Do End-of-Rotation "Hand-Offs" Lead to Patient Deaths?

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The start of a rotation on the hospital floors is a very stressful time. Interns and residents with no knowledge of the patients they will be inheriting receive "hand offs" from the prior crop of interns and residents. Handoffs convey all sorts of information about the patient list: major diagnoses of course, but importantly, complications along the way, the current plan of care.  In my experience there's a fair amount of cautious editorializing as well: "This is a 73 year old gentleman with a very interesting affect…"

It makes sense that these end-of-the-month handoffs could put patients at risk.  There is a ton of information to convey – and some likely gets lost. But could it lead to a 10% increase in inpatient mortality? That's what this study appearing in the Journal of the American Medical Association suggests. 

And in the end, I'm not buying it.

Researchers looked at 10 Veterans Affairs hospitals affiliated with academic medical centers and identified around 230,000 hospitalization episodes from 2008 to 2014.  About 10% of those patients were exposed to a "transition" day.

Overall, the inpatient mortality rate was around 2 percent. But among those exposed to a transition day, the rate jumped to 3.5 – 4%.  Watch out for that new team, huh?

Of course, when you think about it a bit, it's not as straightforward as it might seem.  Here's why, schematically:

Sicker people are more likely to die.

Sicker people are also more likely to have long hospital stays.

The longer your hospital stay is, the more likely you are to experience a care transition. 

So care transition may be an innocent bystander of longer length of stay in this analysis. To their credit, the authors adjust for this, but length of stay isn't the only issue.  There is something else I call the "wait til Monday" effect. 

Doctors don't like to discharge sick people on weekends, even if they may appear ready for discharge.  That's because the services they may need at home are not as readily available. Also many nursing facilities don't accept patients on weekends.

Care transitions very rarely happen on weekends for the same reason – you want all hands on deck for a switch.  So the sicker you are, the more likely you are to stay til Monday and be exposed to a care transition, independent of length of stay. Teams may also try to discharge their more stable patients prior to a switch to make things easier on the incoming team. So we’d expect patients exposed to transition to be sicker than those not so exposed.  And indeed, that's what we see. Transition patients were more likely to have congestive heart failure, renal failure, liver disease, complicated diabetes, and a host of other conditions. While the authors adjusted for something called the Elixhauser comorbidity score, this is likely not enough to account for the myriad factors that keep those patients in the hospital during a transition.

Why does this matter?  Well, this paper calls for more robust handoffs.  That's a good thing.  But it may also dishearten our hard-working interns and residents who are actually doing a great job. Trust me, they already feel the weight of the world on their shoulders. Forcing them into some handoff-reeducation program may not lead to the benefit some think it will.