Hospital Nightcall: Study Finds Gaps In Patient Handover Commuication Interview with:

Brian M. Wong, MD, FRCPC
Staff Physician, Division of General Internal Medicine
Assistant Professor, Department of Medicine
Director, Continuing Education & Quality Improvement
Associate Director, Centre for Quality Improvement & Patient Safety (C-QuIPS)
Sunnybrook Health Sciences Centre

Lisa Richardson, MD., MA, FRCPC
Department of Medicine, University of Toronto,
Division of General Internal Medicine, University Health Network,
HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, Ontario, Canada

Medical Research: What are the main findings of the study?

Answer: Our study sought to characterize how many clinically important issues that occur during the overnight on-call period were handed over and discussed by the on-call resident with the daytime medical team. For example, if a patient developed chest pain in the middle of the night and the on-call resident evaluated the patient, did the resident then ‘handover’ this issue to the team the next morning so that they could follow up and make sure that the patient receives timely care? In our study, we found that approximately 40% of these issues did not get handed over. This finding was consistent across 2 major Canadian academic teaching hospitals.

Medical Research: Were any of the findings unexpected?

Answer:  While we suspected that we might uncover morning handover omissions as part of our study, we were quite surprised to discover that in addition to the lack of verbal handover, the on-call resident frequently did not document their assessments in the progress notes during the overnight period. In fact, over 85% of these assessments did not have an accompanying progress note documented by the resident in the patient record. This is a concerning finding that has important implications for the delivery of safe and timely patient care.

Medical Research: What should clinicians and patients take away from your report?

Answer:  Much of the handover research focuses on the evening handover of care to an on-call resident. For years, we have learned about the potential hazards associated with that transition period. Our study suggests that there are additional hazards that can result from the handover that occurs in the morning back to the daytime medical team. One encouraging finding from our study was that when teams took the time to go systematically through the list of patients — in other words, going patient by patient as a way to cue the on-call resident to remember whether there were any issues to discuss – there tended to be a more reliable handover of clinically important on call issues.

Medical Research: What recommendations do you have for future research as a result of this study?

Answer:  It is important to now focus on interventions that can improve the morning handover process as well as the consistency of on-call documentation at our teaching sites. Other studies have used a bundle of interventions to improve the reliability and consistency of the handover process — for example, the I-PASS study combines structured communication skills training, use of a mnemonic, creating dedicated handover space free of distractions, direct observation and feedback, faculty development, and electronic sign over tools. We might consider a similar approach to the morning handover period as a first step.


Morning Handover of On-Call Issues Opportunities for Improvement

Devlin MK, Kozij NK, Kiss A, Richardson L, Wong BM. Morning Handover of On-Call Issues: Opportunities for Improvement. JAMA Intern Med. Published online July 21, 2014. doi:10.1001/jamainternmed.2014.3033.