Faculty Bibliography

BACKGROUND: Medical errors occur following handoff-related miscommunication. Data regarding the effect on patient-centered outcomes, specifically mortality, are lacking. Our objective was to investigate handoff-related mortality and the effect of duty-hour regulations. METHODS: Retrospective cohort study of adult medical patients at a public, university-affiliated hospital from 2010 to 2012. Patients were divided into 2 cohorts: handoff group (discharged within 7 days following a change in resident physician team) vs control group (discharged the 3 weeks of each 4-week rotation before resident service change). The primary outcome was unadjusted and adjusted hospital mortality rate. As a secondary prespecified analysis, we examined the effect of 2011 Accreditation Council for Graduate Medical Education (ACGME) duty-hour changes. RESULTS: Among 23,736 patients, unadjusted hospital mortality during the handoff group was higher than the control group (2.68% vs 2.08%, respectively; P = .007; odds ratio [OR] 1.30; 95% confidence interval [CI], 1.08-1.57). Following adjustment, this association remained statistically significant (adjusted OR 1.34; P = .003; 95% CI, 1.10-1.62). Similarly, pre-duty-hour unadjusted hospital mortality was higher in the handoff group vs control group (2.87% vs 2.01%, respectively; P = .006; OR 1.44; 95% CI, 1.11-1.86), which remained statistically significant following adjustment (adjusted OR 1.50; P = .002; 95% CI, 1.16-1.95). However, this association lost statistical significance following duty-hour revision with respect to both unadjusted (2.48% vs 2.15%, respectively; P = .30; OR 1.16; 95% CI, 0.88-1.53) and adjusted mortality (OR 1.18; P = .26; 95% CI, 0.89-1.56). CONCLUSIONS: Resident transition in care was significantly associated with an increase in unadjusted and adjusted hospital mortality. Although improved by 2011 ACGME duty-hour amendments, a trend toward higher mortality remained following resident handoff.

Therapeutic hypothermia favorably impacts neurologic outcomes in patients after cardiopulmonary arrest, although the appropriate target temperature is less clear. Its safety profile in patients with systemic sclerosis (SSc) and Raynaud phenomenon (RP), who may be at increased risk for ischemic complications, has not been addressed in the literature, to our knowledge. Digital lesions are commonly seen in patients with SSc, and cold-induced myocardial ischemia has also been reported. We describe a case of a man with SSc, RP, and digital ulcers who underwent therapeutic hypothermia after cardiopulmonary arrest. He regained full neurologic function, and except for digital necrosis, no hypothermia-associated adverse events were observed. Other risk factors for ischemia, such as cocaine use, may have contributed to the development of the digital necrosis. However, clinicians should be aware of the risk for ischemic complications in patients with SSc and RP when considering the appropriate target temperature after cardiopulmonary arrest.

PURPOSE: Many medical errors occur due to miscommunication surrounding transitions in care or "handoffs" Mandated resident duty-hour restrictions have increased the total number of handoffs, yet data regarding the effect of these changes on patient-centered outcomes is lacking. We investigated mortality rates during periods of resident handoff and the effect of duty-hour rule implementation. METHODS: We reviewed 24,739 adult discharges from medical services at a public, university-affiliated hospital in New York City from July 1, 2010 to June 30, 2012. The primary exposure of interest was hospital discharge during the 7 days following a change in resident physician team "handoff period" The primary study outcome was unadjusted and adjusted mortality rate in "handoff periods" compared to "control periods" (the three weeks of each 4-week long rotation prior to resident transition of care). Sub-analysis examined the effect of 2011 ACGME duty-hour changes on mortality. RESULTS: Over the 2-year study period, unadjusted all-cause hospital mortality during the handoff period was significantly higher than the control period (2.74% vs. 2.12%, respectively; p=0.004, OR 1.30 [95%CI 1.09-1.57]). This association persisted after adjustment for age, sex, length of stay, calendar month, and Elixhauser Comorbidity Index (adjusted OR 1.29, p=0.01, [95%CI 1.05-1.57]). On sub-analysis, pre-duty hour unadjusted mortality rate was significantly higher in the handoff period versus control period (2.91% vs. 2.05%, respectively; p=0.003, OR 1.44 [95%CI 1.13-1.84]) with a similar finding in the adjusted mortality rate (adjusted OR 1.42, p=0.01, [95%CI 1.08-1.86]). However, this association lost statistical significance following duty-hour revision with respect to both unadjusted mortality (2.57% vs. 2.19%, respectively; p=0.33, OR 1.15 [95%CI 0.87-1.52]) and adjusted mortality (OR 1.15, p=0.33, [95%CI 0.86-1.54]). CONCLUSIONS: Over a two-year time period, resident handoff was significantly associated with an increase in both unadjusted and adjusted all-cause hospital mortality the week following resident transition in care. Although improved by the 2011 ACGME duty-hour amendments, there remains a trend towards higher mortality during times of resident handoff. CLINICAL IMPLICATIONS: These findings demonstrate a potential patient-centered outcome measure not previously reported that may be affected by enactment of a structured handoff system