Deadly hospital handovers

When doctors in training change hospitals, they put their patients at risk. @NightshiftMD exposes a potentially deadly gap in care.

Residents are a big part of the medical system and their post grad training includes taking care of hospitalized patients. Typically, they do one month rotations on a hospital ward before transferring care to another resident and moving on.  
 A new study says those handovers can seriously harm the patients left behind.  

The study - presented today at a conference of thoracic surgeons - looked at just over 230,000 patients at 10 Veterans Administration hospitals between 2008 and 2014.  Researchers at New York University looked at patients cared for in hospital by a first year resident (we used to call them interns) or a more experienced resident.  They identified nearly 64,000 patients who died or who were discharged from hospital within 7 days of experiencing a handoff from an intern, a handoff from a resident, or a handoff from an intern and a resident together working as a team.  

The bottom line is that when residents handed their patients over to another resident, the patient had an increased risk of dying in the seven days following the handover. The risk of harm to patients was greatest when the person handing the patient off was an intern.

The most disturbing finding of the study is what happened to the patients who made it past the first seven days following the handover. They continued to be at increased risk of dying thirty days following handover and even 90 days following handover.  Again, the risk of dying 30 or 90 days following handover was greatest if an intern was looking after the patient at the time of the handover.  

The sustained risk of dying 90 days following handover was a surprise to the authors.  That suggests that something is set in motion during the handover that sets the patient up for harm later on.

This is an American study, but the situation is the same in Canada as it is in the U.S.  Both countries have teaching hospitals in which teams of residents led by an attending physician or surgeon look after a ward full of patients.  As in the U.S., residents at hospitals in Canada do one or two month rotations.  When they go off to another ward or another hospital, they have to hand their patients over to the incoming team.  At most teaching hospitals across Canada, when a new team takes over, they start off not really knowing the patients over which they have responsibility.  It takes them a few days to get up to speed.  

There's an old saying in hospital medicine: the worst time of year to become sick or need surgery is July 1st. That's the day when entire teams of residents leave not only the ward but the hospital itself.  

There are probably several factors at play to explain why patients are at increased risk of dying following a handover.  The fact that deaths occur more often when interns are involved suggests they lack experience at this sort of handover.  They may be inadvertently omit important details about the patient and what to warn the incoming residents to watch for.  More experienced residents may be better at avoiding such pitfalls because they've learned from participating in bad handovers.

Most hospitals have guidelines for daily handovers  the ones that occur at the end of the day when the interns and residents sign over the care of their patients to the resident on call.  Even so, there are problems with the quality of daily handovers. Few hospitals have written guidelines for monthly handovers.  Quite often, the incoming resident takes over 15 to 20 patients without sitting down and meeting the departing team.
To fix this, the first step is for hospital authorities to acknowledge that poor monthly handovers threaten the safety of patients.  Residents need to be taught, and interns need to be supervised through the process.  Written guidelines will help, but they aren't enough.  The biggest gap is the lack of a face to face meeting between the outgoing and incoming residents to talk about each patient in front of the patient and the family so they can be part of the handover.  The system needs to build in time for that meeting to take place, because as soon as the monthly rotation is over, the outgoing residents often depart for another hospital.  

Patients and families need to be vigilant at or near the end of the month especially at the end of June and December, months when wholesale changes of residents take place.  Ask if the residents are leaving, and how they will be handed over to the incoming team. That alone should increase the diligence of residents, and help patients from falling through the cracks.


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