End-of-rotation resident handoffs associated with slightly higher patient mortality

1. In this retrospective cohort study, patient mortality during end-of-rotation handoffs was slightly increased. This effect was increased after ACGME’s resident duty hour regulations were adopted.

2. A more restrictive analysis that reduced sample size but increased homogeneity of patient comparisons did not find a similar association.

Evidence Rating Level: 2 (Good)

Study Rundown: Since the adoption of the ACGME’s duty hour regulations for interns and residents, there has been concern that the increase in shift-to-shift patient handoffs has decreased the quality of care. While handoffs between shifts have been previously evaluated, little is known about end-of-rotation handoff periods between outgoing and incoming resident teams. This retrospective cohort study was conducted at 10 VA hospitals. Patients were included in the “transition cohort” if they were admitted before an end-of-rotation transition and were discharged or died within 7 days. All other patients were included in the “control cohort.” Analyses were conducted separately for transitions among interns only, residents and interns, and residents only.

There was a modest but significant increase in mortality observed in the transition cohort when treated by the intern only and resident/intern groups. Additionally, there was an increase in 30-day and 90-day mortality for the transition cohort in all physician groups. Mortality rates in the transition cohort increased after ACGME hour restrictions were adopted. However, when the data was restricted to patients who were admitted up to 2 days before a transition and patients admitted 2 days later (controls), there were no associations for increased mortality at any level of analysis. No significant differences were found before or after ACGME hour restrictions for this analysis.

These results suggest a small increase in patient mortality during end-of-rotation handoffs. While the study reports no significant differences in length of stay between transition and control cohorts, the mean length of stay for those in the transition group was nearly twice as high as those in the control cohort, casting doubt as to the root cause of mortality differences. Considering the results of the alternative analysis, it remains unclear if end-of-rotation transitions are truly more detrimental to patient care than shift-to-shift transitions.

Click to read the study in JAMA

Relevant Reading: Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients

In-Depth [retrospective cohort]: A total of 230 701 patients across 10 VA hospitals were analyzed in this study. Of this, 25 938 (11.2%) were exposed to intern-only transition, 26 456 (11.5%) to resident-only transition, and 11 517 (5.0%) to intern and resident transition. The remaining 166 790 patients did not experience an end-of-rotation transition and were included in the control cohort. Median length of stay was greater for transition patients than controls by 3 days for both the intern-only group (5.0; IQR, 3.0- 9.0 for transition vs 2.0; IQR, 1.0-5.0 for control) and the resident-only group (5.0; IQR, 3.0-9.0 for transition vs 2.0; IQR, 1.0-5.0 for control), and by 4 days in the intern and resident group (6.0; IQR, 4.0-10.0 for transition vs 2.0; IQR, 1.0-5.0 for control). Adjusted hospital mortality was significantly increased for the transition group when considering intern-only transitions (OR 1.12; CI₉₅ 1.03- 1.21) and intern and resident transitions (OR 1.18; CI₉₅ 1.06-1.33), but not for resident-only transitions (OR 1.07; CI₉₅ 0.99-1.16). Adjusted 30-day and 90-day mortality rates were similarly increased in all transition groups regardless of physician-level transition (p < 0.05). There were no significant differences between transition and control cohorts before ACGME duty hour restrictions.

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