In the nearly 10 years since the word “hospitalist” entered our consciousness, it has been inspiring to witness the dramatic growth in the specialty and, accompanying it, the growth in the membership of SHM.1 Over this same period, the healthcare system has made progress toward ensuring that it provides the safest, highest quality healthcare possible.
In my mind, the two phenomena are related. SHM itself and—more generally—the hospitalist field have played a vital role in promoting the use of evidence-based care, improved teamwork, and health information technology. Each of these efforts has made a significant difference in the care patients receive in hospitals. Similarly, the mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans. Both organizations are working to create positive change that will improve the health and healthcare of all patients.
As their numbers continue to grow, hospitalists are becoming integral members of the inpatient care team at many hospitals.
According to a recent survey conducted by SHM, a hospitalist averaged more than 2,300 inpatient encounters in 2005—a 7% increase over 2004.2 Today, hospital medicine groups practice not only in large metropolitan areas, but also in rural regions where one in three groups began operation during 2005.
In addition to their inpatient care responsibilities, the 15,000 hospitalists who practice today in the United States and Canada serve in key physician leadership roles that directly influence quality improvement and patient safety. Most hospitalists—86%—participate in quality improvement. More than half are involved in implementing information technology (54%) and teaching house staff (51%), and more than one-third—35%—are responsible for their organization’s rapid response team. The SHM survey found that nearly all hospital medicine groups provide round-the-clock patient care at their hospitals.
In this article I will emphasize two key areas relevant to improving patient safety for hospitalized patients: patient handoffs and communication.
Responsibility for Patient Handoffs
Hospitalists’ clinical and leadership roles are significant responsibilities for patient safety, including the critical period known as patient handoff or sign-out.
Patient handoffs refer to the interaction, communication, and planning required to achieve a seamless transition from one clinician to the next.3 When executed in a timely and thorough manner, patient handoffs can reduce the likelihood of medical errors and misinformation, prevent lost or missing clinical information, and maintain a high level of medical care.
Given today’s short hospital stays and the complex medical nature of the care necessary for many patients, timely and effective handoffs demand that hospitalists develop skills that extend beyond superior clinical care. They include:
- Communicating in an effective and efficient manner during patient sign-out;
- Demonstrating the use of “read-back” skills when communicating tasks;
- Developing oral and written patient summaries, including characteristics of the patient, provider, and time of the sign-out;
- Evaluating all medications for indication, dosing, and planned duration at the time of sign-out; and
- Anticipating what may go wrong with a patient after a transition in care occurs and clearly communicating this concern to the receiving clinician.
A Fumbled Handoff: A Case Study
A breakdown in communications—notably an error of omission in the patient handoff—contributed to a poor outcome for an elderly patient who was admitted to the hospital for an elective sigmoid resection.
The case, which was published in the AHRQ’s “Morbidity and Mortality Rounds on the Web” (developed by hospital medicine expert Robert Wachter, MD, and his team under contract to our agency), illustrates some of the challenges that face all clinicians in effectively transferring patient information and care responsibilities.4 It also underscores the need for close involvement by hospitalists in improving quality, teaching and supervising house staff, and implementing information systems.