Faculty Bibliography

BACKGROUND: In case reports, transfers in the care of patients among health care providers have been linked to adverse events. However, little is known about the nature and frequency of these transfer-related problems. METHODS: We conducted a prospective audiotape study of 12 days of "sign-out" of clinical information among 8 internal medicine house-staff teams. Each day, postcall and night-float interns were asked to identify any sign-out-related problems occurring during the coverage period and to identify the associated sign-out inadequacies. We verified reported sign-out inadequacies by reviewing each corresponding oral and written sign-out. We then developed a taxonomy of types of errors and their consequences through an iterative coding process. RESULTS: Sign-out sessions (N = 88) included 503 patient sign-outs. A total of 184 patients were signed out twice in the same night. Thus, there were 319 unique patient-days in the data set. We interviewed intern recipients of 84 of 88 sign-out sessions (95%) about sign-out-related problems. Postcall interns identified 24 sign-out-related problems for which we could verify sign-out inadequacies. Five patients suffered delays in diagnosis or treatment, resulting in 1 intensive care unit transfer, and 4 patients had near misses. In addition, house staff experienced 15 inefficiencies or redundancies in work. Sign-outs omitted key information, such as the patient's clinical condition, recent or scheduled events, tasks to complete, anticipatory guidance, and a specific plan of action and rationale for assigned tasks. CONCLUSION: Omission of key information during sign-out can have important adverse consequences for patients and health care providers.

INTRODUCTION: Imperfect sign-out of patient information between providers has been shown to contribute to medical error, but there are no standardized curricula to teach sign-out skills. At our institution, we identified several deficiencies in skills and a lack of any existing training. AIM: To develop a sign-out curriculum for medical house staff. SETTING: Internal medicine residency program. PROGRAM DESCRIPTION: We developed a 1-h curriculum and implemented it in August of 2006 at three hospital sites. Teaching strategies included facilitated discussion, modeling, and observed individual practice with feedback. We emphasized interactive communication, a structured sign-out format summarized by an easy-to-remember mnemonic ("SIGNOUT"), consistent inclusion of key content items such as anticipatory guidance, and use of concrete language. PROGRAM EVALUATION: We received 34 evaluations. The mean score for the course was 4.44 +/- 0.61 on a 1-5 scale. Perceived usefulness of the structured oral communication format was 4.46 +/- 0.78. Participants rated their comfort with providing oral sign-out significantly higher after the session than before (3.27 +/- 1.0 before vs. 3.94 +/- 0.90 after; p < .001). DISCUSSION: We developed an oral sign-out curriculum that was brief, structured, and well received by participants. Further study is necessary to determine the long-term impact of the curriculum.

BACKGROUND: Limits on resident work hours are intended to reduce fatigue-related errors, but may raise risk by increasing transfers of responsibility for patients. OBJECTIVE: To examine changes in outcomes for internal medicine patients after the implementation of work-hour regulations. DESIGN: Retrospective cohort study. SETTING: Urban, academic medical center. PATIENTS: 14,260 consecutive patients discharged from the teaching (housestaff) service and 6664 consecutive patients discharged from the nonteaching (hospitalist) service between 1 July 2002 and 30 June 2004. MEASUREMENTS: Outcomes included intensive care unit utilization, length of stay, discharge disposition, 30-day readmission rate to the study institution, pharmacist interventions to prevent error, drug-drug interactions and in-hospital death. RESULTS: The teaching service had net improvements in 3 outcomes. Relative to changes experienced by the nonteaching service, the rate of intensive care unit utilization decreased by 2.1% (95% CI, -3.3% to -0.7%; P = 0.002), the rate of discharge to home or rehabilitation facility versus elsewhere improved by 5.3% (CI, 2.6% to 7.6%; P < 0.001), and pharmacist interventions to prevent error were reduced by 1.92 interventions per 100 patient-days (CI, -2.74 to -1.03 interventions per 100 patient-days; P < 0.001). Teaching and nonteaching services had similar changes over time in length of stay, 30-day readmission rate, and adverse drug-drug interactions. In-hospital death was uncommon in both groups, and change over time was similar in the 2 groups. LIMITATIONS: The study was a retrospective, nonrandomized design that assessed a limited number of outcomes. Teaching and nonteaching cohorts may not have been affected similarly by secular trends in patient care. CONCLUSIONS: After the implementation of work-hour regulations, 3 of 7 outcomes improved for patients in the teaching service relative to those in the nonteaching service. The authors found no evidence of adverse unintended consequences after the institution of work-hour regulations.

BACKGROUND: Failure to rescue (FTR), the rate of death in patients suffering 1 of 6 in-hospital complications, is an Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator calculated from administrative data. OBJECTIVE: : We sought to assess the accuracy of the AHRQ FTR algorithm. METHODS: We undertook a retrospective chart review of 60 denominator cases of FTR identified by the algorithm at each of 40 University HealthSystem Consortium institutions. The primary outcome was the overall accuracy of the algorithm compared with chart review. We also assessed accuracy by complication type, patient characteristics, institution, service assignment, and mortality. RESULTS: Of 2354 cases, 1193 (50.7%) were accurately identified by the algorithm as having had at least one of the FTR-qualifying complications during hospitalization. Of the 3073 complications identified in these patients, 1497 (48.7%) were correctly flagged by the algorithm, 907 (29.5%) were present on admission, 419 (13.6%) were not confirmed by chart review, and 250 (8.1%) met a predefined complication-specific criterion for exclusion. The case accuracy rate varied significantly by institution (mean, 50.7%; range, 18.3-100%; P < 0.001), service assignment (surgical service, 62.9% vs. nonsurgical service, 42.9%; P < 0.001), and mortality (alive, 43.9% vs. dead, 67.5%; P < 0.001) but was not affected by patients' age, gender, race, or insurance status. CONCLUSIONS: As currently calculated from administrative data, the FTR algorithm misidentifies half of the cases on average, is least accurate for nonsurgical cases, and is widely variable across institutions. This indicator may be useful internally to flag possible cases of quality failure but has limitations for external institutional comparisons. Improvements in coding quality and consistency across institutions are needed.

BACKGROUND: Work hour regulations for house staff were intended in part to improve resident clinical and educational performance. OBJECTIVE: To characterize the effect of work hour regulation on internal medicine resident inpatient clinical experience and didactic education. DESIGN: Cross-sectional mail survey. PARTICIPANTS: Chief residents at all accredited U.S. internal medicine residency programs outside New York. MEASUREMENTS AND MAIN RESULTS: The response rate was 62% (202/324). Most programs (72%) reported no change in average patient load per intern after work hour regulation. Many programs (48%) redistributed house staff admissions through the call cycle. The number of admissions per intern on long call (the day interns have the most admitting responsibility) decreased in 31% of programs, and the number of admissions on other days increased in 21% of programs. Residents on outpatient rotations were given new ward responsibilities in 36% of programs. Third-year resident ward and float time increased in 34% of programs, while third-year elective time decreased in 22% of programs. The mean weekly hours allotted to educational activities did not change significantly (12.7 vs 12.4, P = .12), but 56% of programs reported a decrease in intern attendance at educational activities. CONCLUSIONS: In response to work hour regulation, many internal medicine programs redistributed rather than reduced residents' inpatient clinical experience. Hours allotted to educational activities did not change; however, most programs saw a decrease in intern attendance at conferences, and many reduced third-year elective time.

BACKGROUND: Transfer of responsibility for patient care between physicians is a key process in the care of hospitalized patients. Systems of transfer management and transfer frequency may affect clinical outcomes. METHODS: To characterize the systems by which patient information is transferred ("signed out") between resident physicians in internal medicine residency programs and to determine the impact of recently enacted resident work-hour regulations on the frequency of transfers, we mailed a self-administered survey to chief residents at 324 accredited US internal medicine residency programs outside of New York State. The main outcome measures were sign-out practices, skills training, and transfer frequency. RESULTS: Surveys were returned from 202 programs (62%). Transfer systems varied among and within institutions: 55% did not consistently require both a written and an oral sign-out at transfers of care, 34% left sign-out to interns alone, and 59% had no means of informing nurses that a transfer had taken place. In addition, 60% of the programs did not provide any lectures or workshops on sign-out skills. After work-hour regulations were instituted, transfers of care for a hypothetical patient increased by a mean of 11% (from 7.0 to 7.8 transfers; P<.001) during a Monday-Friday hospitalization. A member of the primary team was in the hospital for 47% of the hospitalization. CONCLUSION: Although transfers of care are increasingly frequent, few internal medicine residency programs have comprehensive transfer of care systems in place, and most do not provide formal training in sign-out skills to all residents.