Handoffs and Fumbles
It's an important area of healthcare management and policy demanding further study. A new paper by Teryl Nuckols and colleagues in the New England Journal of Medicine highlights the greater cost implications (in the US system) of reduced resident work hours. An analysis by James Browne and colleagues concludes that US resident duty-hour reform (during 2002-2004) was associated with an accelerated rate of increased patient morbidity following treatment of hip fractures in teaching institutions.
Other recent and international analyses have confirmed that miscommunication risks arise from increased frequency of handoffs; that few internal medicine residency programs have comprehensive care transfer systems in place; and that most do not provide formal training in sign-out skills to all residents. Recommendations have been made for improvements in standardized, simplified physician sign-out procedures; and for greater rigour in the design, measurement and evaluation of processes that help to identify gaps in knowledge about handover practice.
What Patients Say about Handoffs
Just as recent academic literature identifies rising concerns about handoffs, so too do patients. Examining the physician rating site, RateMDs.com, patients show agitation over the stress of nursing and physician shifts. Interestingly, patients, especially women giving birth, spend time coordinating their hospital encounters to ensure that their physician of choice is on duty throughout the course of their stay.
Consider a sampling of Canadian postings on RateMDs.com:
- "…the nurses were too busy worrying about shift change and getting home to be concerned about my very difficult breathing problem."
- "A new MD took my case over (shift change) and instead of discharging me he ordered 1 week of IV antibiotic - AVOID ****!!!!!!"
- "Unfortunately it was right at shift change, so Dr.*** ended up delivering my son."
- "I would try my damndest to hold on til shift change! She has absolutely horrible bedside manner and is very very rough!"
- "I guess the fact that I arrived in full pre-term labour at shift change really annoyed her."
Since online social rating sites like RateMDs.com are a recent phenomenon, it is difficult to assess whether patients are saying the problem is getting worse. But patient narratives about their experience of shift changes offer a new testing ground for evaluating whether quality interventions underway to improve the relay of information are, in fact, working.
What Healthcare can Learn from FootballA football fumble is easy to see and to quantify. Teams keep statistics on dropped balls; they compare them with other teams; and they count how many of their fumbles result in games lost. If the team's fumbles are on the rise, chances are their losses are mounting, too. Coaches know how to respond: more drills, more concentration on technique, more standardization, more film reels showing players how the best teams do it.
Coach Vince Lombardi famously said: "Winning isn't everything. It's the only thing." To Lombardi, the consequences of a loss were too profound. Machismo aside, this is a good lesson for healthcare on how not to drop the ball.
About the Author(s)
Neil Seeman is a writer, and Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College at the University of Toronto.
Be the first to comment on this!
Personal Subscriber? Sign In
Note: Please enter a display name. Your email address will not be publically displayed