Over the past 25 years since I have practiced nephrology one
thing that seems to have changed for the worse is the
fragmentation of care. In a typical academic medical center, hand-offs represent one of the largest sources of fragmentation and discontinuity. There are a multitude of potential hand-offs: one team handing a
patient over to another, the internist handing off to the hospitalist or nocturnalist
(and back), the "night-float" resident to the day time shift resident, and from weekday to
weekend hand-off's. The number of hand-offs that might occur in a patient’s stay in
the hospital can be quite astounding.
I came across a blog piece by Mathew Weinstock in Hospitals and Health Networks (H&HN) that reinforces the notion that hand-off’s can lead to worse outcomes. Writes Weinstock:
“The Joint Commission estimates that 80 percent of serious medical errors involve miscommunication between caregivers when a patient is handed off or transferred between care settings. Miscommunication was also the leading root cause of sentinel events reported to the commission between 1995 and 2006. That's partly why the Joint Commission's Center for Transforming Healthcare initiated a project aimed at helping hospitals improve transitions of care.”
Digging more deeply into the issue of hand-off’s I came
across a really terrific article by Lee Ann Runy (also in H&HN) that is definitely worth a read because it provides pragmatic recommendations about improving the hand-off. There is also a terrific powerpoint presentation on hand-off's that's worth looking at.
The bottom-line is that bad hand-off’s lead to medical
errors and whether we like it or not doing a good hand-off is now a part of
being a doctor!
Hand-offs from one medical team to another is relative. An internist handing off to a hospitalist is far different from an internist handing off to a specislist like a nephrologist. I detest hospitalists who are unfamiliar with the patient, but asts if they know everything about the patient and often orders test or procedures totally inappropriate.
ReplyDeleteHowever, what is defitiely worse is when a nephrologist hands off their resposibilities to a provider. It has become commnplace that the provider has become the decionmaker in then therapy of the dialysis patient. This is no better exemplified by the prescribing of meds. What has typically become the practice is the provider determines what each patient should be given when when a particular pharmaceutical is paid for through the bundle. It is the provider that signs the purchasing agreements for the ESA's. It is the provider that determines the analog "D" and iron. And it will be the provider that purchases the phosphate binder and calcimimedic beginning in 2014.
Is there a better example than DaVita entering into a seven year contract with Amgen that stipulates 90% of its ESA usage will be EPO. I'm a firm believer that what might be better for one patient is not necessarily better for another. The choice of one drug over another should not be the decision of the dialysis provider, but that of the nephrologist and patient. Nephrologists have ceded too much of their responsibilities to the provider to the detriment of the patient. That has led to the corporate practice of medicine and should be ruled as illegal wherever it is practiced.