Shift Changes Leave Residents Ill-Prepared for Cross-Cover

Emma Hitt, PhD

October 25, 2011

October 25, 2011 — More frequent patient handovers as the result of residents' shorter shifts may affect continuity of care for patients, according to a new report.

Adam S. Helms, MD, from the Department of Internal Medicine, University of Virginia Health System, Charlottesville, and colleagues published their results online October 14 in the Journal of General Internal Medicine.

According to the researchers, in 2003, the Accreditation Council for Graduate Medical Education instituted common program requirements to limit the number of hours worked in a week to 80 hours, with no more than 30 hours worked at consecutively. The resulting scheduling changes increased the number of patient handoffs in patients admitted to teaching hospitals.

The current study sought to assess the sign-out process at a single institution to determine how it might affect patient care.

The researchers analyzed the existing attitudes of 89 internal medicine residents toward the current and ideal sign-out processes. Surveys were then analyzed, and the duration and content of sign-out sessions were observed. To determine best sign-out practice, the authors also interviewed 5 residents whose sign-out process was considered superior by their peers.

Wide variations in the methodology used by residents for sign-out were noted. Only 13% and 16% of residents reported that medication and laboratory information, respectively, were up to date "most" or "all" of the time, and only 3% of residents reported discussing the "sickest" patients first. Up to 40% of residents did not expect to make decisions about cross-cover patients. Also, there was a difference between sign-out procedures on day and night shifts. For day shifts, the average duration of sign-outs was just over 2 minutes compared with only 1 minute for the subsequent night shift sign-out for the same patients (P = .0002). In addition, active problems (89% vs 98%; P = .013), treatment plans (52% vs 73%; P = .004), and test results (56% vs 80%; P = .002) were discussed less frequently during the night vs day sign-outs.

The 5 residents voted as "best at sign-out" identified 5 key strategies for best practice: discussing acutely ill patients first, minimizing discussion on straightforward patients, limiting plans to active issues, using a systematic approach, and limiting error-prone chart duplication.

Limitations of the study include the lack of generalizability because of inclusion of only 1 institution in the analysis, the evaluation of only weekday sign-outs, the lack of assessment of the sign-in process, and the lack of blinding. In addition, there was no measurement of how the sign-out process may have affected patient outcomes.

"The apparent degradation of information that occurs with multiple sequential sign-outs during a 24-h period is striking and has not been previously reported," Dr. Helms and colleagues note.

"Initiating an educational curriculum for sign-out at teaching hospitals is critical not only for establishing a standardized process for sign-out, but also for creating a culture of patient ownership among cross-covering physicians," they conclude.

The study was supported by grants from the National Library of Medicine, the University of Virginia's Graduate Medical Education office, and the University of Virginia's Institute of Quality and Patient Safety. One author reports that she serves as an investigator for Bristol Meyer Squibb on diabetes. The other authors have disclosed no relevant financial relationships.

J Gen Intern Med. Published online October 14, 2011. Abstract