End-of-rotation handoffs associated with in-hospital mortality, study finds

End-of-rotation transitions may heighten mortality risk in internal medicine inpatient care, a study found.

To examine the association of end-of-rotation house staff transitions with mortality among hospitalized patients, researchers conducted a multicenter cohort study of 230,701 patients admitted to internal medicine services in 10 Veterans Affairs hospitals. Patients who were admitted prior to an end-of-rotation transition and died or were discharged within 7 days following transition were stratified by type of transition (intern only, resident only, or intern and resident) and compared with all other discharges (control). An alternative analysis comparing admissions within 2 days before transition with admissions on the same 2 days 2 weeks later was also conducted.

The primary outcome was in-hospital mortality. Secondary outcomes included 30-day and 90-day mortality and readmission rates. A difference-in-difference analysis assessed whether outcomes changed after 2011 Accreditation Council for Graduate Medical Education (ACGME) duty-hour regulation changes. Results were published by JAMA on Dec.6.

Overall mortality was 2.18% in-hospital, 9.45% at 30 days, and 14.43% at 90 days. Authors noted that compared to controls, adjusted hospital mortality was significantly greater in transition patients in the intern-only group (2.0% vs. 3.5%; odds ratio [OR], 1.12 [95% CI, 1.03 to 1.21]) and the intern and resident group (2.1% vs. 4.0%; OR, 1.18 [95% CI, 1.06 to 1.33]), but not significantly different for those in the resident-only group (2.0% vs. 3.3%; OR, 1.07 [95% CI, 0.99 to 1.16]).

Adjusted 30-day and 90-day mortality rates were greater in all transition versus control comparisons. For 30-day mortality, rates were 14.5% versus 8.8% in the intern-only group (OR, 1.17; 95% CI, 1.13 to 1.22), 13.8% versus 8.9% in the resident-only group (OR, 1.11; 95% CI, 1.04 to 1.18), and 15.5% versus 9.1% in the intern and resident group (OR, 1.21; 95% CI, 1.12 to 1.31). For 90-day mortality, rates were 21.5% versus 13.5% in the intern-only group (OR, 1.14; 95% CI, 1.10 to 1.19), 20.9% versus 13.6% in the resident-only group (OR, 1.10; 95% CI, 1.05 to 1.16), and 22.8% versus 14.0% in the intern and resident group (OR, 1.17; 95% CI, 1.11 to 1.23).

Also, duty-hour changes were associated with greater adjusted hospital mortality for transition patients in the intern-only group and intern and resident group than for controls (intern-only: OR, 1.11 [95% CI, 1.02 to 1.21]; intern and resident: OR, 1.17 [95% CI, 1.02 to 1.34]). The alternative analyses did not demonstrate any significant differences in mortality between transition and control groups.

The researchers concluded that end-of-rotation transition in care was associated with significantly higher in-hospital mortality in an unrestricted analysis that included most patients, but not in an alternative restricted analysis, and that the association was stronger following institution of ACGME duty-hour regulations.

An editorial concluded, “Given the need to cultivate a shared mental model during handoffs, using proactive communication is warranted. Yet in [this study], only 3 of the 10 study sites reported a handoff format that reliably and consistently used verbal communication during service change. Instead, 7 sites reported relying predominantly on written communication for service changes, which does not facilitate interactive questioning or confirmation of understanding through ‘read-backs'—practices endorsed by the Joint Commission and the Society of Hospital Medicine.”