by Andrew R. Jones and Barbara Durr, avlwatchdog.org
Mission Hospital nurses wrote to the North Carolina Department of Health and Human Services beginning more than a year ago saying that staffing issues and communication procedures for transferring patients from the emergency department had jeopardized patient safety, but the state has yet to send an investigator to the hospital, citing staff shortages.
Asheville Watchdog obtained four complaint letters that were sent to NCDHHS and conducted exclusive interviews with nurses who had expressed concerns that the transfer procedures, known as handoffs, lead to needless delays in care and sometimes endanger patients. In some cases, they said, patients have “disappeared,” showing up unexpectedly to other, sometimes incorrect, departments due to lack of communication.
“There is a dangerous practice pattern of bringing unstable patients to medical or stepdown floors or patient decline because of improper transport practices,” according to a May 18, 2022, letter authored by the Professional Practice Committee [PPC], nine unionized nurses at Mission designated to raise nursing concerns with hospital leadership. Step-down units are transitional areas where patients go between the Intensive Care Unit and a general floor.
Four nurses said that handoff practices at Mission had resulted in patients requiring urgent transfer to the ICU or being sent to floors where nurses were not equipped to care for them.
Mission has had a committee working on “process improvement related to hand-offs” for at least 15 months, according to emails from the hospital’s chief nursing officer to union nurses obtained by The Watchdog.
But Mission’s policy remains unchanged, nurses say.
The policy requires phone calls between nurses for critical care and dialysis patients but not for others.
State and federal regulations do not require calls for handoffs, but Mission nurses and a former emergency department doctor said nurse-to-nurse communication ensures a smoother transition and is best for the patient. And the region’s three other hospitals – UNC Health Pardee, AdventHealth and Asheville VA Medical Center – require calls for all handoffs.
Mission allows a range of communication methods, including a review of electronic medical records. The hospital has invested in iMobile technology, a communication system that is accessible to all health care providers, Mission Hospital spokeswoman Nancy Lindell said.
“Handoff methods are dependent upon the acuity of the patient and what the caregiver deems as appropriate,” Lindell said. “These processes have been reviewed by both The Joint Commission and NCDHHS with no deficiencies found in scheduled or unannounced surveys and no citations given.”
The Joint Commission, the nation’s largest hospital accreditation organization, specifies that hospitals’ hand-off procedures should allow “for the opportunity for discussion between the giver and receiver of patient information.” The organization recommends that staff communicate by telephone or video conference and not solely by electronic or paper methods.
Hannah Drummond, a Mission ED nurse and a National Nurses United union member, said the practice in the emergency department is to call handoff reports for ICU level, pediatric and trauma patients but not for other patients.
“There’s so much that can be given in nurse-to-nurse handoff that can’t be captured when you’re just reading the chart that it’s important to touch base about,” Drummond said. “It also leaves room for things to fall through the cracks.”
Calls, video conferences recommended
The PPC at Mission has been asking the state health care agency to investigate the hospital’s handoffs for more than a year.
In its May 18, 2022, letter to NCDHHS, the PPC requested an onsite investigation by the agency. The nurses received a response July 13, 2022, from an NCDHHS nurse consultant lead, Deborah S. McCarty.
“We regret that the care provided by this hospital has not been satisfactory,” McCarty wrote. “Your concerns have been reviewed and will be assigned for investigation by a member of our Acute Care Team. You will be contacted when the investigation is complete.”
McCarty also responded with identical wording in April 2023 to another nurse complaint letter that raised concerns about cancer care.
No one from the state has visited the hospital to investigate the complaints, nurses say.
“DHSR [Division of Health Service Regulation] lacks sufficient staff to investigate the numerous complaints that it receives as timely as it would like,” NCDHHS spokeswoman Bailey Pennington wrote in an email to The Watchdog. “Governor [Roy] Cooper’s Recommended Budget included additional positions that are desperately needed in DHSR to more timely investigate the increasing number of complaints about patient care in acute and psychiatric hospitals, and other healthcare facilities.”
Lindell did not respond to a question from The Watchdog about whether Mission or its owner, HCA Healthcare, were aware of nurses’ reports that patients were put at risk because of the hospital’s communication protocols, as the nurses say.
Lindell said Mission’s handoff procedures remain largely the same as they were before HCA bought Mission in 2019.
“HCA Healthcare has gone above the minimum standards and made a substantial investment in our iMobile technology” in 2021, Lindell said, referring to the hospital’s electronic communication system. “Once the patient’s information is in their electronic health record [EHR], it follows [the patient] and is accessible by any nurse, physician, pharmacy tech or other person who needs that real-time data.
“Because iMobile can be accessed via computers and handheld devices, staff and offsite providers can send this EHR information through secure messaging from anywhere,” Lindell said. “iMobile phones also allow staff to call or text to get an answer quickly, allowing for streamlined and efficient communications. This adds up to more time spent caring for patients.”
iMobile devices “are used to signal a heads up at best and not utilized to communicate in real time a proper nurse-to-nurse report,” said Mark Klein, a nurse who has worked at Mission since 1999, previously in the emergency department and intensive care unit, and since 2014 as a vascular access nurse inserting ports in patients. Klein sits on the PPC, which communicates concerns to Melanie Wetmore, Mission’s chief nursing officer.
Handoffs by calls take several minutes, Klein said.
“Nurses reporting via phone is inefficient but safe,” Klein said. “HCA wants maximum productivity, so they are trying to eliminate the time-tested method of nurse-to-nurse communication. It’s unsafe, and we have pointed to many examples where we feel patients were harmed, yet HCA leadership is extremely reticent to change.”
Nurses are constantly being reminded of the importance of the time span from patient arrival to time of discharge, known as “throughput,” one of the hospital’s metrics, Drummond said.
“This word that we hear all the time is ‘throughput, throughput, throughput, throughput,’” Drummond said, “So if the patient is holding in the ER for longer, that looks bad on paper.”
Complaint letter cites six cases
The nurses’ May 18, 2022, complaint letter to NCDHHS describes six emergency department patients who ended up in the wrong area or didn’t receive proper care because of handoff communication problems.
“There have been multiple incidents of patient decline because, in many cases, there is no called report,” according to the letter. “The patient is often brought to the room on the incorrect oxygen delivery device and subsequently declines. At other times patients … are transported to a medical floor where implementation of the orders was not possible before subsequent transfer to a stepdown unit.”
The letter provided to The Watchdog redacted patient specifics for privacy purposes, but Klein said they included multiple incidents “where patients were transferred to non-ICU units inappropriately, and the patients required emergent intervention by the Rapid Response Team and transfer to the ICU. Frequently, there was no report or handoff.”
Some patients who should have gone to the ICU, for example, went to a general medical floor, two of the nurses said in a joint interview.
Each case “represents a patient we feel was harmed … because of the unsafe profit-centric system in place at HCA,” Klein said. None of the letters provided to The Watchdog states that patients died.
Kerri Wilson, a cardiac nurse and a member of the PPC, told The Watchdog during the interview with Klein, “People are going to die,” if the hospital doesn’t change its handoff policy.
“Every day patients are transferred from the ER with no report and often to areas that are not the appropriate level of care, which then requires the resources of our rapid response nurse to care for these patients until they can be transferred to ICU,” Wilson said.
Claire Siegel, a PPC member who works on a medical surgical unit, said the supervising nurse is often assisting patients and does “not have adequate time to look up incoming patients to ensure they are safe and appropriate to come to our floor. This often results in patients coming to us who are on medications and IV drips that we are not educated or certified to take care of.
“I have never in the last two years received a nurse-to-nurse report from the ED or holding units unless I proactively look up the nurses, call them myself and demand [a] report.”
‘Many patients disappear’
Another letter to the NCDHHS, dated Nov. 4, 2022, and signed by Klein, described how “many patients ‘disappear’ from the ER and unexpectedly show up on the floors.”
“In this situation someone signs [their] transport form and transport takes the patients to the floor. Nurses are forced to learn about the patient by looking over the chart when they arrive,” the letter stated. “Facts about the history and acute events should be included, and the report should be called.”
Drummond, the ED nurse, said that nurses often don’t know patients have been moved from the emergency room.
“Sometimes patients are moved to [a] different pod in the [emergency] department,” she said, “Or they’re going upstairs and I will be in a critical situation or different room and come back and be like ‘Where did room seven go?’”
This sometimes prevents her from getting patient charts up to date and passing medication along, she said.
The Nov. 4 letter also raised concerns about a section of the emergency department for patients with especially acute medical needs, known as the orange pod, that was “grossly under-resourced.”
“The ‘orange pod’ area of the ER continues to be a disaster,” the letter said. “The existing nurses have expressed significant concern to HCA about this ER area. Some nurses have quit or changed jobs, and some travelers never return after working in the orange pod.”
Klein, Wilson and Drummond told The Watchdog the problems in the orange pod and elsewhere in the ED continue.
“The Orange Pod is designated for those patients who are holding to be admitted,” Lindell said. “Sometimes there is a wait for beds to be available and we understand that anytime waiting is involved it can be frustrating for patients, family members and the teams that care for them. We take concerns brought directly to Mission Hospital leadership very seriously, implementing changes in process and workflow as needed.”
The May 18 complaint letter to the state said the nurses had asked Mission administrators to end the “dangerous” transport process and require calls for patient handoffs.
“We have met personally with senior leadership and they will not change this process,” the letter said.
PPC’s letter to Mission’s chief nursing officer
The PPC also sent a letter to Wetmore, dated May 18, 2022, saying it had previously raised concerns to her and others about the risks related to Mission’s transferring of patients.
According to the letter, union nurses invited her to a resolution meeting but she did not attend. Klein told The Watchdog that she sent two representatives.
“The significant issue about patient safety regards the emergency department … not calling [a handoff] report on all patients,” the letter to Wetmore said. “Numerous ED [Emergency Department] patients are being transported to floors and step-down units inappropriately. This process places patients in immediate danger and has placed patients in inappropriate care areas,” leading to “multiple patients being transferred” to the ICU.
At the meeting, the PPC showed the two representatives details about the six patients’ cases listed in the NCDHHS complaint, Klein said.
The Watchdog obtained an email, written by Wetmore to a PPC nurse after the meeting on May 18 that said Mission had a committee “working on process improvement related to hand-offs. … [Any] significant process change requires much thought and consideration, which is why we have had a team working on this.”
Wetmore said in the email she was told that “our leaders had great dialogue with the committee members during the meeting and have taken the committee’s suggestions into consideration.”
Also in the May 18 email, Wetmore addressed the six patient cases, Klein said.
“These patient charts were thoroughly reviewed by our quality team,” Wetmore said in her email. “As is the case with any patient complaint/grievance, they fall under the heading of patient safety work product and any specific findings would not be shared in this venue. However, what I can share, is that in these cases any system opportunities are addressed as appropriate.
“I can assure you that the committee’s suggestions have [and are being] considered by leadership.”
Lindell did not respond to a request from The Watchdog to interview the two representatives. She did say the chief nursing officer can send representatives in her place, according to the union’s contract.
Two months later, on July 20, 2022, a PPC nurse emailed Wetmore, saying, “Despite having brought this up multiple times in PPC suggestions and also within the PPC Resolution Process, patients continue to be sent to medical floors without [a] report being called from ED nurses. ED nurses report even being told not to call [a] report.”
Wetmore replied in an Aug. 11, 2022, email, writing, “As was shared already, we have a team reviewing handoff process improvement strategies.” She requested the nurses to alert their supervisors of issues with “following the procedures that are in place.”
A year later, on Aug. 9, 2023, Wetmore sent an email to a PPC nurse, saying “we have a joint team of ER and inpatient leaders who continually evaluate this process and are looking at process improvements for handoff communication between caregivers. In the meantime, we will continue to follow the guidelines set forth by the Joint Commission.”
When asked by The Watchdog if Wetmore would comment for this story, Lindell issued the following statement:
“Mission Hospital’s Chief Nursing Officer regularly responds to communications from staff, including concerns from the nursing union. In addition, she regularly attends staff meetings and meets with all nursing areas in the hospital on a rotating basis.”
Two doctors’ perspectives
Allen Lalor, an emergency department doctor who retired last year after 27 years at Mission, said that nurses are the experts on these type of handoffs, but based on his experience, “there’s nothing quite like having a conversation with people so they can get the subtle nuances of the other parts of conversation, and it gives the accepting nurse a chance to ask questions and get a sense of how sick this person is.
“I liken it to what happens in the military, when people change guard duty — I’m going off duty, you are now responsible for the people you are guarding and watching. So much of medicine is based on experience and what you’ve seen before and your sort of inside knowledge and insight about how sick the patient in front of you looks. To communicate that safely to the person, to the nurse upstairs, I think is invaluable.”
Dr. Amanda Green, chief medical officer at Paris Regional Health in Paris, Texas, wrote a July 5 article in The Hospitalist magazine about emergency department handoffs and spoke to The Watchdog.
“That discussion is expected because there’s just a lot that you can’t express in a medical record,” said Green, who is a liaison between administration and medical staff and who works on projects to improve patient safety and physician workflow. “Most hospitals I know, there has to be a handoff phone conversation from nurse to nurse and clinician to clinician whenever there’s a transition of care.
“I think especially as we’ve gotten more electronic, we’ve gotten more texting, people don’t talk to each other as much. It takes an effort. There’s a little bit of an inertia you have to overcome to have that conversation, but it’s always positive. It’s always in the patient’s best interest.”
Direct communication can even create more camaraderie across the hospital, she added, noting that calls during handoffs help prevent burnout.
Data cited by the Joint Commission as well as recent academic research shows that communication failures, including those involving patient handoffs, have led to numerous medical errors and thousands of malpractice claims in the past two decades.
A procedure that comes with risks
Communication involving handoffs is the nurses’ primary concern in the complaint letters. Handoffs are risky regardless of how they are managed, research shows.
“While it sounds simple, a high-quality hand-off is complex,” the Joint Commission stated in a 2017 issue of its Sentinel Event Alert publication, a statement that is still applicable today, according to a spokesperson. “Failed hand-offs are a longstanding, common problem in health care.”
The Joint Commission’s hospital standards for accreditation require only that, “The organization’s process for hand-off communication provides for the opportunity for discussion between the giver and receiver of patient information.”
But the Joint Commission has provided additional guidance for hospitals with eight tips for “high-quality hand-offs,” recommendations issued in 2018 that a TJC spokesperson confirmed were current.
“Don’t rely solely on electronic or paper communications to hand-off the patient,” the third tip reads. “If face-to-face communication is not possible, communicate by telephone or video conference. This allows the time and opportunity to ask questions.”
The state does not specify how hospitals should conduct handoffs, said Kelly Haight Connor, an NCDHHS spokeswoman. “Hand off is a standard seen in health care facilities to promote follow through and a continuity of care among staff. There is no mandated statute or regulation to define the process,” she said. “Each facility is responsible for defining the practice and protocol.”
A section of the North Carolina Administrative Code mandating the responsibilities of registered nurses requires communication by them to be “direct,” to “evaluate the responses to information reported” and to “determine whether further communication is indicated.” Klein contends the optimal handoff is a two-way call or face-to-face conversation between care providers.
Lindell said Mission’s handoff policy is evaluated “on an ongoing basis… [and] meets the elements outlined by The Joint Commission, allowing for electronic transmission, in-person exchange and/or telephone communications between caregivers with the receiver’s ability to further ask questions at any time.’’
Other hospitals in North Carolina require calls for handoffs.
“At UNC Health Pardee a handoff report via a phone call from the nurse is required whenever a patient is transitioned to a new caregiver or care unit regardless if it is an internal or external location,” said Marilee Arnold, Hendersonville-based Pardee’s interim chief nursing officer.
AdventHealth Hendersonville’s emergency department team “is required to call [a] report when transferring an ER patient to an inpatient unit,” said spokeswoman Victoria Dunkle.
The Western North Carolina VA Health Care System requires “a nurse-to-nurse handoff,” said the system’s spokesman Vance Janes. “The ED nurse will call and give the report over the phone to the receiving nurse or, if medically necessary, the ED nurse caring for the veteran will transport the veteran to the next level of care and give a bedside report to the receiving nurse.”
A spokesperson for Novant Health’s Forsyth Medical Center in Winston-Salem said “Our teams rely on telephone and face-to-face handoffs for emergency department transfers.”
Drummond, the ED nurse and union member, said traveler nurses who spend time at Mission are surprised by its handoff policy.
“When we have travelers come in…they’re like, ‘We don’t call [a] report at this hospital?’” she said.
Concerns about nursing staffing
The complaint letters mostly focus on handoffs but say that short-staffing on several nurse floors is also endangering patient safety.
Wilson said that “pretty much every shift” she files a formal complaint known as an Assignment Despite Objection, developed by the nurses’ union to document unsafe assignments that they believe put patients at risk.
“My unit is pretty much always short-staffed,” Wilson said. “Anytime I have more than four patients, which is our recommended nurse-to-patient ratio for our level of care, I fill one out and I would say several units in the hospital every day fill those out.”
Lindell said hospitals across the country are facing nursing shortages, as The Watchdog recently reported.
“Healthcare staffing challenges continue across the country,” Lindell said. “We have made positive strides in 2023 to fill open positions, having added almost 200 experienced RNs and 100 new graduate RNs to our staff so far this year.”
She said Mission Health continues to heavily recruit and fund caregiver education in Western North Carolina.
Investigative staff shortages
NCDHHS investigations are conducted by the Division of Health Service Regulation (DHSR) on behalf of the U.S. Centers for Medicare and Medicaid Services (CMS). The division reviews complaints with CMS, then prioritizes them for investigation.
The DHSR suffers from a staffing shortage, said Pennington, the NCDHHS spokeswoman. The department hopes the next state budget will include funds allowing it to add positions, she said.
“Without additional investigators and more funding to increase the pay for those already employed, DHSR’s ability to respond to complaints will worsen and the backlog of complaint investigations will continue to grow,” Pennington said.
NCDHHS currently has a 26% overall vacancy rate, Pennington said.
“One of every four positions is vacant — a statistic that’s even higher in our state-run facilities — and the Department’s annual turnover rate (number of staff who leave their jobs each year) is approximately 34%,” she said.
A CMS spokesperson said the agency “has communicated with NCDHHS about its delays and are providing technical assistance and collaboration for NC State to overcome obstacles that may cause delays in CMS’s complaint investigations within the levers CMS has available to do so.”
“Pay remains low, and the agency is competing with hospitals and others for the kinds of people needed to do these investigations,” said Sen. Julie Mayfield, D-Buncombe. “The state simply cannot compete until we raise wages to market or close to market rates.”
She encouraged nurses and the public to continue sending complaints to DHHS, “Maybe someone will hit on a hot button issue that demands a response or maybe we will eventually be the squeaky wheel that gets the grease,” Mayfield said.
Mission nurses remain frustrated.
“If it were really about a lack of investigators, why are we still having people come to investigate a patient or family member complaint … within a couple of weeks even of it happening?” said Wilson, the cardiac nurse.
Drummond, the ED nurse, said the absence of mandated calls for all handoffs ultimately threatens both patients and nurses.
“If something bad happens to my patient, number one, that bothers me so much as a nurse. I take it personally when something preventable happens to my patient, and I think we all do,” she said. “Secondly, that’s on my nursing license. If I’ve sent a patient who becomes more unstable up to the medical surgical floor and I didn’t get [a] handoff report and something happens, theoretically that comes back on me.”
Klein said he wants investigators to talk to Mission nurses.
“I would like them to go up on the floor and essentially conduct a survey of the nurses and see if they ever get [any handoff] report because I asked the nurses upstairs and they tell me they never [do]. … I think it’s just dangerous.”
Reporter Sally Kestin contributed to this story.
Asheville Watchdog gratefully acknowledges the assistance of Lawyers for Reporters, a joint project of the Cyrus R. Vance Center for International Justice and the Press Freedom Defense Fund.
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