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

Abstract

BackgroundHospitalised patients whose inpatient teams rotate off service experience increased mortality related to end-of-rotation care transitions, yet standardised handoff practices are lacking.ObjectiveDevelop and implement a multidisciplinary patient-centred handoff intervention to improve outcomes for patients who are critically ill during end-of-rotation transitions.Design, setting and participantsSingle-centre, controlled pilot study of medical intensive care unit (ICU) patients whose resident team was undergoing end-of-rotation transition at a university hospital from June 2017 to February 2018.InterventionA 4-item intervention was implemented over two study periods. Intervention 1 included: (1) in-person bedside handoff between teams rotating off and on service, (2) handoff checklist, (3) nursing involvement in handoff, and (4) 30 min education session. Intervention 2 included the additional option to conduct bedside handoff via videoconferencing.Main outcome measuresImplementation was measured by repeated clinician surveys and direct observation. Patient outcomes included length of stay (LOS; ICU and hospital) and mortality (ICU, hospital and 30 days). Clinician perceptions were modelled over time using per cent positive responses in logistic regression. Patient outcomes were compared with matched control ‘transition’ patients from 1 year prior to implementation of the intervention.ResultsAmong 270 transition patients, 46.3% were female with a mean age of 55.9 years. Mechanical ventilation (64.1%) and in-hospital death (27.6%) rates were prevalent. Despite high implementation rates—handoff participation (93.8%), checklist utilisation (75.0%), videoconferencing (62.5%), nursing involvement (75.0%)—the intervention did not significantly improve LOS or mortality. Multidisciplinary survey data revealed significant improvement in acceptability by nursing staff, while satisfaction significantly declined for resident physicians.ConclusionsIn this controlled pilot study, a structured ICU end-of-rotation care transition strategy was feasible to implement with high fidelity. While mortality and LOS were not affected in a pilot study with limited power, the pragmatic strategy of this intervention holds promise for future trials.

Will Any Road Get You There? Examining Warranted and Unwarranted Variation in Medical Education

“…Additionally, the variable approach to managing transitions between rotations has serious, negative ramifications for learners and patients. [26][27][28][29] For example, Denson and colleagues found an association of increased patient mortality in internal medicine programs when patients were discharged during intern and resident service transitions. 27,28 Bernabeo and colleagues uncovered numerous stories of the negative impact of rotation transitions on patients, learners, and other health care professionals.…”

I-PASS handover system: a decade of evidence demands action

“…[8][9][10][11] In addition to their use in routine shift-to-shift provider sign-off, these may be of particular value in the high-risk transfers of critically ill patients, such as from operating rooms to postoperative care units and ICUs [12][13][14][15][16] ; admissions to a surgery unit 17 ; management of trauma patients [18][19][20] ; ICU to general ward transfers 21 22 ; night and weekend coverage of large services, many of whose patients are unfamiliar to the physician receiving the handover [23][24][25][26][27][28] ; and end-of-rotation resident transitions. [29][30][31] Given these considerations, standardised handovers, often involving mnemonic devices, have been widely advocated and studied in the past several decades, though many lack rigorous evaluation and few if any showed demonstrable associations with outcomes. 32 33 Further, although some individual hospitals, units and services have implemented their own idiosyncratic handover systems, this does not solve the issue of handover inconsistency between different care delivery sites.…”