Transitions of care are periods of vulnerability of patients
to a variety of errors and adverse events. We usually think of such transitions
as when a patient moves from one venue to another. But in academic medical
centers we also see a different sort of transition of care: the end-of-rotation
change in the whole caregiving team (interns, residents, attendings).
Note that similar changes also commonly take place in non-academic settings,
for instance, when hospitalists rotate.
A recent study done at 10 academic-affiliated VA hospitals
looked at mortality rates associated with housestaff
end-of-rotation shifts on internal medicine services between 2008 and 2014 (Denson
2016). The data were stratified by
type of transition (intern only, resident only, or
intern + resident). Apparently change of attending physician was
not considered.
Adjusted hospital
mortality was significantly greater in transition vs control patients for the
intern-only group (3.5% vs 2.0%) and the intern + resident group
(4.0% vs 2.1%) but not for the resident-only group (3.3% vs 2.0%). Adjusted
30-day and 90-day mortality rates were greater in all transition vs control
comparisons. Because ACGME duty hour regulations changed in 2011 they also
looked at whether there were changes in mortality rates related to those. They
found that duty hour changes were associated with greater adjusted hospital
mortality for transition patients in the intern-only group and
intern + resident group than for controls. They note that the
magnitude of the findings was generally greater in relation to intern rotations
than resident rotations. They note that interns are the least experienced
physicians, thus likely more prone to errors in managing patients, and the work
hour restrictions may have resulted in their having less time to prepare for
such transitions.
The accompanying editorial (Arora 2016) notes that some of the excess mortality is likely unrelated to the transition of care. They note that sicker, more complex patients are more likely to be present during an end-of-rotation transition of care. Such patients are more likely to die so the statistics may be skewed in such cases. They also note that there may be socioeconomic factors that result in delayed discharges in many patients whose stay overlaps an end-of-rotation transition and those socioeconomic factors may influence downstream mortality. But they concur that we need to take steps to reduce any adverse impacts such end-of-rotation changes may cause.
Back in the mid-1990’s
at the Erie County Medical Center we recognized that month-to-month transitions
of care on our academic units were problematic even when we staggered the times
that attending physicians changed or staggered times when senior residents
would change relative to interns and junior residents. Thinking back to your housestaff days, you’ll recall that it was always much more
difficult to manage “inherited” patients than brand new admissions. And that
first day on a new service was always a nightmare. You might have to rapidly
become familiar with 10 or more existing patients, even on a day when you were
admitting new patients. Such transitions were problematic in terms of both
patient outcomes and hospital lengths of stay.
Our solution: we
developed a nurse case manager program (see our February 5, 2008 Patient
Safety Tip of the Week “Reducing
Errors in Obstetrical Care”). Our Director of Nursing, Karen Maricle, and I took 4 of our best RN’s and worked with them
to develop the nurse case manager program. One nurse case manager was assigned
to each of 4 general medicine teams. They provided the day-to-day and
month-to-month continuity that was desperately needed. They became much more
familiar not only with patients but also with the patients’ families and other
support providers. They were especially helpful on days when residents had
their continuity clinic and would be off the ward for several hours. And with
advent of resident workhour restrictions in New York State the nurse case
managers were the ones most knowledgeable about many patients on many days.
Soon after we implemented the program as a pilot, other services began
clamoring for their own nurse case managers and we expanded the program to
other services. We found that the nurse case manager improved continuity of
care tremendously, not only on a day-to-day basis, but also when teaching
services would rotate on a monthly basis. This program was largely responsible
for a substantial improvement in mortality rates, reduction in length of stay,
and improvement in patient and family satisfaction. The resultant reduction in average
length of stay more than offset the costs of the program. Adding such valuable
resources can result in an overall net savings of both human and financial
resources.
Another concept that
helps is use of the “firm” system, variations of which most academic medical
centers are probably already using. At Johns Hopkins we had several medical
“firms” where the interns, residents, and attendings
were assigned. Patients were also assigned to a firm. So a patient would always
be seen by someone in that firm on the outpatient side and if they required
hospitalization they would be admitted to that firm’s ward. The result was that
for many patients you already knew much about them when you rotated onto the
inpatient service.
Certain types of
diagnostic error are probably more common in “inherited” patients. There is a
tendency to accept the diagnoses that were being used by the team that just
rotated off service so “anchoring” bias and the related concept of “premature
closure” (see our November 29, 2011 Patient Safety Tip of the Week “More
on Diagnostic Error”) may come into play. So you have to be very careful to
make sure that you evaluate all new information on “inherited” patients, paying
particular attention not to ignore “disconfirming” information that doesn’t
quite fit with their working diagnoses. (We should also note, however, that
such transitions may sometimes combat “anchoring” bias in that the incoming
team is a “new set of eyes” that may question prior working diagnoses.)
Similarly, some of
the subtleties of medication reconciliation may be lost in such transitions of
care. Just as medication reconciliation should be done every time a patient
moves from one level of care to another, you can make a case that it should be
done each time there is transfer of care from one team to another.
The outgoing team
also needs to clearly spell out what test results are “pending”. In our many
columns on significant findings falling through the cracks (see the list below)
we’ve noted that official reports (eg. imaging
studies, pathology reports, etc.) may differ from preliminary reports. For
example, the team may review a patient’s CT scan and consider it normal and
describe it as normal in the patient chart. The teams change and no one notices
that the official report from Radiology noted a suspicious incidental finding.
The incoming team eventually discharges the patient without attention to that
finding. That’s the reason that discharge summaries and off-service notes
should always have a specific section for “studies done, result pending”. It’s
also a reason why your Radiology department needs a system in place for
flagging significant or unexpected findings with mechanisms to contact the
right people for follow up.
It’s also important
for the incoming team to become acquainted with family or others who will help
care for patients after discharge. Often the rapport the outgoing team had
developed with such caregivers is lost during the end-of-rotation transition.
That was one area where our nurse case manager program was extremely valuable.
We don’t think that
the findings of the Denson study are an anomaly. We suspect similar analyses at
most hospitals (academic and nonacademic) may find similar adverse impacts of changes
in continuity of the care team(s).
See also our other
columns on communicating significant results:
References:
Denson JL, Jensen A, Saag JS, et
al. Association between End-of-Rotation Resident Transition in Care and
Mortality Among Hospitalized Patients. JAMA 2016; 316(21):
2204-2213
http://jamanetwork.com/journals/jama/article-abstract/2589342
Arora VM, Farnan JM. Inpatient
Service Change: Safety or Selection? JAMA 2016; 316(21): 2193-2194
http://jamanetwork.com/journals/jama/article-abstract/2589329
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