Improving resident education and patient safety: a method to balance initial caseloads at academic year-end transfer

Year-End Resident Clinic Handoffs: Narrative Review and Recommendations for Improvement

BACKGROUND

Year-end clinic handoffs in resident continuity clinics are an important patient safety issue.

METHODS

Intervention articles addressing the year-end resident clinic handoff were identified in a targeted literature search. These articles were reviewed and abstracted to summarize the current literature. On the basis of these reviews and consensus expert opinion, recommendations to improve year-end clinic handoffs were developed.

RESULTS

Of 23 identified articles, 10 intervention articles in the fields of internal medicine, internal medicine-pediatrics, psychiatry, and family medicine were ultimately included. The additional 13 nonintervention studies were used as background material. There were 12 clinic handoff recommendations for improvement: (1) focus on patients most at risk during the handoff, (2) educate residents, (3) consider balancing caseloads for the residents, (4) prepare patients for the handoff and perform patient-centered outreach, (5) standardize a written method of sign-out and require verbal communication for a subset of patients, (6) use a standardized template or technology solution for the handoff, (7) identify specific tasks that require follow-up, (8) enhance attending supervision during the handoff, (9) make patient assignments clear after the handoff, (10) have patients establish care with the new provider as soon as possible after the handoff, (11) establish care with telephone contact prior to the first visit, (12) perform safety audits to ensure that sign-out occurs, patients receive appointments, no-shows are rescheduled, and task follow-up is completed.

CONCLUSION

There is emerging evidence for interventions to improve year-end resident clinic handoffs, and the recommendations provided are a starting point to guide training programs.

Influence of learner knowledge and case complexity on handover accuracy and cognitive load: results from a simulation study

CONTEXT

The handover represents a high-risk event in which errors are common and lead to patient harm. A better understanding of the cognitive mechanisms of handover errors is essential to improving handover education and practice.

OBJECTIVES

This paper reports on an experiment conducted to study the effects of learner knowledge, case complexity (i.e. cases with or without a clear diagnosis) and their interaction on handover accuracy and cognitive load.

METHODS

Participants were 52 Dutch medical students in Years 2 and 6. The experiment employed a repeated-measures design with two explanatory variables: case complexity (simple or complex) as the within-subject variable, and learner knowledge (as indicated by illness script maturity) as the between-subject covariate. The dependent variables were handover accuracy and cognitive load. Each participant performed a total of four simulated handovers involving two simple cases and two complex cases.

RESULTS

Higher illness script maturity predicted increased handover accuracy (p < 0.001) and lower cognitive load (p = 0.007). Case complexity did not independently affect either outcome. For handover accuracy, there was no interaction between case complexity and illness script maturity. For cognitive load, there was an interaction effect between illness script maturity and case complexity, indicating that more mature illness scripts reduced cognitive load less in complex cases than in simple cases.

CONCLUSIONS

Students with more mature illness scripts performed more accurate handovers and experienced lower cognitive load. For cognitive load, these effects were more pronounced in simple than complex cases. If replicated, these findings suggest that handover curricula and protocols should provide support that varies according to the knowledge of the trainee.

Unpacking the Complexity of Patient Handoffs Through the Lens of Cognitive Load Theory

ISSUE

The transfer of a patient from one clinician to another is a high-risk event. Errors are common and lead to patient harm. More effective methods for learning how to give and receive sign-out is an important public health priority.

EVIDENCE

Performing a handoff is a complex task. Trainees must simultaneously apply and integrate clinical, communication, and systems skills into one time-limited and highly constrained activity. The task demands can easily exceed the information-processing capacity of the trainee, resulting in impaired learning and performance. Appreciating the limits of working memory can help identify the challenges that instructional techniques and research must then address. Cognitive load theory (CLT) identifies three types of load that impact working memory: intrinsic (task-essential), extraneous (not essential to task), and germane (learning related). The authors generated a list of factors that affect a trainee's learning and performance of a handoff based on CLT. The list was revised based on feedback from experts in medical education and in handoffs. By consensus, the authors associated each factor with the type of cognitive load it primarily effects. The authors used this analysis to build a conceptual model of handoffs through the lens of CLT.

IMPLICATIONS

The resulting conceptual model unpacks the complexity of handoffs and identifies testable hypotheses for educational research and instructional design. The model identifies features of a handoff that drive extraneous, intrinsic, and germane load for both the sender and the receiver. The model highlights the importance of reducing extraneous load, matching intrinsic load to the developmental stage of the learner and optimizing germane load. Specific CLT-informed instructional techniques for handoffs are explored. Intrinsic and germane load are especially important to address and include factors such as knowledge of the learner, number of patients, time constraints, clinical uncertainties, overall patient/panel complexity, interacting comorbidities or therapeutics, experience or specialty gradients between the sender and receiver, the maturity of the evidence base for the patient's disease, and the use of metacognitive techniques. Research that identifies which cognitive load factors most significantly affect the learning and performance of handoffs can lead to novel, contextually adapted instructional techniques and handoff protocols. The application of CLT to handoffs may also help with the further development of CLT as a learning theory.

Systematic training in internal medicine-pediatrics end of residency handoffs: residency director attitudes and perceived barriers

BACKGROUND

It is unclear why systematic training in end-of-residency clinic handoffs is not universal.

PURPOSES

We assessed Internal Medicine-Pediatrics (Med-Peds) residency program directors' attitudes regarding end-of-residency clinic handoff systems and perceived barriers to their implementation.

METHODS

We surveyed all Med-Peds program directors in the United States about end-of-residency outpatient handoff systems.

RESULTS

Program directors rated systems as important (81.5%), but only 31 programs (46.3%) utilized them. Nearly all programs with (29/31 [93.5%]), and most programs without systems (24/33 [72.7%]) rated them as important. Programs were more likely to have a system if the program director rated it important (p = .049), and less likely if they cited a lack of faculty interest (p = .023) or difficulty identifying residents as primary providers (p = .04).

CONCLUSIONS

Most program directors believe it important to formally hand off outpatients. Barriers to establishing handoff systems can be overcome with modest curricular and cultural changes.

What do patients think about year-end resident continuity clinic handoffs? A qualitative study

BACKGROUND

Although Internal Medicine year-end resident clinic handoffs affect numerous patients, little research has described patients' perspectives of the experience.

OBJECTIVE

To describe patients' perceptions of positive and negative experiences pertaining to the year-end clinic handoff; to rate patient satisfaction with aspects of the clinic handoff and identify whether or not patients could name their new physicians.

DESIGN

Qualitative study design using semi-structured interviews.

PARTICIPANTS

High-risk patients who underwent a year-end clinic handoff in July 2011.

MEASUREMENTS

Three months post-handoff, telephone interviews were conducted with patients to elicit their perceptions of positive and negative experiences. An initial coding classification was developed and applied to transcripts. Patients were also asked to name their primary care physician (PCP) and rate their satisfaction with the handoff.

RESULTS

In all, 103 telephone interviews were completed. Patient experiences regarding clinic handoffs were categorized into four themes: (1) doctor-patient relationships (i.e. difficulty building rapport); (2) clinic logistics (i.e. difficulty rescheduling appointments); (3) process of the care transition (i.e. patient unaware transition occurred); and (4) patient safety-related issues (i.e. missed tests). Only 59 % of patients could correctly name their new PCP. Patients who reported that they were informed of the clinic transition by letter or by telephone call from their new PCP were more likely to correctly name them (65 % vs. 32 % p = 0.007), report that their new doctor assumed care for them immediately (81 % [68/84] vs. 53 % [10/19], p = 0.009) and report satisfaction with communication between their old and new doctors (80 % [67/84] vs. 58 % [11/19], p = 0.04). Patients reported positive experiences such as learning more about their new physician through personal sharing, which helped them build rapport. Patients who reported being aware of the medical education mission of the clinic tended to be more understanding of the handoff process.

CONCLUSIONS

Patients face unique challenges during year-end clinic handoffs and provide insights into areas of improvement for a patient-centered handoff.

Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety

PURPOSE

Although internal medicine resident clinic handoffs present risks for patients, few interventions exist. The authors evaluated an enhanced handoff.

METHOD

In 2011, the authors formalized a handoff protocol including a standardized sign-out process, resident education, improved scheduling, and time to establish care through telephone visits. The authors surveyed 25 residents in 2011 and 19 in 2010 regarding their perceptions and performed chart audits to examine patient outcomes.

RESULTS

Compared with 2010, residents in 2011 reported longer handoffs (>20 minutes, 52% versus 6%, P<.01), more verbal handoffs (80% versus 38%, P<.01), more patients aware of the handoff (100% versus 74%, P=.01), less discomfort with paperwork for patients not yet seen (40% versus 74%, P=.03), and more ownership of patients before the first visit (56% versus 26%, P=.05). In 2011, more patients saw their correct primary care provider (82% versus 44%, P<.01), and more tests were followed up appropriately (67% versus 46%, P=.02). The authors detected in 2011 a trend for patients to be seen the month their physician intended (40% versus 33%, P=.06) and a trend toward fewer acute (hospital and emergency department) visits three months post handoff (20% versus 26%, P=.06).

CONCLUSIONS

Enhancing clinic handoffs can improve the handoff process, increase the likelihood of patients seeing the correct primary care provider within the target time frame, reduce missed tests, and possibly reduce acute visits.

Current Practice in End-of-Residency Handoffs: A Survey of Internal Medicine-Pediatrics Program Directors

BACKGROUND

End-of-residency outpatient handoffs affect at least 1 million patients per year, yet there is no consensus on best practices.

OBJECTIVE

To explore the use of formal systems for end-of-residency clinic handoffs in internal medicine-pediatrics residency (Med-Peds) programs, and their associated categorical internal medicine and pediatrics programs.

METHODS

We surveyed Med-Peds program directors about their programs' system for handing off ambulatory continuity patients.

RESULTS

Our response rate was 85% (67 of 79 programs). Thirty-one programs (46%) reported having a system for end-of-residency handoffs. Of the 30 that offered detailed information, 22 (73%) formally introduced the program to residents, 12 (40%) standardized the handoff, and 14 (47%) used multiple methods for information exchange, with the electronic health record and oral transfer of information (15 of 30, 50%) the most common. Six programs (20%) indicated they did not offer residents protected time to complete end-of-residency handoffs, and 13 programs (43%) did not identify a specific postgraduate year level for residents to whom patients were handed off. Programs were more likely to have a system for end-of-residency handoffs if another categorical program at their institution also had one (P < .001).

CONCLUSIONS

Fewer than half of responding Med-Peds programs have outpatient handoff systems in place. Inclusion of end-of-residency handoff information in the electronic health record may represent a best practice that has the potential of enhancing continuity and safety of care for patients in resident continuity clinics.

Outcomes for resident-identified high-risk patients and resident perspectives of year-end continuity clinic handoffs

BACKGROUND

Many patients nationwide change their primary care physician (PCP) when internal medicine (IM) residents graduate. Few studies have examined this handoff.

OBJECTIVE

To assess patient outcomes and resident perspectives after the year-end continuity clinic handoff

DESIGN

Retrospective cohort

PARTICIPANTS

Patients who underwent a year-end clinic handoff in July 2010 and a comparison group of all other resident clinic patients from 2009-2011. PGY2 IM residents surveyed from 2010-2011.

MEASUREMENTS

Percent of high-risk patients after the clinic handoff scheduled for an appointment, who saw their assigned PCP, lost to follow-up, or had an acute visit (ED or hospitalization). Perceptions of PGY2 IM residents surveyed after receiving a clinic handoff.

RESULTS

Thirty graduating residents identified 258 high-risk patients. While nearly all patients (97 %) were scheduled, 29 % missed or cancelled their first new PCP visit. Only 44 % of patients saw the correct PCP and six months later, one-fifth were lost to follow-up. Patients not seen by a new PCP after the handoff were less likely to have appropriate follow-up for pending tests (0 % vs. 63 %, P<0.001). A higher mean no show rate (NSR) was observed among patients who missed their first new PCP visit (22 % vs. 16 % NSR, p<0.001) and those lost to follow-up (21 % vs. 17 % NSR, p=0.019). While 47 % of residents worried about missing important data during the handoff, 47 % reported that they do not perceive patients as "theirs" until they are seen by them in clinic.

CONCLUSIONS

While most patients were scheduled for appointments after a clinic handoff, many did not see the correct resident and one-fifth were lost to follow-up. Patients who miss appointments are especially at risk of poor clinic handoff outcomes. Future efforts should improve patient attendance to their first new PCP visit and increase PCP ownership.

An intervention to improve ambulatory care handoffs at the end of residency

INTRODUCTION

The medical literature shows evidence of numerous initiatives to improve inpatient physician handoffs. In contrast, handoffs of ambulatory patients to incoming interns or junior residents at the end of residency are an area of potential concern that has been overlooked.

OBJECTIVES

To examine handoffs of high-risk ambulatory patients by outgoing residents to junior colleagues and to compare current practice to a standard handoff process. We hypothesized the intervention would lead to increases in the number and quality of ambulatory care handoffs.

METHODS

Fourteen graduating internal medicine and combined internal medicine-pediatrics residents who practiced at an academic continuity clinic were randomized to an intervention or a control group. E-mail instructions were sent asking the intervention group to write a handoff note using the clinic's electronic medical record system. The e-mail included a detailed outline of information to incorporate and highlight features of the electronic medical record that would facilitate the process. The handoff notes of the intervention and control group were independently evaluated and scored for quality using a predetermined point system.

RESULTS

Six of the 7 residents (86%) in the intervention group completed 19 handoff notes; none of the residents in the control group completed handoff notes. Most of the handoffs provided a brief paragraph or 2 of background information on the patient and then focused on issues needing short-term follow-up during the coming months.

CONCLUSIONS

The standardized handoff process implemented via simple e-mail instructions increased the number of outpatient handoffs at the completion of residency. Further study with a larger number of residents, identification and removal of barriers to the handoff process, and correlation of handoffs to clinical outcomes are key next steps.

Educating generalists: factors of resident continuity clinic associated with perceived impact on choosing a generalist career

BACKGROUND

Fewer residents are choosing general internal medicine (GIM) careers, and their choice 5 be influenced by the continuity clinic experience during residency. We sought to explore the relationship between resident satisfaction with the continuity clinic experience and expressed interest in pursuing a GIM career.

METHODS

We surveyed internal medicine residents by using the Veterans Health Administration Office of Academic Affiliations Learners' Perceptions Survey-a 76-item instrument with established reliability and validity that measures satisfaction with faculty interactions, and learning, working, clinical, and physical environments, and personal experience. We identified 15 reliable subscales within the survey and asked participants whether their experience would prompt them to consider future employment opportunities in GIM. We examined the association between satisfaction measures and future GIM interest with 1-way analyses of variance followed by Student-Newman-Keuls post hoc tests.

RESULTS

Of 217 residents, 90 (41%) completed the survey. Residents felt continuity clinic influenced career choice, with 22% more likely to choose a GIM career and 43% less likely. Those more likely to choose a GIM career had higher satisfaction with the learning (P  =  .001) and clinical (P  =  .002) environments and personal experience (P < .001). They also had higher satisfaction with learning processes (P  =  .002), patient diversity (P < .001), coordination of care (P  =  .009), workflow (P  =  .001), professional/personal satisfaction (P < .001), and work/life balance (P < .001).

CONCLUSIONS

The continuity clinic experience 5 influence residents' GIM career choice. Residents who indicate they are more likely to pursue GIM based on that clinical experience have higher levels of satisfaction. Further prospective data are needed to assess if changes in continuity clinic toward these particular factors can enhance career choice.

Improving follow-up of high-risk psychiatry outpatients at resident year-end transfer

BACKGROUND

Few studies have examined the safety risks of the annual outpatient clinic handoffthat occurs when residents either advance to a higher level of training or graduate ("year-end transfer"). A multifaceted intervention was designed and implemented to identify and improve followup of high-risk patients during academic year-end outpatient transfers in a psychiatry resident continuity clinic.

METHODS

Departing residents identified "acute" patients, who were scheduled on a priority basis for longer appointments during the first month after the transfer. In addition, standardized written and face-to-face sign-outs occurred, incoming clinicians contacted every patient in the first week, and specialized didactics were provided.

RESULTS

For the three intervention years combined, the odds ratio of hospitalization for acute patients compared to nonacute patients was 9.2 (95% confidence interval [CI]: 2.43, 34.7; p = .001). Compared to Year 1, the proportion of acute patients seen within 31 days in Years 2 and 3 increased by 32.2% (from 64.3% to 85.0%, p < .0001). The median time-to-first visit for acute patients decreased by 42% (from 24 days in Year 1 to 14 days in Year 3, p = .001). Finally, resident perception of the quality of the handoffim-proved in all areas compared to baseline, including resident-to-resident communication (2.8 to 3.0, p = .03), accuracy of caseload lists (2.8 to 4.1,p = .003), identification of high-risk patients (2.1 to 3.7, p < .0001), and usefulness of supervision during the transition (2.7 to 4.3, p < .0001).

CONCLUSIONS

Categorical designation by the outgoing clinicians effectively identified patients at higher risk for hospitalization during the transition. Relatively low-cost interventions may significantly improve patient safety and resident training in not only psychiatry, but also other disciplines and specialties.