Handover issues

A family doctor refers an elderly patient to your ED at 5 pm for admission for xray proven pneumonia with severe cough and oxygen saturation of 93% but rock solid vitals. The family doctor has admitting privileges and clearly tells the nurses to make arrangements for admission through the ED but he cannot come in and do the admission as his kids have activities that evening. He will come and see her at 8 am the next day once she is admitted. The patient arrives but because there are no admission orders done has to see the ED physician who receives all the instructions from the nurse. The ED physician refuses to admit the patient and disagrees that she needs admission. The family physician is unavailable now. The ED physician elects to treat her with antibiotics and suppress her cough and keep her overnight in the ED. At midnight you come on and hear the whole story from him as he politely disagrees with the need for admission and dismisses the oxygen saturation as not affecting her in any way and stating that she still looks pink and not cyanotic. He dismisses any of the family doctors recommendations and says he wants her to rest overnight and then she can go home and the nurses can update the family doctor when he is back.

Would you take this handover?

4 thoughts on “Handover issues

  1. Don’t fuck around with this patient. They need to be admitted….do the right thing and admit them yourself or you will waste 10 mins arguing with the moron that is handing this over to you. This will literally take 10 mins to write their orders. Puffers, and, bronchodilators etc. elderly patients don’t do well in general so have a low threshold to admit. Even if vitals seem to be okay. Politely take the handover. Admit the patient yourself. Dictate the note copying both original family doc, emerg doc, who were both too lazy to admit.

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  2. Agreed…. Not sure what it is like everywhere now with all of the changes, but I have been in Stratford and the nurses will do a med req of home meds that only takes a minute or 2 to do in most cases. Even if for a short admission, will probably make everyone involved feel better (patient, family, yourself)

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  3. Another handover story/lesson: We saw an 80-something year old female from a nursing home with severe, acute abdo pain just prior to end of shift. History was vague other than had just started that day and was not acting herself at NH. I don’t remember exact vitals but nothing was extremely abnormal (ie. borderline tachy, BP okay, no fever), and blood work showed a slightly elevated wbc (12 or 14). Belly was tensely distended with diffuse tenderness. We ordered a CT abdo to R/O ischemic bowel vs appendicitis vs diverticulitis, and then had to handover. The CT report came back in the middle of the night as normal, with no acute intra-abdominal process. The overnight doc therefore asked nurses to prepare her for discharge in the am with an enema, meds for pain control and stool softeners (without seeing the patient!).

    When the new staff came on at 08:00, nursing staff expressed concern that the patient was still in severe pain. From what I understand, there was no physician-physician handover since it was expected that the patient would be discharged. When the new staff went to see the patient, he immediately called general surgery regarding her abdomen. Repeat BW was done which showed an elevated lactate and wbc was now >20. The general surgery team took her to the OR for exploratory surgery which showed a gangrenous gall bladder. She became much more sick after surgery, but sounds like was starting to turn the corner when I left the rotation.

    I think the biggest lesson I learned from this case, time on ACCESS and time in radiology is that CT is (shocking!) never 100%… I don’t know what the reaction of ACCESS would have been had this happened in London, but in Stratford the surgery team came quickly to see the patient despite the “negative” CT. The clinical gestalt played a big role, so actually seeing the patient was crucial!

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