing a patient because they don’t want to handoff the patient to the incoming physician. Sometimes providers may avoid ordering a test that may not provide results in a timely manner.
● It is not the handoff that is the problem. The problem is that the second provider is not taking ownership of that patient. The risk of handoff significantly decreases if you take ownership. Go in and see the patient. Put a directed note on the chart. Make sure you discuss test results and evaluate the patient.
● What was the diagnosis? The patient had salicylate toxicity. The lab was so surprised by the level of toxicity that they decided to rerun the results to confirm prior to releasing the results. The salicylate level was 119. The patient was admitted to the ICU and dialysis was arranged.
● There were several aspects of communication breakdown in this case. The failure of the lab to notify the providers regarding the elevated level before confirming is a systems-based failure. There should be an automatic call to the emergency department regarding a potentially critical lab value. There was a power differential between the midlevel provider and supervising physician. Scanlon felt uncomfortable requesting the physician take over the patient.
● The patient’s condition continued to decline and his respiratory status worsened. The intensivist decided the patient needed to be intubated. Shortly after intubation, the patient arrested and died.
● Within a year, all three providers were subpoenaed for a lawsuit.
● The first physician was deposed first. They were asked, “Doctor, don’t you think if someone has abdominal pain, tachycardia and diaphoresis, the first thing on your differential should be salicylate toxicity?” His answer was “Yes.” “Shouldn’t your PA also consider salicylate toxicity at the top of their differential diagnosis?” The answer was “Yes”.
● The case was settled for $750,000. There were several contributing factors to the decision to settle the case. The deposition by the first physician was not a good reflection of the realities of the case. Also, the overnight physician should have gotten involved sooner in the case. The documentation was not sufficient. Scanlon did not have the opportunity to document real-time progress notes and the documentation was not started until the patient was admitted and his shift was ending.
● What could have been done differently? Scanlon wishes he was more assertive. Midlevel providers and residents look to the supervising physician and trust their input and advice but it is ok to disagree respectfully. If the midlevel provider or resident asks you for help, be receptive.
● This is an interesting problem in the emergency department. Midlevel providers often have overlapping shifts with physicians resulting in sign-outs. These are more challenging as you don’t know the patient as well.
● They did a good job managing the case. They made the diagnosis and arranged for dialysis. The attorney for the plaintiff argued care was not provided in a timely manner rather than failure to diagnose. Timing is very important in these cases. The patient was likely very acidotic and had they received dialysis sooner, they may have survived.
● Don’t throw another provider under the bus. However, someone has to take ownership of the patient. The midlevel needs to have an honest conversation with the physician and let them know that they need help with the patient. The supervising physician has to take ownership of the patient. This is their role.
o Document times. Document what time you spoke to someone and a brief description of what was said.
● The patient presented at 11pm. They were diagnosed with salicylate toxicity and serum bicarbonate of 19. Nephrology and toxicology was consulted. They planned to place a catheter and start dialysis. Unfortunately, the patient died.
o Sometimes we do everything right and there is still a bad outcome. Juries may feel sympathetic for the patient.
● What is the take-home message for midlevel providers and physicians? If the midlevel provider feels the case is outside their scope of practice or level of expertise, the patient should be handed over to the physician. The physician should take over the patient without hesitation. The midlevel provider should not be placed in a position where they feel they are unable to care adequately for the patient.