Duty hour hour restrictions were first implemented for resident physicians in 2003. These became more stringent in 2011 as 16-hour work hour limits were put in place for some residents and overnight shifts for interns were banned. Implementation of these restrictions has had conflicting effects on patient safety. One obvious change resulting from work hour limits is the increase in transfers of care between residents, also known as handoffs or sign-outs. In one month, an intern will perform approximately 300 handoffs, an increase of 40 percent since 2003, and an inpatient will be signed out an average of 15 times (J Hosp Med. 2006;1:257-266).
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September 2013Many of the safety benefits seen with the reduction of resident fatigue may be offset by the additional handovers, which are conducted using a highly variable, unsupervised, non-standardized system fraught with communication breakdowns and medical errors. These unstructured sign-outs have led to adverse events, longer hospital stays and unnecessary medical expenses. Currently, 20 percent of malpractice claims against internal medicine residents are the result of miscommunication during patient care transfer (Arch Int Med. 2007;167:2030-2036). One study found that adverse events were strongly associated with coverage by a physician who was not on the patient’s primary team and those risks doubled when the cross-covering physician was an intern (Ann Int Med. 1994;121:866-872). Despite the Joint Commission’s 2009 call for standardization of sign-out communication, handoffs remain unstructured and generally overlooked in residency programs nationwide.
The Current System
In a 2006 survey sent to 324 internal medicine programs, Horwitz and colleagues showed that 55 percent of these programs did not consistently require both a written and an oral sign-out, 34 percent left sign-out to interns alone and 60 percent had no instruction on effective sign-out practices (Arch Int Med. 2006;166:1173-1177). Results also showed that a member of the patient’s primary team was present in the hospital for only 47 percent of the patient’s hospitalization. More recently, a 2011 study in a single institution showed that among 204 observed sign-outs, there were 124 unique versions of the patient handoff (Teach Learn Med. 2011;23:105-111).
Currently, the most common sign-out methods involve the use of spreadsheets or handwritten notes. Wohlauer and colleagues demonstrated that this laborious process required 51 percent of residents to spend one to two hours every day transcribing data and occasionally this resulted in patients being completely missed on rounds (J Surg Res. 2012;172:11-17). With a system that is already subject to staffing stressors due to work hour restrictions, valuable time spent copying results from the EMR is ill advised, inefficient and extremely susceptible to human error.