According to the case study, a 73-year-old female patient with a history of hypertension, non-insulin dependent diabetes, and chronic renal insufficiency became tachycardic two days after surgery, despite receiving a low-dose beta-blocker. The same day, she informed her nurse that she had developed pain in her left leg.
Assuming the pain was related to the pre-operative epidural, the nurse contacted the anesthesia service, which responded by decreasing the epidural rate; the primary surgical team was not called. Late on the third day after surgery, the cross-covering intern was contacted about the patient’s left leg pain. No information about the intern’s findings was relayed to the primary team the following day.
On the fourth day, the patient complained to the nurse about mild chest discomfort, resulting in attention within 20 minutes by house staff and from the attending physician several hours later. The patient’s exam was unremarkable and a work-up was initiated.
Within an hour of the attending’s visit, the patient’s blood pressure dropped to 70/40, followed by a pulseless electrical activity arrest. The patient could not be resuscitated. A post-mortem examination revealed a pulmonary embolism.
Handoffs in an Era of Work-Hour Restrictions
Missing information about pain in the patient’s leg and a breakdown in communication between physicians contributed to the patient’s poor outcome. In this case, the breakdown may also have been influenced by the intern’s involvement on the third day. Like all medical residents this intern is subject to duty-hour restrictions.
Work-hour limits for all residents training in U.S. hospitals took effect in July 2003. Under these standards, created by the Accreditation Council for Graduate Medical Education (ACGME), residents are limited to a maximum of 30 consecutive work hours—known as the 30-hour rule, which includes time used for sign-out, teaching, and continuity of care. They are also prohibited from working more than 80 hours per week.
Despite the clear safety benefit of preventing fatigue-related mistakes, work-hour mandates have increased the number of patient handoffs and the potential for communication breakdowns.5 A survey of interns conducted at the hospital where this case study occurred identified a higher volume of sign-outs and the resulting potential for harm to patients as main concerns with the work-hour restrictions.6
Concerns about the quality and continuity of care that hospital patients receive are evident even among those medical residents whose work hours were restricted before the ACGME requirements took effect. (In New York state residents’ work hours have been restricted since 1998.)
A 2006 study of surgical residents at New York’s Beth Israel Hospital found that most believed that the quality of care patients received was either unchanged (63%) or worse (26%) since the work-hour restrictions took effect.7 Possible reasons for this perception include unresolved issues with continuity of care, miscommunication, and cross-coverage availability. The study concluded that interventions that target intern sign-out coverage constraints will be important for future efforts to improve the quality of care for hospital patients.
Written sign-outs appear to overcome some of the human errors that inevitably result from verbal patient summaries, such as disruptions and forgetfulness. Recent findings have, however, identified significant shortcomings in the quality and timeliness of written reports.
Critical information, such as code status and allergies, was missing in 80% of written sign-outs in one recent study.8 And in a 2006 study of the quality of discharge summaries, only 19% of hospital physicians with an outpatient practice reported being satisfied with the timeliness of discharge summaries. Only a third reported being satisfied with their quality of information. Most troubling, 41% believed that at least one of their patients hospitalized in the previous six months had experienced a preventable adverse event related to poor transfer of information at discharge.9