What Are Current Practices?
At this time, there are recommended strategies and templates on specific steps to improve resident handoffs. In a research letter published in JAMA, researchers report on the implementation of recommended handoff strategies in a cohort of internal medicine residency programs and the association with satisfaction levels by program directors.3 Researchers examined program directors’ responses to the 2014 Association of Program Directors in Internal Medicine electronic survey, which looked at properties of verbal handoffs, properties of written handoffs, and educational resources.
Among the 361 programs contacted, 234 (65%) responded to the survey.3 The researchers found that implementation of handoff strategies ranged from 6% to 67%.3 They also found that few directors reported interactive workshops, simulation exercises, and faculty-level supervision.3 These 3 approaches were included in a handoff bundle that in a multicenter trial had previously demonstrated improved patient safety.
Study author Charlie Wray, DO, MS, assistant clinical professor of medicine at the University of California, San Francisco, said the establishment of residency duty hour regulations in 2010 led to increased discontinuity of inpatient care and more resident shift work. Since then, educators and researchers have attempted to establish which shift handoff techniques or strategies work best. He noted that national organizations such as the Accreditation Council for Graduate Medical Education, the Agency for Healthcare Research and Quality, and the Joint Commission have made specific recommendations that are considered best practice.
“We found that while 61% of program directors reported being satisfied with their institutions’ strategies, a large degree of heterogeneity in implementation existed, with implementation rates of respective strategies ranging from 6% to 67%,” said Dr Wray. Program directors reported being most satisfied with having a dedicated room, supervision by a senior resident, using an electronic health record-enabled handoff, and the recipient getting a written copy of the sign-out, he noted.
Dr Wray also said the current study sheds light on the heterogeneity in the implementation rates of different strategies and may help focus on those singular strategies or bundled strategies that have been shown to improve outcomes.
Dr Wray said iPASS (Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by receiver) is a multifaceted, bundled intervention that was prospectively tested and demonstrated a remarkable improvement in adverse event rates. In addition, he suggested that institutions should consider exposing their residents to proper handoff communication early on in their training. At the University of Chicago, Dr Wray said, all entering interns go through a multiday “boot camp,” where they are put in clinical simulations and asked to perform a handoff. The residents are given immediate feedback and taught ways in which they can improve. He said this is done before the residents ever hit the wards; it is a simple task that can easily be implemented at all hospitals.
The optimal approach to end-of-rotation transition in care has yet to be determined, and it would be a mistake if medical societies implement policies that are not evidence-based, according to Dr Denson. He explained that it is possible that new policies may not help outcomes after transitions in care.
“It could mean unnecessary work for the residents and more logistical work and more scheduling,” said Dr Denson. “We have to prove that their time is worth it on this.”
- Denson JL, Jensen A, Saag HS, et al. Association between end-of-rotation resident transition in care and mortality among hospitalized patients. JAMA. 2016;316(21):2204-2213. doi: 10.1001/jama.2016.17424
- Arora VM, Farnan JM. Inpatient service change: safety or selection? JAMA. 2016;316(21):2193-2194. doi: 10.1001/jama.2016.16398
- Wray CM, Chaudhry S, Pincavage A, et al. Resident shift handoff strategies in US internal medicine residency programs. JAMA. 2016;316(21):2273-2275. doi: 10.1001/jama.2016.17786