Handoffs or Fumbles: Transferring Care Amongst Physicians

There are many patient hand offs during EVERY physician’s day.  Primary care physicians hand their patients off to ED docs, who in turn hand them off to hospitalists or specialists, who in turn (eventually) hand them back to their out patient physician.  Additionally, there are hospitalist to hospitalist hand offs and specialist to specialist hand offs.  Yikes! 

Here’s my advice on preventing fumbles:

From PCP to ED/Hospitalist: please call the ED or admitting hospitalist if you are direct admitting.  DO NOT HAVE YOUR NURSE CALL BECAUSE YOU ARE TOO BUSY!  Make sure your patient has the following paper work attached to his body:

• today’s note that clearly states WHY the patient needs an ED eval or admit, and what you did for him in the clinic.
• legible medication list.
• legible problem list that includes surgeries and hospitalizations  (Yeah, remember that from med school?  You may have all that in your head, but we are seeing this patient for the first time).
• contact information on how to get back to you.
• the concerning EKG that caused you to send Mr. Prinzmetal to the ED in the first place.

From ED MD to hospitalist/specialist:

• Why the patient needs to be admitted.  Please, please, please don’t say “He just needs to come in.”  Have labs, EKGs, and xrays on hand when you call, and please don’t mind if I ask you a fair amount of questions.  I do NOT expect ED physicians to think of every contingency (that’s my anal retentive job), but I do expect a working diagnosis.
• What you have done for the patient in the ED, and how he responded.
• Which specialists you have called, and what their plan is.

From hospitalist to specialist:

• Why you are calling.  Be VERY clear: “I want you to manage Mr. Prinzmetal’s acute MI.  I think he needs to go to the cath lab.”
• In what time frame the specialist needs to see the patient.  My favorite specialists will tell me when they will come by, but I try to ask so I can tell the patient.  For pity’s sake, if you need them to see the patient NOW say it!  They aren’t mind readers.
• What you have done for the patient and how the patient has responded.
• Have your data handy. I expect the ED to do this for me, and we need to do it for the specialists/consultants.

From specialist to hospitalist/primary care:

• Communicate the treatment plan.  I love a phone call, but the minimum is a readable note.
• When you will follow up with the patient.  Expecting a PCP or hospitalist to call you to inquire about follow up plans reduces us to minions and is poor patient care.  Besides, you should be telling this to the patient when you hand them your business card.

From hospitalist to PCP:

• Call the PCP at discharge(or email the THOROUGH discharge report if you are set up that way).  Most hospitals send dictated summaries, but they frequently arrive after the patient has been seen by the PCP.
• Make sure the PCP ( and the patient!) has a complete medication list.  Be VERY clear about what medications are new, what has been stopped and what medications remain.
• Make sure you review pertinent tests and results.
• Review which specialists saw the patient and what the follow up plans are.
• Let the PCP know when they need to the newly discharged patient.

There is an interesting post from the Wall Street Journal on surgical resident’s hand offs, but I didn’t find it the most helpful for the PCP-ED-Hospitalist-Specialist circuit.  However, some of the comments are pretty entertaining. Here’s the link if you are interested: http://blogs.wsj.com/health/2008/10/20/how-doctors-can-avoid-perilous-patient-hand-offs/

 FYI: the Washington Redskins had the most fumbles in 2007, reflecting the fumbling going on in the nation’s capitol.

Love to hear your hand off tips!