End of Resident Rotation May Be Risky Time For Hospitalized Patients

MedicalResearch.com Interview with:

Joshua L Denson MD Pulmonary and Critical Care Medicine University of Colorado School of Medicine

Dr. Joshua Denson

Joshua L Denson MD
Pulmonary and Critical Care Medicine
University of Colorado School of Medicine

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Miscommunication during physician transition in care has been associated with adverse patient events and medical errors; however, an understudied topic is the transition in care that occurs each month when resident physicians switch clinical rotations, also called an end-of-rotation transition. During this handoff, hospitalized patients (up to 10-20) are handed over to an oncoming physician who has never met the patients. We sought to investigate if this type of transition was associated with worse patient outcomes, specifically mortality.

On July 1, 2011, the Accreditation Council for Graduate Medical Education (ACGME) duty-hour regulations limited first-year resident physicians (interns) to 16 continuous hours of work. Although these rules do not appear to have affected overall patient safety outcomes, they have been associated with an increase in shift-to-shift handoffs among training physicians. Given this, we wanted to study how they might impact patient outcomes surrounding end-of-rotation transitions in care.

MedicalResearch.com: What are the main findings?

Response: We performed a retrospective multicenter cohort study of hospitalized internal medicine patients at 10 university-affiliated US Veterans Health Administration hospitals from 2008 to 2014. We defined transition patients as those admitted prior to an end-of-rotation transition who then died or were discharged within 7 days following the transition while all other discharges were considered controls. We also stratified this cohort further by level of training of the doctor performing the handoff (i.e. interns, residents, or a combination of the two).

The primary outcome was in-hospital mortality with a number of secondary outcomes that were adjusted for age, sex, race, ethnicity, month, year, length of stay, comorbidities, and individual hospital site. Additionally, the primary outcome was compared before and after duty-hour regulations.

Our main findings show that among 230,701 patient discharges, adjusted hospital mortality was significantly greater in transition vs. control patients for the intern-only and intern + resident groups with an absolute increase of 1.5-1.9% in mortality rates, and a 12-18% increase in the odds of death. 30-day and 90-day mortality rates were similarly increased for all transition vs. control comparisons with 10-21% greater odds of death. Duty hour changes were also associated with greater hospital mortality for transition patients in the intern-only and intern + resident groups vs. controls.

MedicalResearch.com: What should readers take away from your report?

Response: End-of-rotation transitions may introduce risk to internal medicine inpatient care both in the hospital and after discharge. This risk may be greater for complex, longer hospital stay patients and in the post-duty hour period. The results demonstrate a clear association with mortality that is concerning and should raise awareness for this often overlooked, more substantial transition in care.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: Given the rapidly changing environment of healthcare and medical education, it is incredibly important that we identify gaps in clinical care that may introduce error, such as transitions in care. Educators are responding with innovative techniques and strategies to combat these potential gaps in care, but studies are needed to improve communication and test practical interventions.

One such approach, termed the “warm handoff”, has been implemented at some academic institutions across the country to improve end-of-rotation transitions. Although this intervention is unlikely to be harmful, it will be important to study patient outcomes related to this intervention if possible.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.


Denson JL, Jensen A, Saag HS, Wang B, Fang Y, Horwitz LI, Evans L, Sherman SE. 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

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on December 9, 2016 by Marie Benz MD FAAD