“Mission Critical” Patient Hand Off

Rom Duckworth is a Fire Captain and paramedic educator from the greater New York City area. A prehospital clinical practitioner, Rom has interest and expertise in human factors, especially mission critical communications.

Rom opened the session by describing mission-critical communications as any exchange of information whose disruption results in catastrophic failure of the mission at hand. He described how his experience in fire/rescue services lead to research in military, law enforcement, aviation, and other industries with an eye towards emergency and critical care medicine. Clinicians may not normally consider routine communications as “mission critical”, but that is because when they fail it is not as obvious as it is in other industries. “When mission-critical communications fail for firefighters, it becomes a headline. When mission-critical communications fail for healthcare, it becomes a statistic.”

In the United States, when the Joint Commission was searching for the root cause for hospital related sentinel events they found that 70% involved communications, with 50% occurring during patient care handoff, concluding “patient care handoff communications have been identified as a critical safety and quality problem.” 1 2 Worldwide the problem has not only been cited by every major healthcare organization, but even the Wall Street Journal in 2006 referred to patient handoff as “The Bermuda Triangle of Healthcare”. 3 Further investigation tied such communication failures directly to treatment delays, inappropriate treatment, omissions of care, increased length of stay, avoidable readmissions, increased treatment costs, and other minor and major inefficiencies and patient harm. 2 4 5

Duckworth says that the key is to focus on four aspects of patient information in order for all attending providers on the healthcare team to share a “mental model” or understanding of what’s going on, and what actions are immediately needed. These four components are, in order, the focused priority for the patient (what is the crux of the problem?), the history of prior care (what got us to this point?), the patient’s current state (where are we right now?), and the patient’s immediate needs (what is the very next thing that needs to happen?). 6

While healthcare providers tend to pay more attention to handoff during pre-alerts, poor handoff habits tend to get established during the regular transfer of low acuity patients. Research shows that ED staff members typically remember less than half of the information EMS crews give them, and that, in surveys, ambulance staff feel that physicians do not pay attention when EMS is handing off patients. 4,7

This is not so surprising when one considers that similar dynamics caused issues in mission-critical communications in other industries.8 Luckily, healthcare can just as easily turn to those industries for lessons learned and potential solutions. 9 10 In one example when Great Ormond Street Hospital turned to Ferrari’s Formula One racing pit stop crew to teach them how to better handoff patient care. As a result, technical errors dropped by 42% and information omissions decreased by nearly 50%.

The central idea is to not just avoid errors but rather to provide a hand off that allows receiving clinicians or teams to “pick up the ball” and continue forward progress, rather than having to start their assessment and treatment as if the patient just fell in from the sky. Rom’s own work has produced five general recommendations for clinicians to avoid failure and improve efficiency during handoff whether sending or receiving information. 11

For clinicians sending report the recommendations are:

Eye Contact: For clinicians handing over patient care, responsibility, and information, it is critical to begin by ensuring eye contact with the person to whom the patient is being transferred. Especially during team-to-team transfers and situations where receiving clinicians are multitasking this sends the message that “We are communicating now, you and I.”

Environment: Whenever possible minimize noise and interruptions by simply closing the door, pulling a curtain, or moving to a slightly quieter area to give report.

Ensure ABC’s: If there is a true “Focused Priority”, it should be immediately conveyed and performed by the receiving clinician or team. If at all possible, while another receiving clinician is identified to take the handoff report.

Structured Report: Numerous standardized report formats exist from MIST (and variations) to the most widely used, SBAR, originally developed by the US Navy Submarine service. Dozens of others exist with much evidence showing the use of any is better than the use of none, but little evidence supporting the use of one over another.

Supply Documentation: Separate verbal reports of the Priority, Past Hx, Current State, Immediate Needs with the many patient details that can be transferred on paper or electronic report. This helps clinicians avoid clouding their report with non-critical information.

For clinicians receiving report the recommendations are:

Eye Contact: With the same benefits, this can be initiated by reporter or receiver of patient care.

Environment: In many Emergency Departments in the US during “Alert” level team-to-team hand offs, the receiving clinician initiates a “moment of silence” so that all team members stop what they are doing and focus on the reporting EMS provider.

Ensure Understanding: Always ask questions if there is any possibility of misunderstanding.

Summarize: Not a regurgitation of the report that was just given, but rather a summary of the receiving clinician’s mental model, verbalized so that it can be error-corrected by the clinician giving report as well as anyone else on the receiving team.

Supplementary Documents: Again, this is not only a mention of the importance of the receipt of paper documents, but, where possible, details and patient monitoring located so that the entire receiving team can see the same information, contributing to that shared mental model.

To conclude his presentation Capt. Duckworth said that “handover of care is one of the most perilous procedures in medicine, and when carried out improperly can be a major contributory factor to subsequent error and harm to patients” according to the Medical Director of the UK National Patient Safety Agency. 12 However, when done properly patient handoff can also provide the opportunity for clinicians to gain a fresh perspective, foster critical thinking and a more collegial experience, and help improve patient satisfaction.




1.        The Joint Commission. Improving Hand-Off Communication. 1, (The Joint Commission, 2007).

2.        The Joint Commission. Handoff Communications. (Joint Commission Resources, 2008).

3.        Landro, L. Hospitals combat errors at the ‘Hand-Off’. (2006). at <http://www.wsj.com/articles/SB115145533775992541>

4.        Hilligoss, B. & Cohen, M. D. in Biennial Review of Health Care Management 11, 91–132 (Emerald Group Publishing Limited, 2011).

5.        Dawson, S., King, L. & Grantham, H. Review article: Improving the hospital clinical handover between paramedics and emergency department staff in the deteriorating patient. Emergency Medicine Australasia 25, 393–405 (2013).

6.        Cheung, D. S. et al. Improving Handoffs in the Emergency Department. Annals of Emergency Medicine 55, 171–180 (2010).

7.        Talbot, R. & Bleetman, A. Retention of information by emergency department staff at ambulance handover: do standardised approaches work? Emergency Medicine Journal 24, 539–542 (2007).

8.        Coiera, E. W., Jayasuriya, R. A., Hardy, J., Bannan, A. & Thorpe, M. E. C. Communication loads on clinical staff in the emergency department. Med. J. Aust. 176, 415–418 (2002).

9.        FOJP Service Corporation. Handoff Communications: Heeding the Call to Change. in focus Journal for Health Care Practice and Risk Management 5, (2007).

10.     Weinger, M. B. et al. Improving actual handover behavior with a simulation-based training intervention. Proceedings of the Human Factors and Ergonomics Society Annual Meeting 54, 957–961 (2010).

11.     Duckworth, R. L. Rescue Digest. RescueDigest.com at <http://www.rescuedigest.com>

12.     British Medical Association. Safe Handover – Safe Patients. 1, (British Medical Association, 2006).


Survival Guide: how to work in a crowded ED – Dr Adrian Boyle’s talk from RCEM15

Adrian Boyle, undoubtedly one of the gurus of Emergency Medicine process/flow/crowding, had an attentive audience for his talk on the final day of RCEM15. The official title was “How to work in a crowded ED”, but his theme soon veered onto “never waste a good crisis”!


“The kind of day when your patient flow managers have waved the white flag’’ – does this sound familiar? ED crowding is endemic in the UK (and elsewhere in the world) and very dangerous for patients. Even patients you think are OK to go home are more likely to die if there are long waits in the ED (!) and RCEM estimates that a department seeing 50k patients/year will see 13 extra deaths each year due to crowding.

Why does it occur?

We have known for years that the causes and effective solutions to ED crowding lie outside the ED, and Adrian emphasised the key points to hammer home to your management:

  • Win the argument that crowding is not “just a busy day”
  • Challenge the myth that this is about “inappropriate attenders” – it is not
  • Emphasise that the most effective solutions lie outside the ED
  • Think of solutions for Input/Throughput/Output

Adrian emphasised some of the key evidence-base about ED crowding. Firstly, it doesn’t usually occur in all parts of the ED at the same time – your resus room may be overflowing whilst minors or paeds is OK. Secondly, ED crowding is usually a reflection of a crowded emergency care system. And thirdly, the link between hospital capacity (or, I assume, lack of!) is overwhelming.

What to do when it happens

So how did Adrian recommend we actually manage a crowded ED? Think of the principles used for major incident management – “you must have hands off roles”.

If you’re in charge, you need to maintain situational awareness and not get sucked into the hands-on care of individual patients – think “Bronze Command”. Some EDs call this the “Fat Controller” role, others EPIC (Emergency Physicians in Charge) – in ours, it’s the Shop Floor Supervisor (or “Head Chef”) ! You also need a Nurse Controller. And you need to escalate and delegate in order not to get caught up doing hands-on tasks whilst trying to manage the situation.

This is all such an important skill for today’s Emergency Physicians we now have an assessment tool to help trainees develop it – the Extended Situational Learning Event or ESLE.

As for tasking your team, did you know those tricks that we’ve all learned to do when it’s gone belly up – blitzing minors, or making sure that senior docs concentrate on the potential discharges leaving obvious admissions to the juniors? They’ve all got names!

Never waste a good crisis!

It’s no good going to your managers and shouting at them that your ED is overflowing and dangerous. Have some specifics up your sleeve to ask for:

  • Ask for improvements in the co-ordination of available capacity (e.g. early discharges, discharge lounges, and weekend discharges).
  • Ask for a hospital-wide Full Capacity Protocol
  • Ask for boarding (i.e. sending patients to wards before their identified bed is ready)
  • Ask how they’ll enforce this (Board to Ward)

Overall, a very useful talk from a subject matter expert who has to fight the same battles as the rest of us when facing crowding problems in our departments.

Rapid Assessment in the ED: how to make it work – Dr Paul Jarvis’ talk from RCEM15 (“Marginal Gains” session, Day 3)

As the opening speaker in the “Marginal Gains” session on Day 3 of RCEM15, Paul Jarvis offered a very practical overview of Rapid Assessment schemes in UK Emergency Departments – including an honest appraisal of why they so often fail. As well as being a Consultant in EM, Paul Jarvis works as a management consultant – definitely a system/change guru – and formed his own business in 2012. Arguably, he’s had much greater experience of supporting successful introduction of Rapid Assessment (i.e. into multiple EDs) than most of us who have just done it once or twice.

What are Rapid Assessment schemes?

Most UK Emergency Physicians will now be familiar with the concept of “Rapid Assessment” (many of us having seen a variety of schemes of varying success during training). However, for colleagues new to EM (or who aren’t working in the UK), the philosophy is that front-loading senior decision-making can assign patients into the correct “stream” of processing within the ED (and beyond) from the outset, front-loading diagnostic and early treatment activity. A typical Rapid Assessment set-up might be:

  • Patients assessed as soon as they arrive by senior doctor and senior nurse
  • Investigation profile decided, based upon presenting complaint
  • Standardised investigation panel
  • Healthcare Assistant undertakes the required tasks
  • Point of care testing (POCT) utilised
  • Prescribed medications administered
  • Healthcare bundles commenced
  • Patients discharged home directly from Rapid Assessment where appropriate

Why are Rapid Assessment schemes useful?

Our entire EM system is designed to make people wait, with traditional triage merely being a “step to decide how long you should wait”. There are two points of access to the system (i.e. ambulance and self-presenters) and potential for inexperienced staff to order unnecessary investigations. The “patient journey” through even a relatively straightforward hospital admission is mind-boggling, and it’s estimated that one-third of healthcare expenditure is wasted on three items (Six Sigma devotees will recognise this mantra!):

  • Delays – having to care for people who do not need to be there (and, to make matters worse, delays breed more delays)
  • Defects – errors cost money by increasing length of stay and creating additional work – which introduces delays
  • Deviation – under-processing creates defects, whereas over-processing generates the expense of unnecessary tests (and creates more delays)

The caveats

So, we can see that front-loading experienced decision-makers to attempt to streamline ED processing makes sense for both patients and the system – “we’re moving the flurry of activity so often seen at 3 hours 30 minutes into the start of the four hours instead” – so why do attempts to provide this seemingly logical service so often fail? Paul explained that Rapid Assessment schemes are doomed to fail if they are seen as a luxury, asking the impossible, or when patient flow through the system is do poor that there’s basically no point. Trying to run a Rapid Assessment service with too few staff, not enough skill-mix/experience, inadequate equipment and inadequate outflow options will scupper your scheme from the outset.

And for those thinking that allocating a single senior doctor onto a Rapid Assessment shift will solve your departmental woes? Forget it – “… do not even start to think that one consultant on Rapid Assessment can hold back the tide. You’ll burn them out”. Similarly, the performance of Rapid Assessment nose-dives if a single consultant tries to “head chef” inside the ED and do Rapid Assessment at the same time … so forget that, too.

So having started with how not to run Rapid Assessment, here were Paul’s top tips for making it work:

Top tips from the expert

1. The right number of staff

In Paul’s own department, Rapid Assessment is largely delivered by experienced nurses, supported by senior doctors. Staffing is matched to demand, which is variable in amplitude but entire predictable: 4pm always sees more patients arriving than 4am. His rapid assessment nurses can process two Majors patients an hour, but at peak time as many as 10 Majors patients arrive each hour – simple maths dictates you need at least 5 members of the nursing staff to undertake rapid assessment at peak times. If you don’t resource Rapid Assessment adequately, you’ll just create another queue.

2. The right skill-mix

“Learners in the environment slow you down” – you must increase staffing levels to compensate. Jarvis suggested you require 25% more staff when you have learners (medical students, newly-qualified staff nurses, FY1/2 doctors or Core Trainees) within your team – a sobering challenge for many of us!

3. The right layout & equipment immediately to hand

Staff cannot be expected to do the job if the equipment is broken or they have to hunt for it – pay attention to room layout, and have a robust re-stocking system that ensure paperwork and kit never runs out.

4. “Never pass a defect down the line”

Works as well for processing a septic patient as for car manufacturing… give IV antibiotics as soon as the problem is identified!

5. Protocols need gatekeepers: the 80:20 rule of rapid Assessment

About 80% of cases are stereotypical, and can easily be managed (after rapid assessment) by a junior following a protocol, with the safety net of consultant sign-off. But 20% of cases are trickier. These atypical cases can’t be handled via protocols and need to be taken off-line with early involvement of consultants – “the last thing these patients need is a succession of doctors of increasing seniority with conflicting plans”.

6. Rapid Assessment is where POCT can pay dividends

Increasing POCT capability in your ED won’t magically reduce your length of stay within traditional processing models – but it can be very effective used with Rapid Assessment models.

7. Don’t de-skill your trainees

For seniors working in Rapid Assessment, don’t write down your diagnosis – instead your documentation should emphasise the presenting complaint, plus investigation profile. Otherwise you may leave your trainees feeling de-skilled.

8. Try to do it 24/7

If you don’t have consultants 24/7, then overnight consider using nurses supported by middle-grades

Why the NHS should listen and care more: Professor Rosalynd Jowett’s talk from RCEM15

The first speaker in the “End Game” session on Day One of RCEM15 (Monday 28th September) was Professor Rosalynd Jowett, a Board Member of the Patients Association. Rosalynd – a nurse by profession – is a Professor of Health Sciences at the School of Healthcare Sciences, University of East Anglia. From a personal viewpoint, I wasn’t really sure what to expect as I took my seat for this talk. I am uncomfortably aware that we often reduce the input of our “service users” to a token representative on project boards, and may only get to see what patients really think of our services when the Community Health Council periodically appear in the ED armed with clip-boards (or, increasingly, from comments on social media). I was completely unaware of the size, scale & influence of the Patients Association – whose President is Robert Francis QC (as in the Francis Report about Mid Staffs). The Patients Association aims to represent the voice of patients, carers and their relatives at a senior level, and to influence key health & social care policy, as well as managing a helpline and casework service, plus campaigning on health/social care issues that arise via the Helpline. They lobby at governmental level, and comment upon reports of interest to patients… which means, of course, just about anything to do with the NHS. The bulk of Professor Jowett’s talk concerned the findings of the joint RCEM/Patients Association report Time to Act – Urgent Care and A&E: the Patient Perspective which was published in early June this year. Based upon a large patient survey undertaken between September 2014 & February 2015, the survey asked patients who had used EDs and arrived under their own steam (ambulance patients were excluded) how they had come to be there. The findings make sobering reading for anyone who persists in thinking that campaigns like “Choose Well” do anything to reduce the British population’s love affair with Emergency Departments. Firstly, 39.2% had attended on the advice of another part of the healthcare system (including those who, it is suggested, could act to reduce ED attendances), whilst 7.2% attended on advice of friends, relatives or colleagues and 51.8% decided themselves to attend (interestingly, 1.8% said they “did not remember” – one hopes they paid more attention to the rest of the questions!) “A&E departments” (the terminology used by the survey) were the first choice for almost half of the respondents (47%) with GP surgeries being second (33%). And it was clear that patients opted not to wait very long before heading to the ED – most attended within a few hours of symptom onset and many chose to attend A&E despite being offered a prompt same-day appointment with their own GP. Nevertheless a “substantial proportion” of patients had symptoms for several days – even weeks – and yet still elected to attend the ED. We know from the RCEM Sentinel Site Survey that 15% of patients presenting to ED can be seen safely in the community (if appointments are available within 24 hours), and patients do regularly access GP and community services for urgent care… but many patients are reluctant to accept a wait of as little as three hours to see their GP when they perceive their care needs as urgent. The bottom line? Patients have confidence in UK Emergency Departments, and they value the convenience of the service. The “pull” of the “A&E superbrand” is so strong that redirection has repeatedly been shown to be ineffective. Patients are perfectly well aware of community alternatives to ED. They just don’t want to use them. From this report came the first calls for urgent care services to be co-located with Emergency Departments, a call that has now reached the stop of the current RCEM STEP campaign. And as for Choose Well? Based on what I took away from Professor Jowett’s talk, it’s clear that we just need to forget it. The patients aren’t for turning!

Sepsis SMACC-down panel.

This is a long one but worth it for broad concepts which are not discussed everyday. This panel comprises of the leading minds in sepsis research and information dissemination. It also demonstrates that we don't know as much as we think we know and are far from consensus on the subject even in 2015. 
Thanks to the SMACC team for the plenary panel vid.