Resident Handoffs: Improved Strategies for Better Inpatient Care

End-of-rotation transitions may introduce greater risk in internal medicine inpatient care than previously recognized, according to research published in JAMA. The study, which included 230,701 patients admitted to internal medicine services at 10 Veterans Affairs (VA) hospitals, showed that end-of-rotation transition in care was linked to significantly higher in-hospital mortality, an association that was stronger after institution of the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations.¹

“We want to highlight the issue and bring it to attention,” said study investigator Joshua Denson, MD, a fellow in the Division of Pulmonary Sciences and Critical Care Medicine at the University of Colorado School of Medicine in Aurora.

Dr Denson and colleagues found that end-of-rotation in-hospital mortality was 3.5% for intern-only transition compared with 2.0% for all other transitions (control group).¹ In-hospital mortality was 4.0% for intern plus resident transition compared with 2.1% for control.¹ In this study, in-hospital mortality was the primary outcome. Secondary outcomes included 30-day and 90-day mortality and readmission rates. The researchers adjusted for age, sex, race/ethnicity, month, year, length of stay, comorbidities, and hospital.

“There are no standards currently in place. One resident goes from one area to another and they communicate in different ways. We may be putting people at risk unnecessarily,” Dr Denson told Endocrinology Advisor.

He said at the University of Colorado they are conducting “warm handoffs.” When a resident is leaving at the end of one month, he or she meets with his or her replacement and discusses all the patients and sees all the patients at the bedside together. This helps improve communication and ensures that higher-risk and more complex patients get more attention. “We call it a warm handoff. It is an idea of transition in-person and not over the phone or through email. It involves the patient and the patient’s family,” said Dr Denson.

Where Can Improvements Be Made?

In an editorial also published in JAMA,² Vineet Arora, MD, associate professor at the University of Chicago in Illinois, wrote that changes in personnel on the inpatient service can create uncertainty. She noted that residents who are handing off their patients to a new resident team generally prefer the service to be neat, tidy, and small. However, patients remaining after a service change may differ in important ways from those patients who have been discharged.

“This issue is important to look at because handoffs are an inherently risky time for patients. In teaching hospitals, residents work on ‘service rotations,’ and are constantly changing every month or every 2 weeks,” Dr Arora said in an interview “The problem may be getting worse because with shorter resident duty hours, there is less time to follow a patient through the course of illness and get to know your patients as a resident.”

She said this current study by Denson et al is notable because at many of the sites, the communication at service change was not being done in a uniform way with written and verbal communication. “I think that it’s also important to note that the selection (sicker patients stay longer) could still be driving these findings,” said Dr Arora.

Service changes are inherently different from shift handoffs, she noted. Dr Arora explained that shift handoffs have been studied extensively, and there have been many interventions demonstrated to improve shift handoffs. However, service handoffs are less well studied. The information required by the resident is different and often relates to “big picture” issues for the patient. These issues may include consult recommendations, requirements to execute a discharge, and what the patient/family or primary care physician knows about the patient.

“I would like to see investment in infrastructure in technology and communication tools to facilitate a standard transfer of this information. It is also important to empower patients, since they are the ones who are often not aware this transfer took place and may have important questions or information that they can add to help ease the transition,” explained Dr Arora.