# Presentation: 209848

## Spotlight Case February 2006

**Lost in Transition**

## Source and Credits

- This presentation is based on the February 2006 AHRQ WebM&M Spotlight Case
- See the full article at _[http://webmm.ahrq.gov](http://webmm.ahrq.gov/)_
- CME credit is available through the Web site
- Commentary by: **Christopher Beach, MD; Northwestern University**
- Editor, AHRQ WebM&M: Robert Wachter, MD
- Spotlight Editor: Tracy Minichiello, MD
- Managing Editor: Erin Hartman, MS

## Objectives

*	**At the conclusion of this educational activity, participants should be able to:*
- Provide an overview of transitions in continuously operating industries
- Review cognitive error
- Describe the complex dynamics of transitions in emergency care
- Provide suggestions to decrease risk at shift transitions

## Case: Lost in Transition

*	**A 41-year-old woman came to the ED with mental status changes. She had been diagnosed with a urinary tract infection and started on oral ciprofloxacin 4 days earlier. She had fever, nausea, and vomiting in the days preceding presentation. She did not have headache, focal weakness, or numbness. Past medical history was otherwise unremarkable. *

## 	On physical examination, the patient was afebrile, with sinus tachycardia (heart rate 123 beats per minute) and otherwise normal vital signs. Able to follow most commands, she was alert but oriented to person and place only. Neurologic examination was otherwise non-focal. There were no signs of meningeal irritation. 

**Case (cont.): Lost in Transition**

## 	Approximately 40 minutes after the patient arrived, initial laboratory results returned, and included: white blood cell count 12.7 K/μL with 89% granulocytes; hematocrit 20.2%; glucose 204 mg/dL; blood urea nitrogen 36 mg/dL; serum creatinine 1.4 mg/dL. Urinalysis showed moderate blood. Platelet count was pending at that time.

**Case (cont.): Lost in Transition**

## 	Sixty minutes after arrival, the patient was admitted to the internal medicine service with a diagnosis of anemia and hematuria in the setting of a urinary infection. The medicine team completed the admission paperwork, with plans to administer empiric broad-spectrum antimicrobial agents and packed red blood cells for the severe anemia. 

**Case (cont.): Lost in Transition**

## 	The outgoing ED physician had just completed the shift, and signed the patient out to the oncoming colleague as “admitted,” with care already transferred to the internal medicine service.

**Case (cont.): Lost in Transition**

## Transitions in Care

- Shift change over
- Two or more workers exchange mission-specific information, responsibility, and authority for an operation
- Poses opportunity for rescue and risk of error
- Potential for either increases with number of workers involved

*Lardner R Health and Safety Executive. June 1996.**Wears RL, et al. Human Factors and Ergonomics Society 47th Annual Meeting; 2003.*

## Emergency Department Transitions

- Geography dictates starting and stop point
- Interruptions are frequent
- Physician sign out generally separate from nursing sign out
- Chart rarely used

*Perry S. Focus Patient Safety. 2004;7:1-3. *

## Emergency Department Transitions

- May occur at bedside or in remote location
- May be interactional or transactional
- Must be brief and complete

*Perry S. Focus Patient Safety. 2004;7:1-3.   *

## Phases of ED Transitions

- Pre-turnover
- Arrival
- Meeting period
- Post-turnover

*Matthews AL, et al. Human Factors and Ergonomics Society 46th Annual Meeting; 2002.  *

**Notes:**
5. Matthews AL, Harvey CM, Schuster RJ, Durso FT. Emergency physician to admitting physician handovers: an exploratory study. Proceedings of the Human Factors and Ergonomics Society 46th Annual Meeting; September 29-October 4, 2002; Baltimore, MD. 

## High Reliability Organizations (HROs)

- Organizations or systems that operate in hazardous conditions but have fewer than their fair share of adverse events
- Air traffic control systems, nuclear power plants, naval aircraft carriers

*High Reliability Organizations. AHRQ WebM&M Glossary. *

## Effective Transition Models

- Nuclear submarines
- Precise, unambiguous, impersonal, and efficient language used by officer and sonar tech for navigation
- Trauma centers
- Acknowledgment and action, ensuring situation awareness

*Xiao Y, Moss J. Human Factors and Ergonomics Society 44th Annual Meeting; 2000.  *

**Notes:**
9. Xiao Y, Moss J. Practices of high reliability teams: observations in trauma resuscitation. Proceedings of the Human Factors and Ergonomics Society 44th Annual Meeting; July 30-August 4, 2000; San Diego, CA. 

## Transition Techniques Used by HROs

- Verbal, face-to-face interactive questioning coordinated with written summaries
- Read back
- Limits on interruptions
- Unambiguous transfer of responsibility
- Pre-turnover data scans

*Patterson ES, et al. Intl J Qual Health Care. 2004;16:125-132.*

## Case (cont.): Lost in Transition

*	**Four hours after arrival, the lab called the ED to report a critical lab result, a platelet count of 4,000/mm3 (normal range 150,000 to 400,000). The critical result was received by the ED unit secretary. It is unclear who this information was passed on to, but neither the ED attending nor the internal medicine service was made aware of it. *

## Case (cont.): Lost in Transition

*	**Sixteen hours after the patient presented to the ED, the internist noted the abnormal finding when checking the morning lab data. She diagnosed thrombotic thrombocytopenic purpura (TTP). The patient was transferred to the ICU due to progressive deterioration in mental status, and was eventually intubated. Hematology initiated emergent plasma exchange to treat TTP. *

## What Went Wrong

- TTP is rare, but is fatal in 90% of cases left untreated
- Delay in plasma exchange due to
- Breakdown in communication of serious lab abnormality
- Lack of recognition of clinical entity

*Rose BD, George JN. UpToDate Online 13.3. **Terrell DR, et al. J Thromb Haemost. 2005; 3:1432-1436.*

## Failure to Identify Serious Laboratory Abnormality

- Most desirable method to deliver critical lab results is direct face-to-face communication
- Indirect methods also used
- Overhead page, text message, email alert, written documentation
- Method must be coupled with shared interpretation of what constitutes critical result

## Communication Failures: Three Categories

- System
- Communication channels are used infrequently, are non-functional, or are non-existent
- Message
- Poor or non-existent transfer of information
- Reception
- Misinterpretation or late arrival of proper information

*Reason JT. Aldershot, Hampshire, England: Ashgate; 1997:135.**Van Eaton EG, et al. Surgery. 2004;136:14-15.**Patterson ES, et al. Human Factors and Ergonomic Society 49th Annual Meeting; 2005.  *

## Failure to Reach Correct Diagnosis

- Pre-turnover stage
- Clinicians content with diagnosis of urinary tract infection for explanation of mental status change, contradictory evidence set aside
- Demonstrated anchoring bias

*Anchoring Error. AHRQ WebM&M Glossary. *

## Failure to Reach Correct Diagnosis

- Meeting stage
- It was unclear who was responsible for follow-up and interpretation of results for this patient
- Post-turnover
- Clinicians did not reconsider diagnosis of UTI with mental status change and anemia
- Suffered from a framing effect

*Croskerry P. Acad Med. 2003;78:775-780.*

## Case (cont.): Lost in Transition

*Despite these interventions, the patient’s status continued to deteriorate. The patient died the following day, within 48 hours of presentation to the ED.*

## Improving Transitions

- Reduce transitions when not necessary
- Assure clear delineation of authority and responsibility at times of transition
- “Dr. Smith, please check the platelet count, it is currently pending.”
- When possible use discrete end-points, simply communicated
- “If the platelet count returns below 30,000, call hematology.”

## Improving Transitions

- Describe symptoms and ancillary studies to support interpretations; use diagnoses only when clearly supported
- Say: “This patient has recently been treated for UTI and presents with mental status change, hematuria, and anemia...”
- Instead of: “This patient has UTI and anemia.”
- Encourage and accept cross-collaborative feedback and questioning

## Improving Transitions

- Transition should be observed and taught to students before they become transition leaders
- Limit interruptions; if necessary, delay transfer of responsibility
- Use written and verbal tools to augment transfer knowledge