Handoffs: Contingency Planning

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Question 1: What makes this patient different from others with similar symptoms or diagnosis?

1. The goal of the handoff is to provide tailored medical care.
   1. Think beyond the chatbot version of your contingency plans.
2. Chest Pain
   1. The chest pain example demonstrates a more broad framework that can broadly be applied to other problems.
   2. Framework
      1. What makes this patient different? Suspected etiology? 
         1. Ex 1: L main disease, awaiting cor angio tomorrow
         2. Ex 2: Normal cor angio, severe anxiety
      2. Next steps for evaluation
         1. Ex 1: Evaluate at bedside. Repeat troponin and EKG.
         2. Ex 2: If no change, then no need for in person evaluation. If change in quality, repeat EKG and troponin and evaluate at bedside.
      3. Empiric treatment recommendations
         1. Ex 1: Maximize nitro drip.
         2. Ex 2: Trial hydroxyzine or Tums. If those do not work, trial nitro.
      4. When you should escalate the problem to a consultant
         1. Ex 1: If Chest pain persistent despite nitro drip then reach out to the cardiology fellow to discuss cath lab activation overnight.
         2. Ex 2: If newly anginal, EKG changes or troponin elevation, reach out to cardiology fellow.
3. Altered Mental Status
   1. Be very specific about what altered means.
      1. Neurologic exam that day as well as baseline (when they were well)
      2. Mental status exam that day
         1. Are they conversational?
         2. Do they doze off during speech?
         3. Are there hallucinations?
   2. Provide multiple layers of recommendations for management of hyperactive delirium.
      1. Are there any tips to help with reorientation like family members, music, etc.
      2. What medications have worked in the past?
      3. What medications have caused side effects?
      4. Are there IV or IM options if reorientation and oral options are not available?
4. Pain
   1. It can be really distressing to the night team when there is nothing to offer.
   2. Discuss what is available - oral opioids, NSAIDs, acetaminophen.
   3. Have a low threshold to reassess pain at the bedside!

Question 2: Does your covering team have the tools to follow up on tasks and information they need for success?

1. Think about whether you could carry out your recommendations overnight and what the barriers might be. Try to reduce them as much as possible.
2. GI Bleed
   1. If asking to follow up a CBC, make sure that there is a consent, type and screen and IV access.
3. Procedural Complications
   1. Ask your procedural colleagues about expected complications and when to call overnight.

Question 3: Is the handoff updated?

1. It may seem like a no-brainer, but updating the handoff is really important.
2. Think through the other questions in this episode and see if anything needs to be added.
3. Outdated information can be just as dangerous. Sometimes the most important update is removing information that is no longer pertinent like recommendations for a resolved problem.

Question 4: What information about goals of care and prognosis should be communicated to the night team, especially for critically ill patients?

1. Goals of Care
   1. You don't need to have everything wrapped up by sign-out.
   2. Letting your night team know that it's a complicated situation is helpful in and of itself.
   3. Starting the conversation during the day will give the patient and family time to process in case complications or progression occur overnight.
2. Prognosis
   1. Prognosis is really challenging, but if you have information then it can be helpful to pass along to your night team.
   2. The example discussed in this example was a patient who likely would not be liberated from a ventilator.

Question 5: What are we still uncertain about?

1. Acknowledging uncertainty can help the night team triage better.
2. Being aware that there is uncertainty can prompt the team to rethink preliminary diagnoses, especially if the patient isn't responding appropriately to treatment.

Closing Thoughts

1. Be generous to yourself and others. Every complication cannot be forecasted.
2. If something came up the prior night then try and figure out how to keep it from being a problem tonight.

Contributors

Shreya Trivedi, MD, ACP Member – Author
Taylor Cox, MD - Author
Maria Rosasco, MD – Guest Expert
Margot Hedlin, MD – Guest Expert
Aaron Troy, MD – Guest Expert

Reviewers

Jenny Schreiber, MD
Adam Strauss, MD
Mahathi Komaragiri, MD

Those named above, unless otherwise indicated, have no relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.  All relevant relationships have been mitigated.

Release Date:  August 7, 2024

Expiration Date: August 6, 2027

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