Training and Consistency Needed in Transferring Patients from Doctor to Doctor

Leora Horwitz

Medical residency programs across the country should modernize their transfer systems and train residents in how to properly transfer a patient’s care from one doctor to another, according to a study by Yale School of Medicine researchers in the Archives of Internal Medicine.

“In this first national assessment of transfer management in residency programs, we found widely disparate methods of transferring care,” said the lead author, Leora Horwitz, a postdoctoral fellow in internal medicine. “This is significant because patients not cared for by their primary physicians are at higher risk for adverse events. In fact, communication failure is the number one root cause of error in major events reported to the Joint Commission on Accreditation of Healthcare Organizations.”

“Airline pilots have standardized lists of checks and procedures they must follow before every single takeoff and landing, in every type of plane, in every type of weather,” Horwitz continued. “Likewise, nuclear plant technicians, military personnel, railroad dispatchers and others in high risk fields have long standing practices of formal communication to improve safety. We were surprised to learn that hospital doctors use few such standard procedures despite transferring care of very sick patients multiple times a day.”

The survey of chief residents included 202 responding programs from the 324 accredited internal medicine residency programs nationwide. Chief residents answered questions about systems of transfer for ward patients and whether information transfer “sign out” was oral, written or at bedside rounds. They also responded about the format of written sign out, which personnel participated in the sign out, and how the staff was informed that a transfer had taken place.

Further, the questionnaire asked whether the residency program included a lecture or workshop on sign out skills and whether there was supervision of oral or written sign out by a chief resident or attending. The researchers calculated how many times patients were transferred based on additional questions.

According to the compiled answers, the average patient is now subject to approximately two transfers between doctors a day and is directly cared for by the primary inpatient physician for less than half of the hospitalization. Over half of the hospitals that responded do not inform their nurses when doctors have changed responsibility for the night. Fewer than half of programs require that information about their patients always be conveyed in both oral and written form, and fewer than half of programs provide any formal training in sign out skills.

Most programs that had written sign outs used low technology formats–handwritten or typed into a text program. Only 14 per cent used a Web-based or clinical information sign out system. Only seven percent imported clinical information directly into the sign out.

Horwitz said it was apparent from the survey results that most residency programs in internal medicine could take better advantage of existing technology to reduce misinformation transmitted during sign out. She said that in a prior study, patients who were being taken care of by a physician other than their primary physician were more than twice as likely to suffer a preventable adverse event as those being taken cared for by their primary physicians. This risk disappeared after the introduction of computerized written sign outs. The researchers also said residency programs do not place enough emphasis on training in communication and sign out skills.

The report concluded by saying that formal sign out systems, including computerized procedures, have been shown to improve patient outcomes, improve information content of records and are preferred by residents to handwritten sign outs. They were particularly concerned that “nurses in the majority of programs were not told that a transfer had taken place, and there was no formal mechanism to forward pages.”

“These are all easily remediable processes that we know are contributing to medical errors,” Horwitz said. “But, only by describing and quantifying the problem, can we generate sufficient interest and pressure to change the system.”

Co-authors include Harlan Krumholz, M.D., Michael Green, M.D., and Stephen Huot, M.D., all of Yale.

Archives of Internal Medicine 166: 1173-1177.

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