Faculty mentor/PI email address
jim010@aol.com
Is your research Teaching and Learning based?
1
Keywords
Emergency Department Handoffs; Transitions of Care; Patient Safety; Communication; Complex Adaptive Systems; Referral Processes
Date of Presentation
5-6-2026 12:00 AM
Poster Abstract
Background
Transitions of care are recognized sources of patient safety risk. Structured handoff processes have improved communication reliability in inpatient and emergency department (ED) settings. However, outpatient-to-ED referrals—despite representing a transfer of care—are not consistently conceptualized or operationalized as formal handoffs.
Objective
To reframe outpatient-to-ED referrals as clinical handoffs occurring across a system boundary, and to propose a conceptual and operational framework to improve safety through recognition, structure, and signal preservation.
Methods
Conceptual analysis informed by clinical experience, systems thinking, and existing literature on handoffs and patient safety. Comparative evaluation of structured (ED→ED, ED→inpatient) versus less-structured (outpatient→ED) transitions.
Results
Outpatient-to-ED transitions, conceptualized as a referral/call-in model: :
May lack a standardized handoff process
May involve variable content
May not be durably documented
May rely on asynchronous transmission to the treating clinician
Reframing these transitions as a handoff of care model enables:
structured communication
EHR-based signal preservation
improved visibility to the treating team
Conclusions
Outpatient-to-ED transitions represent a high-frequency, under-structured handoff interface. Recognizing these encounters as handoffs creates an opportunity to improve patient safety through minimal, scalable system design.
Disciplines
Emergency Medicine | Health and Medical Administration | Medicine and Health Sciences | Quality Improvement
Included in
Reframing Outpatient-to-ED Transitions as a Patient Safety Interface: Recognizing, Structuring, and Preserving Signal Across Clinical Boundaries Conceptualizing the Call-In to ED Referral Model as a Handoff of Care Model
Background
Transitions of care are recognized sources of patient safety risk. Structured handoff processes have improved communication reliability in inpatient and emergency department (ED) settings. However, outpatient-to-ED referrals—despite representing a transfer of care—are not consistently conceptualized or operationalized as formal handoffs.
Objective
To reframe outpatient-to-ED referrals as clinical handoffs occurring across a system boundary, and to propose a conceptual and operational framework to improve safety through recognition, structure, and signal preservation.
Methods
Conceptual analysis informed by clinical experience, systems thinking, and existing literature on handoffs and patient safety. Comparative evaluation of structured (ED→ED, ED→inpatient) versus less-structured (outpatient→ED) transitions.
Results
Outpatient-to-ED transitions, conceptualized as a referral/call-in model: :
May lack a standardized handoff process
May involve variable content
May not be durably documented
May rely on asynchronous transmission to the treating clinician
Reframing these transitions as a handoff of care model enables:
structured communication
EHR-based signal preservation
improved visibility to the treating team
Conclusions
Outpatient-to-ED transitions represent a high-frequency, under-structured handoff interface. Recognizing these encounters as handoffs creates an opportunity to improve patient safety through minimal, scalable system design.