Lee A. Resnick, MD, FAAFP
According to the 2012 Benchmarking Survey from the Urgent Care Association of America, about 4% of urgent care patients are referred to an emergency department (ED) for ongoing care. Some get there by personal vehicle, and others are transferred by emergency services, private ambulance, or other critical-care transportation. Given an average patient volume of 40 patients per day for a single urgent care center, that is 1.5 ED transfers per day. Every day, we are involved in emergency hand-offs, yet not much has been reported about how well we are doing. It is well known that effective communication is critical to the quality and safety of patient-care hand-offs.
Although most urgent care centers have electronic medical records, very few of these are linked to local and regional hospitals. That means all communication about transfers is done by phone, written discharge instructions, or, more frequently, not at all. How did we get here? What has transpired to create such a gaping hole in emergency-care coordination? What can be done to fix this mess?
Three main stressors contribute to poor communication during urgent care to ED transfers: poor professional relationships and culture, work-flow and productivity issues, and inadequate resources and directives.
Poor Professional Relationships and Culture
We have all been the victims of berating and condescending ED physicians, and quite frankly, such a situation is likely to be the largest contributor to communication failures. In an effort to protect ourselves, we simply do not call unless we feel it is absolutely necessary. For example, a patient with abdominal pain whom you determine needs a computed tomography scan and a surgical consult is stable at the time of transfer. You anticipate a barrage of questions and second-guessing from the ED physician that produce no benefit for anyone, including the patient. Instead, you print your note and discharge instructions clearly documenting your reason for transfer. Now it is the hospital’s risk to bear if no one there follows through on your recommendations. To add insult to injury, the ED staff members take great pleasure in telling patients: “That urgent care doesn’t know what it’s doing.” To be honest, we have all taken very little time and completed very little training in transfer communication skills, and we could probably do a better job if we developed this skill. Or perhaps the whole relationship is just too broken to fix.
Work-Flow and Productivity Issues
It has become increasingly difficult to take the time necessary for effective transfer communication. Both the ED physician and the urgent care practitioner are simply too busy. Treating 40 to 50 patients per day requires such an efficiency of flow that even 1 or 2 transfers can completely disrupt the day if we are not careful. These patients have already consumed limited resources and time, and the urgent care physicians can ill afford to spend more. Likewise, the ED physicians are overworked and understandably distracted by patients in critical condition. There is a palpable “this had better be good” tone in their voices whenever they pick up the phone. Everyone loses in this scenario.
Inadequate Resources and Directives
Many large health-care systems have transfer command centers, but such vital resources are still somewhat limited in community hospitals and rural settings. This leads to massive gaps in communication unless the urgent care physician takes the time to inform all parties about the transfer. Making matters worse, most hospitals lack specific policies and expectations regarding transfer communications. This confusion exacerbates the already strained relationships between most urgent care centers and EDs.
It is in everyone’s interest to develop effective solutions. Any improvement should have a considerable impact on quality, safety, risk, and our relationship with our emergency medicine colleagues. In my next column, I will discuss the specific steps necessary to achieve dynamic results.