Faculty mentor/PI email address

jim010@aol.com

Is your research Teaching and Learning based?

1

Keywords

Emergency Department; Hospital Medicine; Clinical Handoff; Patient Safety; Communication; Complex Adaptive Systems; Transitions of Care

Date of Presentation

5-6-2026 12:00 AM

Poster Abstract

Background

Transitions from the Emergency Department (ED) to hospital medicine represent a high-stakes clinical handoff across systems. While often experienced as challenging, these interactions are better understood as occurring between services operating under different cognitive loads, operational priorities, and time horizons. Reframing the ED–hospitalist admission as a structured handoff aligns this process with broader patient safety efforts.

Objective

To characterize the ED–hospitalist admission as a cross-system clinical handoff and to identify practical strategies that enhance safety, clarity, and alignment during this transition.

Methods

Conceptual analysis informed by clinical experience, systems theory, and teaching observations. Key domains of potential misalignment were identified and mapped to targeted communication and system-level interventions.

Results

Six domains of potential misalignment in admission handoffs were identified:

Cognitive load differences

Operational priority differences

Protocol visibility gaps

Loss of visual clinical context

Relational familiarity gaps

Temporal mismatch

These domains represent predictable features of interacting clinical systems. Interventions focused on restoring shared context—including trajectory framing, communication of real-time clinical appearance, protocol clarity, explicit signaling of urgency, and relational familiarity—enhance the quality of handoffs.

Conclusion

The ED–hospitalist admission is best understood as a handoff of both patient and anticipated clinical trajectory. Enhancing shared understanding across systems improves the safety, efficiency, and reliability of care transitions.

Disciplines

Emergency Medicine | Medicine and Health Sciences | Quality Improvement

Share

COinS
 
May 6th, 12:00 AM

Reframing the ED–Hospitalist Admission as a Clinical Handoff: The ED to Hospital Admission as a Cross-System Handoff in a Complex Adaptive Clinical Environment. The Case for Systems Approaches to Enhance Safe and Effective Transitions Across A True System Interface

Background

Transitions from the Emergency Department (ED) to hospital medicine represent a high-stakes clinical handoff across systems. While often experienced as challenging, these interactions are better understood as occurring between services operating under different cognitive loads, operational priorities, and time horizons. Reframing the ED–hospitalist admission as a structured handoff aligns this process with broader patient safety efforts.

Objective

To characterize the ED–hospitalist admission as a cross-system clinical handoff and to identify practical strategies that enhance safety, clarity, and alignment during this transition.

Methods

Conceptual analysis informed by clinical experience, systems theory, and teaching observations. Key domains of potential misalignment were identified and mapped to targeted communication and system-level interventions.

Results

Six domains of potential misalignment in admission handoffs were identified:

Cognitive load differences

Operational priority differences

Protocol visibility gaps

Loss of visual clinical context

Relational familiarity gaps

Temporal mismatch

These domains represent predictable features of interacting clinical systems. Interventions focused on restoring shared context—including trajectory framing, communication of real-time clinical appearance, protocol clarity, explicit signaling of urgency, and relational familiarity—enhance the quality of handoffs.

Conclusion

The ED–hospitalist admission is best understood as a handoff of both patient and anticipated clinical trajectory. Enhancing shared understanding across systems improves the safety, efficiency, and reliability of care transitions.

 

To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.