Increased handoffs are often viewed as a byproduct of the growth in hospital medicine, with heightened scrutiny on the quality of communication that accompanies these transfers of care. As research suggests, though, finding and fixing the weak links can require persistence.
A study led by Siddhartha Singh, MD, MS, associate chief medical officer of Medical College Physicians, the adult practice for Medical College of Wisconsin in Milwaukee, compared a traditional, resident-based model of care to one involving a hospitalist-physician assistant team. Initially, his study found a 6% higher length of stay (LOS) for the hospitalist-physician assistant teams, with no differences in costs or readmission rates.1
But when the researchers pored over their results, they discovered that the increased LOS was limited to patients admitted overnight. Those patients, Dr. Singh says, were admitted by other providers—a night-float resident or faculty hospitalist—and then transferred to the hospitalist-physician assistant teams when they arrived in the morning. These “overflow patients” also were admitted only during busy periods, when limits on the number of admissions by house staff required other arrangements.
To make a direct comparison, Dr. Singh focused on a window from 11 a.m. to 4 p.m., when patients would have an equal probability of being admitted by a resident team or a hospitalist-physician assistant team. From a pool of about 3,000 admitted patients, the study found no significant difference in LOS, cost, readmission rates, or mortality. Instead of highlighting significant differences in models of care, then, Dr. Singh says, his study highlighted a potential weak link in the “treacherous” overnight-to-morning handoffs during busy periods that should be addressed.
“There have been a lot of studies implicating poor communication as a cause of patient-safety issues,” notes Sunil Kripalani, MD, MSc, FHM, chief of the section of hospital medicine and an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn. But fewer studies, he says, have shown how to effectively improve communication in a way that improves patient safety.
One focal point is the often incomplete and inadequate nature of discharge summaries. Several models are emerging on how to build a better discharge summary, Dr. Kripalani says, with researchers offering solid recommendations (as multiple presentations at SHM’s annual meeting suggest). The trick is ensuring that those plans can be implemented into practice on a consistent and timely basis.
Dr. Kripalani says at least one straightforward strategy might help improve handoffs, however: building time into the schedule for them, such as 15-minute overlaps between shifts.—BN
