Among patients admitted to internal medicine services in 10 Veterans Affairs hospitals, end-of-rotation transition in care was associated with significantly higher in-hospital mortality in an unrestricted analysis that included most patients, but not in an alternative restricted analysis, according to a study appearing in the December 6 issue of JAMA, a medical education theme issue.
A handoff is defined as the transition of patient care to another clinician through the transfer of information, responsibility, and authority. Increasing evidence indicates shift-to-shift handoffs are a source of adverse events and errors, and conversely, that interventions to improve such handoffs may have meaningful benefits to patient safety. However, the association between end-of-rotation transition and adverse events is uncertain.
Joshua L. Denson, M.D., of the University of Colorado School of Medicine, Aurora, and colleagues examined the association of end-of-rotation house staff transitions with mortality among hospitalized patients. The study included patients admitted to internal medicine services at 10 university-affiliated U.S. Veterans Health Administration hospitals (2008-2014). Transition patients (defined as those admitted prior to an end-of-rotation transition who died or were discharged within 7 days following transition) were stratified by type of transition (intern only, resident only, or intern + resident) and compared with all other discharges (control). An alternative analysis comparing admissions within 2 days before transition with admissions on the same 2 days 2 weeks later was also conducted.
Among 230,701 patient discharges (average age, 66 years; median length of stay, 3 days), overall mortality was 2.2 percent in-hospital, 9.5 percent at 30 days, and 14 percent at 90 days. Adjusted hospital mortality was significantly greater in transition vs control patients for the intern-only and intern + resident groups, but not for the resident-only group. Adjusted 30-day and 90-day mortality rates were greater in all transition vs control comparisons. Accreditation Council for Graduate Medical Education (ACGME) duty-hour changes (limiting first-year residents [interns] to 16 continuous hours of work) was associated with greater adjusted hospital mortality for transition patients in the intern-only and intern + resident groups than for controls. The alternative analyses did not demonstrate any significant differences in mortality between transition and control groups. There were no significant associations with readmission rates.
"Together, these results showed that end-of¬ rotation transitions in care were associated with increased mortality; however, this increased risk may be limited to longer-stay, complex patients with greater comorbidities or those discharged soon after the transition," the authors write.
(doi:10.1001/jama.2016.17424; the study is available pre-embargo at the For the Media website)
Editor's Note: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Related material: Also available at the For the Media website , the editorial, "Inpatient Service Change," by Vineet M. Arora, M.D., M.A.P.P., and Jeanne M. Farnan, M.D., M.H.P.E., of the University of Chicago.
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