President's Blog

If you have ever played the game of Telephone, you know how messages can get garbled and misstated when transmitted from one person to another.  It is a fun game because the end message often is just the opposite of the initial message.  Well, in the health care field, the game of telephone takes place every day in many ways. The term that is used is “handoffs.” And it is far from a game. When one physician or nurse signs out to another physician or nurse, the complete and accurate information concerning the patient’s history, current medical problems and ongoing treatment must be transmitted accurately and completely in order to assure safe continuity of care.  For example, if a person is on a medication at home which is discontinued in the hospital because a different one is used, it is essential that when the patient is discharged from the hospital, he is instructed to discontinue the hospital medication and resume the medication taken at home (or continue the hospital medication and discontinue the medication usually taken at home). 

Handoffs take many forms. Several years ago, when we were made aware- primarily through the hotline- that a patient who developed an MH episode during surgery outside a hospital setting and later died in the hospital, most likely due to failure to continue dantrolene in adequate dosing and failure to monitor the patient en route, we were very concerned. When the same event happened again and again, we knew we had to take action. 

We, therefore, enlisted the assistance of a number of our PAC members, primarily Marilyn Larach, who previously led the development of the MH Clinical Grading Scale which involved extensive interaction among several consultants, and began a dialogue with the Ambulatory Surgery Center Association (later in the process, the Ambulatory Surgery Foundation became the point of contact) in order to develop a guideline or checklist for proper management of a patient experiencing an MH crisis during transport to a hospital. 

In order to accomplish this goal we began working with representatives of the Emergency Medicine specialty, emergency medical transport personnel, physicians, nurses and administrative personnel involved in patient care in an ambulatory setting. We obtained as much information as we could concerning cases of successful management of MH in such a situation as well as others that were not successful. Over a period of about one year, we developed a guide for caring for the patient experiencing an MH crisis while being moved to a hospital setting for further treatment.   

We tackled such issues as: Who should accompany the patient to the hospital, how can a facility best ensure that the emergency room team is aware of management of MH, and how do the clinicians recognize when the patient is ready for transport?  What became clear was that we could not be overly prescriptive on many of these issues, because in some cases the ambulatory facility was located 10 minutes from the hospital while in other cases it was an hour or more away. Second, not all emergency personnel who transport patients are allowed to administer medications or perform invasive procedures such as starting an intravenous line. Furthermore, it is not always possible for the treating anesthesiologist or surgeon to accompany the patient because he/she might have other patients to care for at the time. 

The final product, a guideline to help ambulatory surgery centers (ASCs) develop their own Emergent MH Transfer Plan, took many months to produce because we wanted it to be only one page long, easy to read, understand, and implement. It was designed much like our MH treatment poster which has been proven so successful.  The transfer guideline has been printed in a poster format and is available through either MHAUS at www.mhaus.org or by phone at 607-674-7901, or by contacting the Ambulatory Surgery Foundation at 703-836-8808.

Although some may complain that the guide is too vague and not prescriptive, it is important to remember that the primary purpose of the guideline is to help each ASC develop its own unique transfer plan, specific to the resources and capabilities available to that particular ASC.  Furthermore, the primary purpose of MHAUS is to increase awareness and education and provide information.  We do not feel that it is in our purview to establish as strict protocol to be followed by each ASC;this would have different legal implications. Second, because of the wide variation in location of ambulatory centers, associations with hospitals, and variations in transport personnel; one size does not fit all.       

Nevertheless, the main point we wished to make is that prior thought, planning and process need to be in place in order to be prepared for an MH event, thus  leading to a successful outcome.  Communication among the various providers and facilities is essential in advance of an MH crisis.  As such, we recommend a mock transfer drill as a preparatory step - one that would include all the parties involved. At present we have not developed such a drill, but using the elements in the MH mock drill for the OR, an advanced drill involving patient transport may be developed.  MHAUS will be working on creating a teaching tool for such a drill in the near future when sufficient resources are in hand. 

We believe that the recommended transfer plans for managing an MH crisis in an out of the hospital facility can be used to develop templates or guides for other emergency situations that may require transport from an out of hospital facility to a hospital, such as a heart attack, stroke, allergic reaction, pneumothorax, seizure, etc.  With over 50% of all surgical procedures now taking place outside the hospital setting, (in ambulatory surgery centers and office surgery centers) it is my opinion that distinct planning for a variety of emergencies which require sophisticated care in a hospital environment, be carried out by facilities that perform invasive procedures.  

Members of the Expert Panel who worked on the recommendations were:

From MHAUS: Marilyn Larach, MD; Henry Rosenberg, MD; E. Jane McCarthy, PhD, CRNA; Charles Watson, MD; Kumar Belani, MD; Barbara Brandom, MD.

From the ASF: Cheryl Fielder, RN; Keith Metz, MD; Tony Piccone, MD; Debra Stinchcomb, RN, BSN, CASC; Arnie Valedon, MD.

From the Society for Academic Emergency Medicine: (SAEM): Michael Policastro, MD, FACEP

From the National Association of Emergency Medical Technicians (NAEMT): Mark Weber, EMT-P.