February 14, 2017

End-of-rotation transitions may increase risk of death for patients, study finds

Daily Briefing

    study finds that patients transitioned to a new medical team at the end of a rotation are "twice as likely as others to die during their hospitalization"—a finding that should spur a more standardized approach to end-of-rotation transitions, among other considerations, Dhruv Khullar writes in the Washington Post.

    Khullar, a resident physician at Massachusetts General Hospital who was not involved in the study, explains that at many teaching hospitals, an entirely new care team—interns, residents, and attending physicians—assumes responsibility for a group of patients at the end of a two- or four-week rotation. "As someone leading these transitions," Khullar writes, "I find the process varied and haphazard, a time when important details and intimate clinical understanding are lost in translation."

    For the study, researchers assessed data on 230,000 patients to examine how the patients fared after a new care team took over. The researchers found that 4 percent of patients who underwent such transitions died, compared with 2 percent of patient who didn't experience a care team transition. And the link persisted after discharge, Khullar writes. "Three months later, 23 percent of transition-group patients had died, compared with 14 percent of the others."

    Joshua Denson, the study's lead author and a fellow at the University of Colorado School of Medicine, said he was surprised by that care transitions had such a large effect on patient outcomes. "These aren't just a couple of mishaps. We may be doing something during transitions that changes the trajectory of patients' health in the long run."

    Identifying the contributing factors

    Khullar writes that part of the negative effect may be attributable to poor communication during transitions. "But more-subtle factors may also be contributing," he adds. For instance, if a member of a previous care team suggests a patient diagnosis, the new team may "anchor" on the suggestion and take longer to discover a patient's true issue, which can delay appropriate care.

    How Brigham and Women's drastically cut medical errors during handoffs

    And there may also be confounding factors. "Patients who remain hospitalized during transitions may simply be sicker," Khullar writes, adding that sometimes doctors work to discharge their least-sick patients before a transition. "Indeed, after accounting for how old and sick patients were, researchers found that the odds that a person would die in the hospital after a transition dropped from nearly 100 percent greater than the odds of other patients to just 20 percent greater," Khullar writes.

    Standardizing care team transitions

    Nevertheless, Khullar says most doctors would agree that team care transitions are a dangerous time. He suggests that such transitions could be made safer by standardizing transition protocols, a strategy that's been implemented for end-of-shift transitions but not end-of-rotation transitions. Such standardization could include ensuring that residents have dedicated time to handle the transition and creating standard templates for communicating about recommendations, discharge recommendations, and important patient conversations.

    "Some programs are experimenting with doing handoffs at the bedside or even having a resident from the prior team participate in rounds with the new team on its first day," Khullar writes. Hospitals might also consider staggering transitions so the members of a previous care team don't leave all at once.

    Denson added that families should also play a role in the transition process. "Most patients aren't even aware these transitions are happening," Denson said. "We need to do a better job of letting them know and engaging family members who can ask questions during high-risk periods."

    Khullar writes, "Care transitions are an unfortunate but inevitable part of providing medical care ... [but] there's much more we can do to minimize harm and maximize safety" (Khullar, Washington Post, 1/23).

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