Improving end-of-rotation transitions of care among ICU patients

Correspondence to Dr Joshua Lee Denson, Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA 70112-2632, USA; [email protected]

Introduction

Medical errors resulting in patient harm are a leading cause of death among Americans,^{1 2} and are an increasingly recognised result of miscommunication during transitions of care.^3–11 However, increasing restrictions to resident work hours mean patient handoffs have increased¹² and continuity of care may be compromised.¹³ Adverse events associated with shift handoffs, during which a physician transfers care of a patient to another physician for a brief amount of time, such as with overnight coverage, are well documented.^{3–6 8 9 14–16} Similarly, patients transitioning between locations^{17 18} or to home from the hospital may be at risk related to ineffective handoffs.^19–21 Evidence-based practices targeting these handoffs have been developed that may improve both communication and patient outcomes.^{4 5 22–25}

However, the effects of end-of-rotation or ‘service’ transitions in care may be equally detrimental to patient care but have received substantially less attention.^{10 26 27} During this transition, one physician permanently transfers the care of an entire list of patients to another physician. Unlike shift handoffs, times at which the original physician resumes care, service transition is permanent—the clinician signing out has no further contact with these patients or their new care team. While early studies suggested patients affected by these transitions experience increased length of stay (LOS) and cost,^{28 29} rigorous large-scale studies have suggested a significant increase in mortality in patients exposed to these transitions.^{10 11} Unfortunately, this specific and substantial transition has not been investigated in the critically ill—a population often considered one of the most vulnerable to medical errors. Organised structure facilitates care in the intensive care unit (ICU), and recent work found that a structured ICU-specific handoff template may improve perceived outcomes during resident shift handoff at night,²⁴ but interventions aimed at service handoff have not been tested.

Given the lack of standardisation regarding this critical transition of care, we developed and implemented a multidisciplinary patient-centred handoff intervention aimed at improving patient outcomes.

Methods

Study design, setting and participant characteristics

This was a single-centre, controlled pilot study of adult medical patients...