Quantifying Improvement of ED-Hospitalist Handoffs by Utilizing ED Scribes at Madera Community Hospital

Vituity staffs both the emergency department (ED) and hospitalist programs at Madera Community Hospital in California, creating many opportunities for integration between the departments.
To help admitted patients transition smoothly from the ED to the hospital, the teams created a care card introducing the hospitalist team and its role. However, implementation proved to be a challenge for the busy ED.
Ali Atabbi, a program analyst from Vituity's practice management organization, came up with a solution. Since each ED provider worked with a scribe, why not have the two team up to enhance the handoff process?
The following is adapted from a poster presented at Vituity's 2014 annual conference.


Integration between the emergency and inpatient departments is a high priority for Madera Community Hospital. Vituity physician leaders have been working toward this goal by holding joint department meanings, sharing data and collaborating on hospital-wide initiatives.
The hospital is also focused on service excellence, with a goal of raising patient satisfaction scores. Research suggests that transitions of care have a significant impact on patients' perceptions. To this end, the teams created hospitalist care cards for use in the emergency department. The cards feature pictures of the hospitalist team plus a brief description of the hospitalist's role and responsibilities.
The purpose of the care card was to introduce the patient to the receiving hospitalist, even at night when he or she couldn't be physically present. While providers liked the idea, it proved difficult to implement due to time constraints. (Providers in Madera's busy ED manage as many as 20 patients at once.) Nor was there an easy way to track compliance with the new protocol.
One asset of Madera's ED is an established scribe program. Providers and scribes move around the department in pairs and are accustomed to working in teams. Atabbi wondered if the scribes could be enlisted to assist with the patient handoff — as well as track compliance with the care card initiative. "Our scribes are a very bright, energetic group," he says. "Many of them are working toward health professions careers. They want to be more involved with the patients, and this seemed like an opportunity for them to add value."


With the support of ED medical director David Main, MD, Atabbi redesigned the ED-hospitalist handoff as a team approach between the ED provider and scribe. During the day shift, when there is onsite hospitalist coverage, the hospitalist participates as well.
Depending on the current workload in the department, the scribe and ED provider may meet with the patient and family together or separately. First, the provider communicates the diagnosis, treatment plan and next steps. Next, the scribe uses the care card to introduce the admitting hospitalist and give a brief introduction to the hospitalist team. (This step is especially useful at night when the hospitalist is not physically present and is handling the admission by phone.)
Atabbi and lead scribe Kenny Paolinelli trained the scribes on the new protocol. They also asked scribes to track and report the number of handoffs performed. (Each month, the scribe with the highest compliance rate receives a gift card as an additional incentive.) To promote accountability, Atabbi followed up with admitted patients to see how many received a card.
Atabbi also presented the new protocol to providers. "They needed to be confident that this was indeed going to be a team effort, and that the scribe wasn't going to communicate any medical information," he says. "We really emphasized the potential benefits, such as increased efficiency and patient satisfaction."


The department's goal was 80 percent compliance with the new handoff protocol. Before the introduction of the team approach, Atabbi estimated that less than 10 percent of patients received a care card (though without a formal reporting mechanism, this was difficult to measure).
When the new process was implemented in June 2014, the department saw a dramatic increase in compliance approaching 50 percent. By August, this number rose to over 70 percent.

The team approach was well received by all stakeholders, but in particular by patients. They liked knowing who their hospitalist would be, both at admission and on the following day. "Hospitalists usually work three days in a row on a rotating basis, which can get a little confusing," Atabbi says. "The scribes have done a great job of clarifying what to expect."
Patients also liked knowing more about the hospitalist's role. "Because it's such a new specialty, a little education goes a long way," Atabbi says. "One of the most frequent questions is, 'Does my [primary care] doctor know I'm here?' Between the handoff, the care card and the follow up, we have multiple chances to assure them that yes, that's part of our job."
Finally, patients report that the card serves as a memory aid. "A lot of the ED patients are pretty ill and not at their best during the handoff," says Atabbi. "They're not always going to remember the hospitalist's name. But we can use the card to create some redundancy."
In addition to satisfying patients, the initiative provides data that can be used to demonstrate progress and inform future improvement efforts.


The Madera ED team has now been performing team handoffs for about a year, and the initiative is still going strong. Atabbi and Paolinelli meet with the scribe team every couple of months to reiterate goals and expectations around handoffs.
In the future, Atabbi would also like to increase hospitalists' involvement in the process: "They could carry copies of the care card to give to patients who didn't receive one in the ED."
This year, the team also hopes to be able to take a closer look at patient satisfaction. "We now receive separate HCAHPS data for our hospitalist program, which will help us gauge the impact of our process improvements," Atabbi says.


Hospitalist News (April 15, 2013). "Taking the Guesswork Out of Patient Handoffs." Accessed April 23, 2015 at

[Image credit: "BXP135677" by tableatny licensed under CC BY 2.0]