Formal Education Not Enough To Teach Effective Patient Handoffs Among Medical Residents

Posted on March 14, 2019 by Marie Benz MD FAAD

MedicalResearch.com Interview with:

Dr. Rattray

Nicholas A. Rattray, Ph.D.
Research Scientist/Investigator
VA HSR&D Center for Health Information and Communication
Implementation Core, Precision Monitoring to Transform Care (PRISM) QUERI
Richard L. Roudebush Veterans Affairs Medical Center
Indiana University Center for Health Services & Outcomes Research
Regenstrief Institute, Inc.
Indianapolis, Indiana

on behalf of study co-authors re:
Rattray NA, Flanagan ME, Militello LG, Barach P, Franks Z, Ebright P, Rehman SU,
Gordon HS, Frankel RM

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

Response: End-of-shift handoffs pose a substantial patient safety risk. The transition of care from one doctor to another has been associated with delays in diagnosis and treatment, duplication of tests or treatment and patient discomfort, inappropriate care, medication errors and longer hospital stays with more laboratory testing. Handoff education varies widely in medical schools and residency training programs. Although there have been efforts to improve transfers of care, they have not shown meaningful improvement.

Led for the last decade by Richard Frankel, Ph.D., a senior health scientist at Regenstrief Institute and Indiana University and professor at Indiana University School of Medicine, our team has studied how health practitioners communicate during end-of-shift handoffs. In this current study, funded by VA Health Services and Research Development, we conducted interviews with 35 internal medicine and surgery residents at three VA medical centers about a recent handoff and analyzed the responses. Our team also video-recorded and analyzed more than 150 handoffs.

Published in the Journal of General Internal Medicine, this study explains how the person receiving the handoff can affect the interaction. Medical residents said they changed their delivery based on the doctor or resident who was taking over (i.e., training level, preference for fewer details, day or night shift). We found that handoff communication involves a complex combination of socio-technical information where residents balance relational factors against content and risk. It is not a mechanistic process of merely transferring clinical data but rather is based on learned habits of communication that are context-sensitive and variable, what we refer to as “recipient design”.

In another paper led by Laura Militello, we focus on how residents cognitively prepare for handoffs. In the paper published in The Joint Commission Journal of Quality and Patient Safety®, researchers detailed the tasks involved in cognitively preparing for handoffs. A third paper, published in BMC Medical Education, reports on the limited training that physicians receive during their residency. Residents said they were only partially prepared for enacting handoffs as interns, and clinical experience and enacting handoffs actually taught them the most.

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Flexible Medical Resident Duty Hours Did Not Pose Risks To Patients

Posted on March 7, 2019 by Marie Benz MD FAAD

MedicalResearch.com Interview with:

Jeffrey H. Silber, MD, PhDDirector, Center for Outcomes ResearchNancy Abramson Wolfson Endowed Chair in Health Services ResearchChildren's Hospital of PhiladelphiaProfessor of Pediatrics, Anesthesiology and Critical CarePerelman School of Medicine, University of PennsylvaniaProfessor of Health Care ManagementWharton School, University of Pennsylvania

Dr. Silber

Jeffrey H. Silber, MD, PhD
Director, Center for Outcomes Research
Nancy Abramson Wolfson Endowed Chair
Health Services Research
Children’s Hospital of Philadelphia
Professor of Pediatrics, Anesthesiology and Critical Care
Perelman School of Medicine, University of Pennsylvania
Professor of Health Care Management
Wharton School, University of Pennsylvania

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

Response: This was a year-long randomized trial that involved 63 internal medicine residency programs from around the US. In 2015-2016, about half of the programs were randomized to follow the existing rules about resident duty hours that included restrictions on the lengths of shifts and the rest time required between shifts (the standard arm of the trial) and the other half of the programs didn’t have those shift length or rest period rules (the flexible arm of the trial). We measured what happened to the patients cared for in those programs (the safety study), and other studies examined how much sleep the residents received, and how alert they were at the end of shifts (the sleep study), and previously we published on the educational outcomes of the interns.

To measure the impact on patient outcomes when allowing program directors the ability to use a flexible shift length for their interns, we compared patient outcomes after the flexible regimen went into place to outcomes the year before in the same program. We did the same comparison for the standard arm. Then we compared the difference between these comparisons. Comparing before and after the implementation of the trial within the same program allowed us to be more confident that a particularly strong or weak program, or a program with especially sick or healthy patients, would not throw off the results of the study. The trial was designed to determine, with 95% confidence, if the flexible arm did not do more than 1% worse than the standard arm. If this were true for the flexible arm, we could say the flexible regimen was “non-inferior” to the standard regimen.