Consistency lacking in transfer of patient data

Many hospitals don’t have protocols for passing patient information among doctors, Yale study finds.

No matter how swift the runners, a relay race is lost if they don’t pass the baton properly. A new Yale study finds that patient care is a baton at increasing risk of being dropped because too many internal medicine residency programs lack systems for transmitting patient information from shift to shift.

Communication failure is one of the chief causes of medical errors, studies have found, and the transfer of care is a weak link in the chain. But the Yale study, published in the Archives of Internal Medicine in June, finds that many hospitals lack an established protocol for passing on patient information, even though transfers, also known as sign-outs, are becoming more common as residents work fewer hours.

“Communication is not something that the layman thinks is a problem,” said Leora I. Horwitz, M.D., a post-doctoral fellow in internal medicine and the study’s lead author. However, patients are now under the care of more doctors, due to limits on residents’ workweeks. Transfers “happen routinely and have the potential for catastrophe,” she said.

Hospitals should have a standardized system each time a doctor hands off a patient to another doctor, Horwitz said.

Horwitz’s team investigated the sign-out practices at 202 internal medicine residency programs in the United States and the impact of the reduced workweek on patient transfer protocols. Patient transfers, they found, rose 11 percent—to an average of twice daily in a four-day hospital stay—since the regulations took effect in 2003.

The procedures for those handoffs varied widely, though. Fifty-five percent of the programs didn’t require doctors to pass on key patient information in both oral and written form, which Horwitz said would curtail the risk for errors. In six of 10 programs, nurses were not informed that a transfer had occurred, and in many programs no workshops or lectures on sign-out skills were offered. In 34 percent of the cases, the handoff was left to interns alone. And fewer than a fifth of the programs used a Web-based program, or forwarded pager messages in the transfer process.

“If you’re the primary doctor, you’re much less likely to make a preventable error than if you’re covering that person just for a day and you don’t know that [patient] well,” Horwitz said. An oral transfer allows the new doctor to ask questions or give “readback”—like a pilot would give to an air traffic controller. Written information can be referred to later if needed.

The sign-out can differ from hospital to hospital, but it needs to be consistent within the health care organization, said Paul M. Schyve, M.D., senior vice president of the Joint Commission on Accreditation of Healthcare Organizations, which made sign-outs one of its chief patient safety goals for 2006. “A standardized approach makes it easy for people to ask and respond to questions,” he said.

The survey didn’t examine whether the various approaches to sign-outs actually prevent medical errors, especially in light of the shorter workweek. “There’s a lot of anxiety around work-hour limitations in terms of whether they increase discontinuity enough that it overwhelms the benefits of physicians being rested,” Horwitz said. Future studies will decide “whether that’s clinically significant or not.”

—John Dillon

New forum offers a place for doctors and nurses to discuss issues of patient care

On a Thursday afternoon last fall, 23 physicians, nurses and social workers at Yale-New Haven Hospital (YNHH) met to discuss a case that made everyone uncomfortable: a patient with colon cancer suffered serious and eventually fatal complications following surgery, and the patient’s daughter refused to leave her side or her room during the two-month hospital stay. The daughter would not allow staff to communicate directly with her mother and slept much of the day in the hospital room, denying access to nurses even when they attempted to administer medications or other care.

The discussion was part of the Schwartz Center Rounds, a program that creates a forum for caregivers to discuss complex emotional and social issues involved in caring for patients. In 1995, Kenneth B. Schwartz, a health care attorney in Boston, was dying of lung cancer. He was fortunate to receive not just top-notch medical care, but also an attention to his comfort and quality of life that made his illness easier to cope with for himself and his family. Shortly before his death, he established the Kenneth B. Schwartz Center, a nonprofit organization that has been helping caregivers provide compassionate care to their patients since 1997. The Schwartz Center Rounds now operate in approximately 100 hospitals in 25 states; the program was brought to the Yale Cancer Center last February as part of a larger effort to increase the focus on supportive care for patients with severe illness.

“It’s a unique forum for talking about difficult and challenging situations in a nonmedical fashion,” said Kenneth D. Miller, M.D., assistant professor of medicine (medical oncology), director of supportive care programs at the Center and the rounds leader for the program. Open to all YNHH staff, the rounds take place once a month and feature a presentation by a medical team followed by a group discussion.

Past topics of the Schwartz Center Rounds have included obtaining informed consent from mentally ill patients; keeping hope alive; and what to do when the patient, doctor and family are not on the same page. “We’re trying to develop a broader view on how different patients, and different families cope with really difficult situations that may be different than what we might have chosen for ourselves or what we think we’d choose,” Miller said.

According to Marjorie Stanzler, director of programs for the Schwartz Center, the ability of caregivers to voice their concerns in a safe environment translates into new insights into caring for patients, an appreciation of the problems faced by colleagues in other disciplines and the realization that they are not alone in dealing with troublesome circumstances.

—Jill Max

et cetera

Stroke, heart attack and firing

Losing a job just as retirement approaches more than doubles the chances of a heart attack or stroke, according to a Yale study published in Occupational and Environmental Medicine in June.

For over 10 years researchers observed more than 4,000 people who were between the ages of 51 and 61 when the study began in 1992. During that period 582 lost their jobs. An earlier six-year study of the same people had suggested a higher risk of stroke, but didn’t make a definitive link between job loss and heart attacks. “With longer follow-up ... on heart attack and stroke events we were able to better assess the association between employment separation and the medical outcomes,” said William T. Gallo, Ph.D., the lead author and an associate research scientist in the Department of Epidemiology and Public Health.

“We do a lot of downsizing in our country and older individuals are often affected,” said co-author Elizabeth H. Bradley, M.B.A., Ph.D., professor of public health. “We need to recognize not only the economic consequences, but also the health consequences.”

—John Curtis

Kidney patients left out of trials

Although at high risk for cardiovascular death, patients with chronic kidney disease (CKD) are frequently left out of cardiovascular trials, School of Medicine researchers reported in the September 20 issue of JAMA: The Journal of the American Medical Association.

The researchers’ review of 153 clinical trials published between 1985 and 2005 found that patients with kidney disease were excluded from 56 percent of the trials and were more likely to be excluded from multicenter trials. Cardiovascular death is the leading cause of death in patients with CKD.

“Inclusion and reporting of kidney disease patients in cardiovascular trials must improve,” said senior investigator Chirag Parikh, M.D., assistant professor in the Section of Nephrology. “Alternatively, we need to design separate trials for cardiovascular treatment exclusively in CKD patients.”

—J.C.


			Originally published in Yale Medicine, Winter 2007. Copyright © 2007 Yale University School of Medicine. All rights reserved.