Hold-over admissions: are they educational for residents?

The Impact of Resident Holdover Admissions on Length of Hospital Stay and Risk of Transfer to an Intensive Care Unit

OBJECTIVE

Implementation of residency duty hour standards has led to adoption of different staffing models, such as the "holdover" model, whereby nighttime teams admit patients and transfer their care to daytime teams who provide ongoing care. In contrast, nonholdover teams at our institution are responsible for both admitting patients and providing ongoing care. We sought to determine whether patients admitted by holdover teams experience worse outcomes than those admitted by nonholdover teams.

METHODS

This is a retrospective cohort study of patients admitted to the internal medicine hospital service at a quaternary care hospital from July 2013 to June 2015. Primary outcomes included hospital length of stay (LOS) and transfer to an intensive care unit within 72 hours of admission. Secondary outcomes were any transfer to an intensive care unit, in-hospital mortality, discharge to home (versus discharge to postacute care facility), and readmission to the health system within 30 days of discharge.

RESULTS

We analyzed 5518 encounters, 64% of which were admitted by a holdover team. Outcomes were similar between study groups, except the LOS, which was 5.5 hours longer for holdover encounters in unadjusted analyses (5.18 versus 4.95 days, P = 0.04) but not significantly different in adjusted analyses. The mean discharge time was 4:00 p.m. for both groups, whereas the mean admission times were 12:00 a.m. and 4:00 p.m. for holdover and nonholdover encounters, respectively.

CONCLUSIONS

Holdover encounters at our institution were not associated with worse patient safety outcomes. A small increase in LOS may have been attributable to holdover patients having earlier admission and identical discharge times.

Mixed effect of increasing outflow of medical patients from an emergency department

Background and aim

Since 2014, the annual number of patients entering our emergency department (ED) has increased significantly. These were primarily Internal Medicine (IM) patients, and of these, 25–30% were admitted. The present governmental policy presents a deterrent to adding IM beds for these patients, and Emergency and IM departments cope with ever-increasing number of IM patients. We describe a quality improvement intervention to increase outflow of IM patients from the ED to the IM departments.

Methods

We conducted a quality improvement intervention at the Shaare Zedek Medical Center from 2014 to 2018. The first stage consisted of an effort to increase morning discharges from the IM departments. The second stage consisted of establishing a process to increase the number of admissions to the IM departments from the ED.

Results

Implementation of the first stage led to an increased morning discharge rate from a baseline of 2–4 to 18%. The second stage led to an immediate mean (± SD) morning transfer of 35 ± 7 patients to the medical departments (8–12 per department), providing significant relief for the ED. However, the additional workload for the IM departments’ medical and nursing staff led to a rapid decrease in morning discharges, returning to pre-intervention rates. Throughout the period of the new throughput intervention, morning admissions increased from 30 to > 70%, and were sustained. The number of patients in each department increased from 36 to 38 to a new steady state of 42–44, included constant hallway housing, and often midday peaks of 48–50 patients. Mean length of stay did not change. IM physician and nurse dissatisfaction led to increased number of patients being admitted during the evening and night hours and fewer during the morning.

Conclusion

We describe a quality improvement intervention to improve outflow of medical patients from the ED in the morning hours. The new ED practices had mixed effects. They led to less ED crowding in the morning hours but increased dissatisfaction among the IM department medical and nursing staff due to an increased number of admissions in a limited number of hours. The present governmental reimbursement policy needs to address hospital overcrowding as it relates to limited community healthcare beds and an aging population.

Undergraduate exposure to patient presentations on the acute medical placement: a prospective study in a London teaching hospital

OBJECTIVES

To identify the availability and variability of learning opportunities through patient presentations on an acute medical placement at a teaching hospital.

DESIGN

A prospective study evaluating all acute admissions to the Acute Medical Unit over 14 days (336 hours). Clinical presentations and the day and time of admission were recorded and compared with the learning outcomes specified in the medical school curriculum.

SETTING

An Acute Medical Unit at a London teaching hospital.

OUTCOMES

(1) Number of clinical presentations to the Acute Medical Unit over 14 days and (2) differences between the availability and variation of admissions and presentations between in-hours and out-of-hours.

RESULTS

There were 359 admissions, representing 1318 presentations. Of those presentations, 76.6% were admitted out-of-hours and 23.4% in-hours. Gastrointestinal bleeding, tachycardia, oedema and raised inflammatory markers were over three times more common per hour out-of-hours than in-hours. Hypoxia was only seen out-of-hours. Important clinical presentations in the curriculum such as chest pain and hemiparesis were not commonly seen.

CONCLUSIONS

There is greater availability of presentations seen out-of-hours and a changing landscape of presentations seen in-hours. The out-of-hours presentation profile may be due to expanded community and specialist services. Medical schools need to carefully consider the timing and location of their clinical placements to maximise undergraduate learning opportunities.

Decisions in the Dark: An Educational Intervention to Promote Reflection and Feedback on Night Float Rotations

BACKGROUND

Night float rotations, where residents admit patients to the hospital, are opportunities for practice-based learning. However, night float residents receive little feedback on their diagnostic and management reasoning, which limits learning.

AIM

Improve night float residents' practice-based learning skills through feedback solicitation and chart review with guided reflection.

SETTING/PARTICIPANTS

Second- and third-year internal medicine residents on a 1-month night float rotation between January and August 2017.

PROGRAM DESCRIPTION

Residents performed chart review of a subset of patients they admitted during a night float rotation and completed reflection worksheets detailing patients' clinical courses. Residents solicited feedback regarding their initial management from day team attending physicians and senior residents.

PROGRAM EVALUATION

Sixty-eight of 82 (83%) eligible residents participated in this intervention. We evaluated 248 reflection worksheets using content analysis. Major themes that emerged from chart review included residents' identification of future clinical practice changes, evolution of differential diagnoses, recognition of clinical reasoning gaps, and evaluation of resident-provider interactions.

DISCUSSION

Structured reflection and feedback during night float rotations is an opportunity to improve practice-based learning through lessons on disease progression, clinical reasoning, and communication.

Implementation of a Hospital Medicine Rotation and Curriculum for Internal Medicine Residents

Introduction

Hospital medicine is a growing field that focuses not only on expertise in inpatient medicine but also on knowledge of nonclinical health system topics. The traditional model for resident education does not lend itself to learning these topics. We developed a unique ward rotation with a dedicated curriculum called the Resident Inpatient Training Experience (RITE) to address this deficiency.

Methods

The RITE rotation was initially implemented in the 2013-2014 academic year. The curriculum accompanying the rotation contained four case-based modules that included content on patient safety, quality improvement, cost-conscious care, hospital metrics/reimbursement, physician billing and coding, and transitions of care. Prior to RITE, residents received an email orientation to the service. To evaluate the rotation and curriculum, residents completed a pre- and postrotation online survey. Forty-six upper PGY 2 residents each rotated on the service for 1 month. An experienced hospitalist attended on the service and facilitated a weekly discussion on each module. This publication includes an updated version of the email orientation, the four modules, and the surveys.

Results

There was a 72% response rate for completion of the pre- and postrotation survey. Confidence in managing hospitalized patients and knowledge of module content taught during the rotation improved.

Discussion

We found that implementation of a hospital medicine rotation and curriculum improved resident independence and knowledge of the module topics and was a successful way to alleviate current deficiencies in resident education.

Improving Resident Feedback on Diagnostic Reasoning after Handovers: The LOOP Project

Appropriate calibration of clinical reasoning is critical to becoming a competent physician. Lack of follow-up after transitions of care can present a barrier to calibration. This study aimed to implement structured feedback about clinical reasoning for residents performing overnight admissions, measure the frequency of diagnostic changes, and determine how feedback impacts learners' self-efficacy. Trainees shared feedback via a structured form within their electronic health record's secure messaging system. Forms were analyzed for diagnostic changes. Surveys evaluated comfort with sharing feedback, self-efficacy in identifying and mitigating cognitive biases' negative effects, and perceived educational value of night admissions-all of which improved after implementation. Analysis of 544 forms revealed a 43.7% diagnostic change rate spanning the transition from night-shift to day-shift providers; of the changes made, 29% (12.7% of cases overall) were major changes. This study suggests that structured feedback on clinical reasoning for overnight admissions is a promising approach to improve residents' diagnostic calibration, particularly given how often diagnostic changes occur.

"You Have to Know the End of the Story": Motivations to Follow Up After Transitions of Clinical Responsibility

PURPOSE

Physicians routinely transition responsibility for patient care to other physicians. When transitions of responsibility occur before the clinical outcome is known, physicians may lose opportunities to learn from the consequences of their decision making. Sometimes curiosity about patients does not end with the transition and physicians continue to follow them. This study explores physicians' motivations to follow up after transitioning responsibilities.

METHOD

Using a constructivist grounded theory approach, the authors conducted 18 semistructured interviews in 2016 with internal medicine hospitalist and resident physicians at a single tertiary care academic medical center. Constant comparative methods guided the qualitative analysis, using motivation theories as sensitizing constructs.

RESULTS

The authors identified themes that characterized participants' motivations to follow up. Curiosity about patients' outcomes determined whether or not follow-up occurred. Insufficient curiosity about predictable clinical problems resulted in the choice to forgo follow-up. Sufficient curiosity due to clinical uncertainty, personal attachment to patients, and/or concern for patient vulnerability motivated follow-up to fulfill goals of knowledge building and professionalism. The authors interpret these findings through the lenses of expectancy-value (EVT) and self-determination (SDT) theories of motivation.

CONCLUSIONS

Participants' curiosity about what happened to their patients motivated them to follow up. EVT may explain how participants made choices in time-pressured work settings. SDT may help interpret how follow-up fulfills needs of relatedness. These findings add to a growing body of literature endorsing learning environments that consider task-value trade-offs and support basic psychological needs of autonomy, competency, and relatedness to motivate learning.

Exploring Physician Perspectives of Residency Holdover Handoffs: A Qualitative Study to Understand an Increasingly Important Type of Handoff

BACKGROUND

The term "holdover admissions" refers to patients admitted by an overnight physician and whose care is then transferred to a new primary team the next morning. Descriptions of the holdover process in internal medicine are sparse.

OBJECTIVE

To identify important factors affecting the quality of holdover handoffs at an internal medicine (IM) residency program and to compare them to previously identified factors for other handoffs.

DESIGN

We undertook a qualitative study using structured focus groups and interviews. We analyzed data using qualitative content analysis.

PARTICIPANTS

IM residents, IM program directors, and hospitalists at a large academic medical center.

MAIN MEASURES

A nine-question open-ended interview guide.

KEY RESULTS

We identified 13 factors describing holdover handoffs. Five factors-physical space, standardization, task accountability, closed-loop verification, and resilience-were similar to those described in prior handoff literature in other specialties. Eight factors were new concepts that may uniquely affect the quality of the holdover handoff in IM. These included electronic health record access, redundancy, unwritten thoughts, different clinician needs, diagnostic uncertainty, anchoring, teaching, and feedback. These factors were organized into five overarching themes: physical environment, information transfer, responsibility, clinical reasoning, and education.

CONCLUSIONS

The holdover handoff in IM is complex and has unique considerations for achieving high quality. Further exploration of safe, efficient, and educational holdover handoff practices is necessary.

A night float week in a surgical clerkship improves student team cohesion

BACKGROUND

We hypothesize that night float rotations in the third-year surgical clerkship improve student learning and perceptions of team cohesion.

METHODS

A 1-week night float (NF) system was implemented during the 2013 to 2014 academic year for students. Each student completed 1 week of NF with the Trauma/Emergency General Surgery service. The Perceived Cohesion Scale survey was prospectively administered and National Board of Medical Examiners academic performance retrospectively reviewed.

RESULTS

We surveyed 70 medical students, 37 traditional call and 33 NF students, with 91% response rate. Perception of team cohesion increased significantly, without perceived loss of educational benefit. Examination scores increased significantly comparing pre- and postintervention groups, with this trend continuing in the following academic year.

CONCLUSIONS

A week-long student NF experience significantly improved perception of team cohesion and standardized examination results. A dedicated period of NF during the surgical clerkship may improve its overall educational value.

Overnight Hospital Experiences for Medical Students: Results of the 2014 Clerkship Directors in Internal Medicine National Survey

BACKGROUND

Since the 2011 Accreditation Council of Graduate Medical Education (ACGME) work hour rules for residents were implemented, 24-30 h call for interns has been replaced by shift work, including night-float. The impact of these changes on undergraduate medical education experiences in internal medicine has not been described.

OBJECTIVE

We aimed to determine the current status of medical students' overnight experiences in Internal Medicine clerkships and sub-internships, and to assess internal medicine educators' perceptions of the importance of overnight work during internal medicine rotations.

DESIGN AND PARTICIPANTS

In May 2014, the Clerkship Directors in Internal Medicine (CDIM) conducted its annual survey. Twenty-eight questions about student participation in overnight work and perceptions of the importance of overnight work (rated on 1-5 Likert scale, 1 = very unimportant and 5 =  ery important) were included. Descriptive statistics were used to summarize responses. Free text results were analyzed qualitatively.

KEY RESULTS

The response rate was 78 %. A minority of respondents reported students having any overnight experience during the clerkship (38.7 %) or the sub-internship (40.7 %). Only 5 % of respondents reported having students assigned to night-float rotations outside of clerkships or sub-internships. Respondents agreed that overnight experiences were more important during the sub-internship than the clerkship, 4.0 ± 1.1 vs. 3.2 ± 1.2, p < 0.001. Admitting new patients, following their course and responding to emergencies were rated as important overnight tasks for both clerkship and sub-internship students.

CONCLUSIONS

Overnight experiences offer students additional educational opportunities. Clerkship directors felt that the overnight experience for the sub-intern in particular was an important chance to practice providing emergency cross coverage and other intern roles. In the era of ACGME duty hours, there is a need to further examine whether there is a role for increased overnight hospital experiences for medical students.