Handoffs in Medicine

Patient safety is crucial for the delivery of effective, high-quality healthcare¹ and is defined by the World Alliance for Patient Safety of WHO as ‘the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum’. The practice and delivery of healthcare is argued to be fundamentally and critically dependent on effective and efficient communication. Depending on physicians’ needs and responsibilities, handoff content will vary, requiring customization by individual physician groups; there is no “one size fits all” content.

Communication

Communication in healthcare: a narrative review of the literature and practical recommendations. Int J Clin Pract. 2015 Nov;69(11):1257-67. doi: 10.1111/ijcp.12686. Epub 2015 Jul 6.

Standardization of Inpatient Handoff Communication. Pediatrics. 2016 Nov;138(5):e20162681. doi: 10.1542/peds.2016-2681.

Communication at Transitions of Care. Pediatr Clin North Am. 2019 Aug;66(4):751-773. doi: 10.1016/j.pcl.2019.03.004.

Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ Open. 2018 Aug 23;8(8):e022202. doi: 10.1136/bmjopen-2018-022202.

Cardiac Surgery

Standardization improves postoperative patient handoff experience for junior clinicians. Am J Manag Care. 2020 Jun 1;26(6):e184-e190. doi: 10.37765/ajmc.2020.43494.

A standard handoff improves cardiac surgical patient transfer: operating room to intensive care unit. J Healthc Qual. Jan-Feb 2015;37(1):22-32. doi: 10.1097/01.JHQ.0000460123.91061.b3.

An Implementation Science Approach to Handoff Redesign in a Cardiac Surgery Intensive Care Unit. Ann Thorac Surg. 2020 Jun;109(6):1782-1788. doi: 10.1016/j.athoracsur.2019.09.047. Epub 2019 Nov 9

A Partially Structured Postoperative Handoff Protocol Improves Communication in 2 Mixed Surgical Intensive Care Units: Findings From the Handoffs and Transitions in Critical Care (HATRICC) Prospective Cohort Study. Ann Surg. 2020 Mar;271(3):484-493. doi: 10.1097/SLA.0000000000003137.

Assuring Sustainable Gains in Interdisciplinary Performance Improvement: Creating a Shared Mental Model During Operating Room to Cardiac ICU Handoff. Pediatr Crit Care Med. 2017 Sep;18(9):863-868. doi: 10.1097/PCC.0000000000001231.

Face-to-face handoff: improving transfer to the pediatric intensive care unit after cardiac surgery. Am J Med Qual. Mar-Apr 2015;30(2):119-25. doi: 10.1177/1062860613518419. Epub 2014 Jan 17.

AnesthesiologyNews: Handovers During Cardiac Surgery Can Increase Mortality, Aug 2021.

Nurses & Shifts

Shift-to-Shift Handoff Effects on Patient Safety and Outcomes. Am J Med Qual. Jan/Feb 2017;32(1):34-42. doi: 10.1177/1062860615612923. Epub 2016 Jul 9

Nurse Handoff Communication. Semin Oncol Nurs. 2017 Dec;33(5):536-543. doi: 10.1016/j.soncn.2017.10.002. Epub 2017 Oct 26.

The Bad Guys in Healthcare Aren’t Who You Think They Are — Doctor Enough

I’m going to take a stand on something that really gets my blood boiling… health insurance companies. People want to blame physicians for bad outcomes (I’m looking at you NRA supporters that are claiming we, as physicians, need to fix our own lane first). They want to blame hospitals for long wait times, they want […]

via The Bad Guys in Healthcare Aren’t Who You Think They Are — Doctor Enough

Paid Maternity Leave

I had just written a response to a partner’s email regarding outpatient coverage and the focus of work-life balance. I think it’s a great initiative that she is tackling while brainstorming what could help the group with flexibility as well as some normalcy while raising a family.

** Please take this brief survey on maternity leave **

This made me think of changes to antiquated practices we currently have in our work environment… primarily, paid maternity leave as well as paid sick leave. Many of my male colleagues can continue to work and can take as little or much leave as they would like for family bonding or vacation time to spend with their newborns. This is their option. Unfortunately, the women physicians in our group are not afforded that same luxury. There is a 6 week medical leave of absence with a vaginal delivery or an 8 week leave of absence with a C/S as proposed by the OBs. During this time, we are not paid. State disability is a joke bc it’s not even enough to cover a mortgage payment. Look at other large companies, there’s often paid leave or sick leave available to the employees. Therefore, women who choose to have kids while working as a physician in our group are penalized, especially if they are the breadwinner.

Not only that, even while off on medical leave, we are required to pay into the trust and pay ridiculously high premiums to cover the wide age gap of partners in our practice. I would be happy to look elsewhere for my medical coverage, but I simply cannot come off our medical insurance plan.

Therefore, I propose there be a fund set aside to create a pool or trust for persons creating families (just as we do for our more distinguished and elderly physician population with our health insurance plans and exorbitant premiums) who will have families and work in our group.

Here are some examples in the news of what is and has been in the pipelines….

Amer Acad of pediatrics

Paid Family Leave

NPR

Here are examples of companies getting it right:

Fairy God Boss

Glass Door

Sick Leave

Please consider updating some or all of the policies for paid maternity leave. I am open to your thoughts and considerations.

Poll on Maternity Leave

What it’s like to be a female anesthesiologist…

Responsibility for your own health

I was shocked to see that the NHS could ban surgery for the obese and smokers. That’s socialized medicine. You take a conglomerate group of people (the UK) on a limited budget for healthcare… and basically find the cheapest most cost-effective way to deliver healthcare. But in a way, it’s empowering patients to take responsibility for their own health. Smoking, for sure — I agree 100% that surgery should be banned for this population. Obesity is a bit trickier — there’s genetics and environmental factors at play in this one. I don’t think anyone chooses to be obese. But, people do have the power to change their eating and exercise habits. Despite these efforts, there are some people who are still obese…. and these people should not be faulted.

Why single out the obese and smokers?

obesity-and-cv-disease-1ppt-44-728 — From SlideShare

obesity-and-cv-disease-1ppt-43-728 — From SlideShare

tobacco-health-statistics — From TobaccoFreeLife.org

Smokers and the obese have elevated surgical risk and mortality, which means more cost to treat and hospitalize and provide ongoing care.

I think the NHS is on to something here. They’re opening doors to moving the liability and responsibility away from physicians and towards patients. This is a plus. Outsiders may see it as separatism and elitist to only provide care for people who are healthy. But look at the facts and the data…. obesity has a lot of co-morbidities associated. Smoking has a lot of co-morbidities associated as well. Why should physicians be penalized for re-admissions, poor wound healing, longer hospitalizations when the underlying conditions themselves are already challenging enough? In fact, I would urge insurance companies to provide incentives to patients/the insured with discounted rates for good and maintained health and wellness. With all the technologies, medications, and information out there, it’s time patients take responsibility for their own health. I take responsibility for mine — watching my diet, exercising, working on getting enough rest, maintaining activities to keep my mind and body engaged, meditating for rest and relaxation. It’s not easy, but my health is 100% my responsibility. I refuse to pass the buck to my husband, my family, my physician, etc. I do what I can to optimize my health and future — and if that doesn’t work… I call for backup.

Patients need to change their mindset re: health. It is not your spouse’s responsibility to track your meds. It is your responsibility to know your medical conditions and surgical history. The single most important (and thoughtful) thing a patient can do is keep an up-to-date list of medications, past/current medical history, surgical history, and allergies to bring to every doctor’s appointment and surgery. This helps streamline and bring to the forefront your conditions and how these will interplay with your medical and surgical plan and postoperative care. Please do not forget recreational drugs, smoking habit, and drinking habit in this list. It is very important to know all of these things. Also, your emotional history is very important. Depression, anxiety, failure to cope, etc. This all helps tie in your current living situation with stressors and your medical history.

Links for educating yourself in taking responsibility for your health:

Responsibility for your own health

Why single out the obese and smokers?

Smokers and the obese have elevated surgical risk and mortality, which means more cost to treat and hospitalize and provide ongoing care.

Links for educating yourself in taking responsibility for your health:

The physician anesthesiologist vs. CRNA debate

Why is this even a debate?

It seems to me that the CRNA-led debate is financial… once you tease through all the fluff.

So here’s some literature I found:

Evidence-based review did NOT find nurse anesthetists’ care equal to that of physician anesthesiologists
Unsupervised anesthesia care by a nurse anesthetist is a threat to patient safety
Anesthesiologist Direction and Patient Outcomes
Is Physician Anesthesia Cost-Effective?
I chose not to include biased studies where sick patients were not compared as well as morbidity and mortality.

As an anesthesiologist, I work in an MD-only anesthesia group. This is by choice: I prefer doing my own cases and being responsible for my own liabilities. The times I have required an anesthetic, I have requested a physician anesthesiologist. As a resident, I had very good insurance coverage, so I wanted a physician for my surgery. At that time, I was ok with having a resident anesthesiologist paired with an attending anesthesiologist for my case. My second surgery was done at my current hospital, and we only have MD anesthesiologists. Perhaps I’m biased? I know and I understand the path/journey/training it takes to get to become a physician anesthesiologist. I want someone who is well-trained, independently thinks, vigilant, and knowledgeable.

I’m sure there are great CRNAs out there… but when I was a resident… we used to supervise CRNAs in our final training year…. and it was scary some of things they would do. Who extubates from a trach R&R on 30% FiO2? Yeah, that particular CRNA told me they had 30 years experience. 30 years experience of doing something wrong doesn’t equate to 30 years of knowledgeable experience. And let’s not forget that CRNAs need a 15 minute morning break, 30 minute lunch break, and 15 minute afternoon break and they go home when their “shift” ends (even if it’s in the middle of a complex case). I take a break when I can… I eat lunch and take a bathroom break when I can…. and I choose to stay and finish complex cases for better continuity of care.

Would you want a nurse practitioner or physician assistant solely performing your surgery without a surgeon? I know I would NOT. I think there’s plenty of room for teamwork in healthcare. This is how to improve hospital efficiency and patient care. My fear is if CRNAs gain independence for purely financial reasons. But then, they will have to carry their own liability, cover their own breaks, take night call and discover that they had it so good in a healthcare team.

Opinions from other physician anesthesiologists:

Bottom line in my opinion:

Physicians endure years of grueling medical education that starts with the why, how, and treatment of disease. This is followed with years of residency training specifically in anesthesia. There’s also further training in the form of a fellowship for specialized fields.
Getting into medical school is an extremely competitive process. You take the top 1% of college graduates and high MCAT scores to get into medical school. The board certification for becoming certified in anesthesiology is quite complex and difficult in both the written and oral board exams.
I will continue to be FOR team-based physician-led anesthesia care.

The healthcare debate

Here it is. I didn’t want to opine, but it’s here and I can’t get away from the topic. I see it at work. I watch it at home. It comes up in discussions… so in order to make it stop, I’m going to give you an idea of what I see and what I think about Obamacare and whatever else is out there.

April 2015

Public Integrity: Insurers backed Obamacare, then undermined it. Now they’re profiting from it.

February 2016

Talking Points Memo: The real reason insurance companies are complaining about Obamacare

August 2016

CNN: Will Obamacare survive as insurers pull out?

October 2016

Salon: Making a killing under Obamacare: The ACA get blamed for rising premiums, while insurance companies are reaping massive profits

November 2016

Portland Press Herald: Maine Voices — The problem isn’t Obamacare; it’s the insurance companies

December 2016

NYT: Health insurers list demands if affordable care act is killed

The Huffington Post: The Obamacare paradox — The real reason health insurance companies don’t like the ACA

January 2017

Market Watch: I’m a former health insurance CEO and this is what Obamacare repeal will do.

Great Z’s: Liberals are out of touch

March 2017

LA Times: Here’s the secret payoff to health insurance CEOs buried in the GOP Obamacare repeal bill

Common Dreams: Why big insurance adores the American Healthcare Act

What I see:

When Obamacare was initiated, I recall seeing a patient who had broken her foot while hiking locally. She had a surgeon who was covered under Obamacare, as well as an anesthesiologist. However, the hospital chose not to accept Obamacare and she had to pay out of pocket for her overnight stay.

It seems that we’re seeing more and more insurance companies pulling out of the system because it doesn’t seem to be profitable for them. Insurance companies are a business; they’re not looking after the wellbeing of the patient. Physicians, nurses, caretakers, the care team look after the wellbeing of the patient.

How many people do you know are satisfied with their insurance coverage?

I’m covered by Anthem on a PPO plan with about 240 physicians. My insurance rate is lousy for the coverage I receive — a high deductible plan. I’m young and healthy and take responsibility for my health — why am I paying $620/mo for barely there medical coverage as a physician? Well, the answer is that our company makeup is a majority of older partners who skew the coverage toward a higher premium — basically a mini-Obamacare environment. I’m subsidizing their health coverage… and someday, hopefully I will still be healthy bc I’m responsible for my health (keypoint right there folks) and doing everything I can now to give my body the best fighting chance to survive into “old” age.

My question:

Anyone think to make insurance companies accountable with transparency re: ACA? Start there. Does anyone else think it’s odd that the people who are helping shape the bill don’t actually participate in the care/exchanges like the public? All the while, government and insurance companies dictate coverage and force physicians into tougher situations to deliver care. Is this what you (the public) want? When was the last time you saw the fine print of the bills being passed? Don’t just follow the masses, look for the details and truth for yourself.

</off soapbox>

What government officials have for insurance:

Oppose AB 72 #politics #healthcare #anesthesia

Subject: I’m strongly “Opposed” to AB 72 (Bonta).

As a physician anesthesiologist, I routinely treat patients during life’s most difficult and uncertain moments, often in life-sustaining surgeries. I agree that patients should not be surprised by out-of-network charges that can arise during these difficult times.

However, AB 72 (Bonta) shifts the onus of arranging for patient care from health plans and insurers onto physicians like me who might not be able to reach contract agreements with health care services plans and insurers.

As such, I’m concerned the net effect of this bill will be to disincentivize health plans and insurers from negotiating fair payment arrangements with physicians and building adequate provider networks.

Moreover, AB 72 (Bonta) requires physicians to be responsible for appealing, then arbitrating compensation disputes…a losing battle and a time consuming process that takes time way from our practice…time better spent caring for our patients.

Most troubling of all, this bill undermines my right to negotiate a fair contract with health plans and insurers by statutorily imposing on me payments that another physician has accepted as the value of their services. Contracted rates of payment already represent substantial discounts to usual and customary market rates. AB 72 (Bonta) will rapidly force a spiral of even lower rates (driven by health plan and insurers) leading to even more restricted provider networks and further reduce access to quality health care for all Californians.

Suggested amendments by the California Medical Association that would have removed our opposition have been summarily rejected by the author and sponsor. Therefore, I strongly urge your “NO” vote on AB 72 (Bonta).

The anesthesiologist vs. CRNA debate ends here.

This website defines the essence of physician care in the field of anesthesiology. Want to know what separates an anesthesiologist from an anesthetist? Check out the link. Plus, it lists tips on what to ask and what to bring for your upcoming surgery.

http://www.doctorbyyourside.org/Get-The-Facts.aspx

My own thoughts on this debate