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.
The overall lack of standardization in the current system results in errors of both commission and omission. In a single-institution study, three recurring problems were identified in the written sign-out: outdated information, a lack of anticipatory guidance and minimal information regarding advanced directives. The authors found that only 50 percent of resident sign-outs had been updated to contain current information, such as accurate medication. In another study, which looked at 6,942 sign-outs, 27 percent of the sheets contained erroneous information, 80 percent of which were omissions. The majority of errors persisted beyond the first day and more than half had the potential to be moderately or severely harmful (Teach Learn Med. 2011;23:105-111).
Anticipatory guidance is defined as a prediction about events that may transpire, coupled with a plan about how to address these possibilities. This has become a central tenet of safe handoffs. In a prospective survey study, resident physicians characterized their night on call, the adequacy of the sign-out they received and where they found needed information they had not received during sign-out (Qual Saf Health Care. 2008;17:6-10). One-third indicated that an event had transpired that they were not adequately prepared for by the sign-out, and a retrospective look at these events showed that most could have been anticipated and discussed during sign-out.
Proposed and Studied Interventions
The obvious first step is to classify the information that should be included in a proper sign-out. The answers lie not only in the completeness and accuracy of the information given to the covering physician, but also in the quality and efficiency of the verbal, face-to-face communication. In a study from the University of Iowa, three handoff methods were implemented in succession and individually evaluated during three respective phases (Ochsner J. 2012;12:331-337). During phase I, the overnight physician left handwritten notes for the primary team. Phase II consisted of an electronic-based sign-out, with no face-to-face interaction. In Phase III, the residents were required to do verbal handoffs with optional use of electronic or written notes. In Phase I, the risk of an adverse event was nine times greater than in Phase III, and in Phase II, the risk of an adverse event was 7.4 times greater, compared with Phase III, demonstrating the value of face-to-face communication. What is said during the verbal communication should also be standardized. Thus far, few methods have been rigorously studied, but common themes include identifying patient information, reasons for admission, new events that have occurred, specific tasks to be completed, progress of illness and anticipated events during the shift, along with a plan of action.
The second necessary intervention is the instruction and ongoing evaluation of resident handoffs. A few studies have demonstrated that formalized handoff instruction and supervision have an effect on clinical outcomes. In a survey of 169 internal medicine programs, 70 percent instructed and 53 percent evaluated their house staff in handoffs (Am J Med. 2012;125:104-110). When they looked at acute disease outcomes, the programs that incorporated handoff training and evaluation had a significantly decreased pneumonia mortality rate compared with programs that did not emphasize standardized sign-outs.
Finally, judicious use of EMRs can greatly improve the accuracy and efficiency of the sign-out process. Research suggests that the use of a computerized sign-out tool can save residents up to 45 minutes per day while also improving continuity of care. Seventy percent of the participating residents reported that the new tool helped them adhere to the 80-hour workweek. Medication history, vital signs, allergy information and code status are continually and automatically updated, thus eliminating the need for an error-fraught, resident-maintained phantom record.
Where We Are Headed
Due to ACGME-mandated work hour restrictions, transfers of patient care among resident physicians have greatly increased. While these work hour changes were implemented to improve patient care by reducing physician fatigue, it is now clear that the inadequacy and inconsistency of patient sign-out has offset some of the intended benefit. In response, the ACGME released a “new standards for transitions of care” in 2011, suggesting that programs should implement standardized sign-out procedures using computerized tools as well as educate residents on handoff communication.
There is now widespread use of EMRs due to Affordable Care Act mandates. Looking at other high-stakes industries shows that standardization of communication and breakdown of hierarchical barriers through the use of formalized checklists can drastically improve situations vulnerable to human error. The three phase sign-out study showed that a structured, verbal communication during the handoff demonstrated the greatest improvement in patient safety when compared to written forms of sign-out. What remains to be investigated is whether the use of a computerized sign-out tool, which provides not only automated data but also a structured verbal communication through a checklist, improves clinical outcomes. The creation of such a tool will be increasingly feasible as more hospitals adopt EMRs and more residency programs adhere to the ACGME 2011 guidelines. As sign-outs increase in frequency, the impact of standardization in patient handoffs among resident physicians has enormous potential to improve future patient safety outcomes.
Dr. Mehta is assistant professor in the department of otolaryngology-head and neck surgery, co-director of head and neck surgical oncology and director of robotic head and neck surgery at the Louisiana State University Health Sciences Center in Shreveport.
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