Presentation
PS12 - Patient Disposition: A Measure of Physician Caseload During ED Patient Handoffs
DescriptionBackground:
Patient handoffs are well known to be a critical point in patient care based on their propensity for communication errors (Arora and Johnson, 2006). Additionally, increased physician workload has been associated with decreased performance and patient safety in emergency settings. Regularly occurring inter-shift patient handoffs represent immediate transfers of patient caseload between physicians that may contribute to the overloading of emergency physicians. However, despite this claim, there is minimal research providing objective measures to evaluate patient handoffs in terms of the workload involved and their effects on physician performance. One integrative literature review of nursing handoffs found that “the overall quality of the quantitative studies to date for medical and surgical units is low” and called for improvements in the research design of such studies (Staggers & Blaz, 2013). One challenge in evaluating handoffs lies in the lack of clearly defined characteristics that could lend themselves to objective and/or quantitative measurement.
An aspect of patient handoffs that has been underutilized in ED handoffs literature is the state of patient disposition at handoff. A patient’s disposition is their intended destination within the patient care pathway which is often either admitted to the hospital as an inpatient for further treatment, transferred to a separate medical facility for further treatment, or discharged from the ED, commonly with plans for follow-up outpatient treatment. Disposition has been well established as a keystone element of emergency physician workflows and a primary goal of emergency medical care. Many studies have evaluated the importance of patient disposition in hospital EDs, yet research pertaining to patient handoffs in the ED scarcely mentions the importance of patient disposition in physician communication and decision-making during handoff. However, there are no studies that have explored the role of varying patient dispositions among patients handed off as a measure of caseload transferred.
Purpose Statement:
The study focuses on defining patient disposition categories as a step towards quantifying caseload, as a measure of workload transferred between physicians across shifts. We present a mixed methods study including observations, interviews with emergency physicians, and statistical analysis of emergency department (ED) patient data to validate the use of the state of a patient’s disposition as a measure of the caseload transferred during inter-shift patient handoffs.
Methods:
Eighteen patient handoffs were observed, with 152 patients that were handed off included in data analyses. Interviews, pertaining to physician workflows and patient handoffs with specific emphasis on the importance of patient disposition in emergency medicine, were conducted with 11 emergency physicians and remain ongoing. The “state of patient disposition” index is categorized as a 5-point scale designed with consultation from Prisma Health emergency physicians. The state of patient disposition index is defined as follows: Category 1 – Disposition Unknown, Category 2 – Disposition Pending, Category 3 – Disposition Expected, Category 4 – Disposition Assigned, Category 5 – Disposition Assigned and Patient Boarding. During observations, researchers used contextual patient information provided during each handoff to index patients based on the state of their disposition as presented by outgoing physicians. Patient indexing was then evaluated through statistical analyses of ED patient data (time until disposition and time until departure) provided by the health system to identify differences between disposition categories and quantify the total caseload (patient related decision-making) transferred during handoff.
Results:
Results from the physician interviews show that disposition is a keystone goal in emergency physicians’ regular workflows. Furthermore, physicians categorized patients who are handed off as either “active sign-outs” or “non-active sign-outs” where active sign-outs are patients who have not been assigned dispositions and non-active sign-outs are patients who have been assigned dispositions. Analysis of variance (ANOVA) was used to compare state of patient disposition index categories using (1) the time elapsed between handoff and disposition assignment and (2) the time elapsed between handoff and departure from the ED. Results show that state of disposition index categories have significant differences in time until disposition (p < 0.001) while time until departure did not yield significant differences between categories. Moreover, results show that “active sign-outs” (defined as category 1, 2, and 3 patients) have reduced times until disposition (p < 0.001) and until departure (p < 0.05) when compared to “non-active sign-outs” (category 4 and 5 patients).
Discussion:
Findings show that the state of patient disposition at handoff demonstrates a significant difference in time until disposition decision while the active and non-active sign-out labels provided by the emergency physicians differentiates both time until disposition and time until departure for patients. This mirrors the findings of previous studies that describe the process of dispositioning patients as “cognitively loading” (Calder et al., 2012) as it is clear physicians are responsible for making disposition-related decisions and making patient care actions for longer periods of time for active sign-outs than non-active sign-outs. This relationship supports future work that examines the relationship between physician caseload and physician workload, as the disposition-related decisions may be best represented as a form of cognitive workload.
Systematic literature reviews examining patient handoffs have often called for more rigorous quantitative evaluation methods that can be applied to proposed interventions (Riesenberg et al., 2010; Staggers & Blaz, 2013). This work strives to address this gap in the literature and proposes a method of utilizing physician workload (measured as the state of patient disposition transferred at handoff) to evaluate patient handoffs. Again, studies examining disposition have emphasized the importance of disposition in the ED workflow (Calder et al., 2012; Heilman et al., 2016), however there is a fundamental disconnect between the ED patient disposition literature and the ED handoff literature. Studies evaluating patient disposition have primarily focused on creating models that predict patient dispositions in triage (Sterling et al., 2019) or investigated differences between physicians of various demographics in their dispositioning practices (Li et al., 2016). Meanwhile, research pertaining to patient handoffs extensively focus on standardization protocols (Campbell & Dontje, 2019; Chladek et al., 2021; Dhingra et al., 2010; Heilman et al., 2016) and the usage of overarching ED metrics such as patient length of stay and patient mortality to evaluate handoff interventions (Dahlquist et al., 2018; Denson et al., 2015). Ultimately, this study aims to utilize a keystone aspect of ED patient handoffs, the state of patient disposition, to provide an objective measure of caseload that can evaluate the quality of handoff-interventions, like the standardizations presented in prior work.
Conclusion:
This study demonstrates that the state of a patient’s disposition during shift change can be used to measure the patient caseload transferred between emergency physicians during handoffs. Indexing patients by disposition provides a basis for future work that evaluates the cognitive workload transferred between physicians during patient handoffs.
Patient handoffs are well known to be a critical point in patient care based on their propensity for communication errors (Arora and Johnson, 2006). Additionally, increased physician workload has been associated with decreased performance and patient safety in emergency settings. Regularly occurring inter-shift patient handoffs represent immediate transfers of patient caseload between physicians that may contribute to the overloading of emergency physicians. However, despite this claim, there is minimal research providing objective measures to evaluate patient handoffs in terms of the workload involved and their effects on physician performance. One integrative literature review of nursing handoffs found that “the overall quality of the quantitative studies to date for medical and surgical units is low” and called for improvements in the research design of such studies (Staggers & Blaz, 2013). One challenge in evaluating handoffs lies in the lack of clearly defined characteristics that could lend themselves to objective and/or quantitative measurement.
An aspect of patient handoffs that has been underutilized in ED handoffs literature is the state of patient disposition at handoff. A patient’s disposition is their intended destination within the patient care pathway which is often either admitted to the hospital as an inpatient for further treatment, transferred to a separate medical facility for further treatment, or discharged from the ED, commonly with plans for follow-up outpatient treatment. Disposition has been well established as a keystone element of emergency physician workflows and a primary goal of emergency medical care. Many studies have evaluated the importance of patient disposition in hospital EDs, yet research pertaining to patient handoffs in the ED scarcely mentions the importance of patient disposition in physician communication and decision-making during handoff. However, there are no studies that have explored the role of varying patient dispositions among patients handed off as a measure of caseload transferred.
Purpose Statement:
The study focuses on defining patient disposition categories as a step towards quantifying caseload, as a measure of workload transferred between physicians across shifts. We present a mixed methods study including observations, interviews with emergency physicians, and statistical analysis of emergency department (ED) patient data to validate the use of the state of a patient’s disposition as a measure of the caseload transferred during inter-shift patient handoffs.
Methods:
Eighteen patient handoffs were observed, with 152 patients that were handed off included in data analyses. Interviews, pertaining to physician workflows and patient handoffs with specific emphasis on the importance of patient disposition in emergency medicine, were conducted with 11 emergency physicians and remain ongoing. The “state of patient disposition” index is categorized as a 5-point scale designed with consultation from Prisma Health emergency physicians. The state of patient disposition index is defined as follows: Category 1 – Disposition Unknown, Category 2 – Disposition Pending, Category 3 – Disposition Expected, Category 4 – Disposition Assigned, Category 5 – Disposition Assigned and Patient Boarding. During observations, researchers used contextual patient information provided during each handoff to index patients based on the state of their disposition as presented by outgoing physicians. Patient indexing was then evaluated through statistical analyses of ED patient data (time until disposition and time until departure) provided by the health system to identify differences between disposition categories and quantify the total caseload (patient related decision-making) transferred during handoff.
Results:
Results from the physician interviews show that disposition is a keystone goal in emergency physicians’ regular workflows. Furthermore, physicians categorized patients who are handed off as either “active sign-outs” or “non-active sign-outs” where active sign-outs are patients who have not been assigned dispositions and non-active sign-outs are patients who have been assigned dispositions. Analysis of variance (ANOVA) was used to compare state of patient disposition index categories using (1) the time elapsed between handoff and disposition assignment and (2) the time elapsed between handoff and departure from the ED. Results show that state of disposition index categories have significant differences in time until disposition (p < 0.001) while time until departure did not yield significant differences between categories. Moreover, results show that “active sign-outs” (defined as category 1, 2, and 3 patients) have reduced times until disposition (p < 0.001) and until departure (p < 0.05) when compared to “non-active sign-outs” (category 4 and 5 patients).
Discussion:
Findings show that the state of patient disposition at handoff demonstrates a significant difference in time until disposition decision while the active and non-active sign-out labels provided by the emergency physicians differentiates both time until disposition and time until departure for patients. This mirrors the findings of previous studies that describe the process of dispositioning patients as “cognitively loading” (Calder et al., 2012) as it is clear physicians are responsible for making disposition-related decisions and making patient care actions for longer periods of time for active sign-outs than non-active sign-outs. This relationship supports future work that examines the relationship between physician caseload and physician workload, as the disposition-related decisions may be best represented as a form of cognitive workload.
Systematic literature reviews examining patient handoffs have often called for more rigorous quantitative evaluation methods that can be applied to proposed interventions (Riesenberg et al., 2010; Staggers & Blaz, 2013). This work strives to address this gap in the literature and proposes a method of utilizing physician workload (measured as the state of patient disposition transferred at handoff) to evaluate patient handoffs. Again, studies examining disposition have emphasized the importance of disposition in the ED workflow (Calder et al., 2012; Heilman et al., 2016), however there is a fundamental disconnect between the ED patient disposition literature and the ED handoff literature. Studies evaluating patient disposition have primarily focused on creating models that predict patient dispositions in triage (Sterling et al., 2019) or investigated differences between physicians of various demographics in their dispositioning practices (Li et al., 2016). Meanwhile, research pertaining to patient handoffs extensively focus on standardization protocols (Campbell & Dontje, 2019; Chladek et al., 2021; Dhingra et al., 2010; Heilman et al., 2016) and the usage of overarching ED metrics such as patient length of stay and patient mortality to evaluate handoff interventions (Dahlquist et al., 2018; Denson et al., 2015). Ultimately, this study aims to utilize a keystone aspect of ED patient handoffs, the state of patient disposition, to provide an objective measure of caseload that can evaluate the quality of handoff-interventions, like the standardizations presented in prior work.
Conclusion:
This study demonstrates that the state of a patient’s disposition during shift change can be used to measure the patient caseload transferred between emergency physicians during handoffs. Indexing patients by disposition provides a basis for future work that evaluates the cognitive workload transferred between physicians during patient handoffs.
Event Type
Poster Presentation
TimeTuesday, March 264:45pm - 6:15pm CDT
LocationSalon C
Digital Health
Simulation and Education
Hospital Environments
Medical and Drug Delivery Devices
Patient Safety Research and Initiatives