One of the consequences of capping resident work-hours is increasing the frequency of patient hand-offs.
In a recent column in The New York Times, surgeon Pauline Chen cites a somewhat frightening statistic that during a course of a typical 5-day hospitalization, patients “are passed between doctors an average of 15 times.”
And residents sign over patients several hundred times during the first few weeks of training.
One interesting solution would be to model physician hand-offs on how nurses do it. When nurses hand-off patients at the end of shift, it’s often in a quiet, undisturbed room. Contrast that to doctors, where patient hand-offs are performed quickly, often interrupted by pages.
Indeed, according to Vineet M. Arora, a physician who studies the effects of patient hand-offs, nurses have a “culture that has developed around [hand-offs]. In contrast, physicians have historically emphasized continuity much more than handoffs. As a result, doctors’ signouts happen quickly, last-minute and on the fly.”
That’s a great point, and something that needs to start early in physician training. As Dr. Arora states, “handoffs are a priority and not an afterthought.”
Indeed.
Related posts:
- Patient hand-offs
- Patient hand-offs are a source of serious patient harm
- Working harder won’t reduce medical errors
- Do electronic medical records really reduce malpractice risk?
- Does telemedicine reduce malpractice risk?
- Is incident reporting effective in reducing medical errors and increasing patient safety?
- Electronic records are supposed to reduce medical errors, right?
{ 6 comments }
We all know that the handoffs from a medical resident to another resident are often not quite seamless. This issue is just as relevant to practicing physicians. We ‘hand off’ patients at night and on weekends to colleagues. Often, we provide a covering physician with a list of patients with a few short annotations about each patient. For example,
ICU Bed 12: Patient X with abd abscess and renal failure
Bed 201: Patient Y with bilateral pneumonia
Stepdown Bed 10: Patient Z with PE and rectal bleeding
Perhaps, once medical residents tighten up the process, they can give the rest of us some pointers.
Patient handoffs have become a hot topic in medicine. For example, the NY Times blog post noted by KevinMD drew several dozen comments, many from physicians and nurses.
The handoff’s role in patient safety is coming under increasing scrutiny not just because reduced resident hours mean many more are occurring than in the past but because mishandled handoffs play such a large role in hospital sentinel events. The Joint Commission, which has made handoff quality a formal part of its accreditation reviews, conducted a study in 2006 that showed 67% of the sentinel events it identified that year arose from mishandled physician communication. The 800 or so such events it tracked that year were double the number in 2002.
The traditional standard for handoff documentation has been slips of paper, index cards or homemade document or spreadsheet templates, which many hospitals are seeking to upgrade in the wake of the Joint Commission’s new handoff requirement and guidelines published by specialty associations such as the Society for Hospital Medicine (developed, among others, by Dr. Arora quoted above).
A sure sign of the the handoff’s rising prominence is that healthcare technology companies have sensed an opportunity and there are now a number of specialized patient handoff applications available, as well as emerging efforts by the large EMR companies to address the handoff on their platforms. The shifting landscape is promoting an animated debate among technologists about how best to recreate the handoff in their software while addressing an imperative to improve communication.
In this atmosphere, there’s a sense everything is on the table with regard to improving the handoff and I take the increasing reference to nurses’ reports as a model for what works to be part of that. Nurses, for their part, have long been vocal about patient safety and their role in promoting it. That the nurse’s report – and the culture that supports it – are increasingly being held up as a possible model for residents and attendings to emulate is intriguing and shows how much ferment there is over handoffs right now.
(Full disclosure: my company, Lime Medical, makes a mobile patient handoff application).
Here is a link to an article on the wsj.com site which describes hospitals using handoff based upon nuclear submarine handoff processes. It is very informative:
http://online.wsj.com/article/SB115145533775992541-search.html.
Ever try to get something important done in the ICU at shift change? Doesn’t happen.
When shift change becomes so important that nurses, the pharmacy and consultants aren’t allowed to page during or otherwise disturb the process, we’ll master hand off.
It will never happen.
Interesting to note that this recent study was not mentioned on this blog regarding the problems associated with long work hours by residents:
http://www.medpagetoday.com/HospitalBasedMedicine/RiskManagement/16085
Residents who work longer hours are at risk for making more major medical mistakes. Sorry, but I’d rather be handed off in a systematic and reliable manner to a “fresh” doctor, than to have someone who’s had 3 hours of sleep in the past 36 hours making decisions about my life and health.
Seriously, if we can “pass off” systematically and reliably in other high-risk professions — and have been doing so for years — the medical profession can also learn this new skill. It is new, and it is a skill, so it will take time to adjust. Make the handoffs more reliable and systematic, and boom! — you have better health care for all — patients (and doctors!).
Having worked as an Operating Room nurse both prior and after the initiation of systematic, routine and standardized hand off tools, I can most definitely say that these kinds of tools are an asset in patient care. I was a skeptic when these tools were first instituted, but have since learned how valuable they can truly be. They do take time to adjust to, but all the effort is definitely worth it in the end result.
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