AURORA, Colo. – Researchers at the University
of Colorado Anschutz Medical Campus have found higher
mortality rates among hospitalized patients during routine transitions of care
from one medical resident to another.
The study, published today in JAMA, was led by
Dr. Joshua Denson, MD, a fellow in pulmonary and critical care at the University
of Colorado School of Medicine.
Denson and colleagues from New York University Langone
Medical Center collected data from 2008 to 2014, and examined 230,701 patient
discharges across 10 academic Veteran’s Health Administration Hospitals around
They found an absolute increase of between 1.5% and
1.9% in hospital mortality rates among hospitalized patients exposed to
end-of-rotation transitions in care between medical residents. This
corresponded with 12% to 18% greater odds of death in the hospital for these
Miscommunications during physician handoffs have been
associated with problems in patient care, including medical errors. But one key
understudied area is the transition in care that happens each month when
resident physicians switch clinical rotations.
During this transition, hospitalized patients (often
10 to 20) are transferred to an oncoming resident physician who has never met
them. The researchers tried to determine if these transitions were associated
with worse patient outcomes, specifically higher mortality.
In the study, `transition’ patients were defined as
those admitted before an end-of-rotation handoff who either died or were
discharged within seven days of the transition.
In addition to higher death rates in the hospital, the
study also found higher mortality rates among these patients long after leaving
the hospital. According to Denson, patients whose hospital stay involved an
end-of-rotation transition in care between interns, residents, or a combination
of the two had between 10% and 21% greater odds of dying at 30 or 90 days.
“That suggests that something is happening during this
transition that we need to work on, focusing on the period when the residents
actually leave,” he said. “It might be that patients are getting discharged
more quickly than they should be once the transition occurs. The incoming
resident might not have enough information to determine when patients are
actually ready to be discharged or even worse, they might have the wrong
information when they are discharged.”
On July 1, 2011, the Accreditation Council for
Graduate Medical Education (ACGME) limited first-year residents (interns) to 16
continuous hours of work, leading to increased handoffs in residency programs.
“Despite these changes, safety outcomes and mortality
rates have remained unchanged but transition-related outcomes have not been
examined,” Denson said.
He said the increased number of handoffs may have
heightened the risk of miscommunication during this much more substantial
transition in patient care.
“The association was stronger following the
institution of ACGME duty hour regulations,” Denson said.
Denson, a former chief resident at New York
University, said researchers adjusted for numerous potential confounders
including age, sex, race, ethnicity, calendar month, calendar year, individual
hospital site, comorbidities, and length of hospital stay.
However, the patients who underwent this type of
transition tended to have more complex, longer hospital stays than others.
Denson noted that in an alternative restricted
analysis, as opposed to the main unrestricted analysis, there were no
significant differences in mortality between patients who experience a handoff
and those who didn’t.
That’s likely because the two analyses dealt with
different patient populations. The main analysis included the majority of
patients who experienced a transition, especially long-stay and complex
patients. However, the alternative analysis excluded those more complex, longer
“It is therefore possible that transitions in care
increase the risk of mortality only for patients who have already had a complex
hospital course or prolonged length of stay,” the study said. “For these
patients, incomplete information transfer or unfamiliarity with patients…may be
particularly harmful, increasing mortality risk.”
Denson said the study does not suggest a `causal
relationship’ between resident handoffs and increased mortality but there is a
`clear association’ between the two that is concerning. .
He said there is no standardized transition process at
many hospitals. Some residents communicate verbally, some do it in writing and
some may not do it all.
But given the rapidly changing health care and medical
education environment, he said, it is critically important to identify gaps that
may cause errors like those that can happen during transitions in care.
Educators are already responding with innovative
techniques to combat these gaps.
“One such approach is called the `warm handoff’ where
residents do transitions in care at the patient’s bedside,” Denson said.
“Although this intervention is unlikely to be harmful, it will be important to
study patient outcomes related to this intervention if possible.”