Background:
Inpatient physicians frequently transfer patient information to cross‐covering physicians. Although there is an increasing interest in formalizing this information transfer, there is little scientific information about the types of problems that cross‐covering physicians are asked to address, or which types of information they need to efficiently solve them.
Method:
We performed a standardized observation of a series of cross‐cover events in a large University Hospital using a structured observation tool.
Summary of Results:
263 cross‐cover events were observed.
The average time spent handling a cross‐cover event was 5 minutes. However, over 15 minutes was required in 10.5% of the events. Cross‐covering physicians consulted information sources other than the nursing staff and the written signout in 39.2% of the events, including online information, the paper chart, or other people (e.g. another physician, the patient, the family, etc.). The written signout was felt to be inadequate in 23% of the cases, and 25.9% of the events resulted in frustration on the part of the cross‐covering physician.
There were 297 individual triggers identified for these events. The triggers could be organized into several general categories, including specific patient symptoms (22.6%), abnormal vital signs (16.2%), medication questions or clarifications (15.2%), IV access issues (7.4%), and diet, nutrition, or maintenance fluid issues (6.7%).
The cross‐covering physicians made 99 suggestions regarding other information that should have been provided to them. These included requests for more information regarding the patient's recent status/ relevant background information (42.4%), medications (21.2%), the medical plan (11.1%), and IV access issues (7.1%).
In 59.3% of the events there was at least one test ordered or medication changed. Even in the events where neither of these occurred, some medical decision‐making was often required. Certain classes of medications were frequently modified by cross‐covering physicians, including analgesic, sedative, antiemetic, and antihypertensive medications.
Statement of Conclusions:
Cross cover events appear to occur in response to a somewhat predictable set of triggers. From our analysis, we conclude that the handoff process for medical inpatients should include the following: (1) Essential background information; (2) An updated list of the patient's active problems with substantial detail about the plan and current status for each; (3) Specific guidance for dealing with anticipatable problems, especially those problems that represent frequent cross‐cover triggers (e.g. IV access issues, pain, nausea, fever, abnormalities in other vital signs, dietary and fluid status); and (4) A complete list of current medications and drug allergies, along with additional, specific comments about selected medications.
Author Disclosure Block:
D.H. Wesorick, None; M. Kramer, None; M. Cohen, None; R. Mangrulkar, None; L. Fiona, None; V. Parekh, None; E. Yakel, None; M. Thompson, None; S. Lim, None; R. Hsu, None.