Study: Cases at end of hand-off get less time
Experts advise steps to prioritize complex cases
A new study, led by researchers at the University of Michigan (UM) in Ann Arbor, suggests that clinicians might not be spending enough time discussing some of the most complex patients when they are handing off these cases during shift changes. And there is a simple reason why, according to Michael Cohen, PhD, professor of complex systems, information, and public policy at UM.
"We found that even when the physicians are very experienced, they spend about 50% more time on the patients discussed early in a hand-off than they do on those discussed near the end of the session," explains Cohen. "This was true despite the fact that they were working from a list ordered by room number, and so they were taking the patients essentially in random order."
Cohen's study consisted of an analysis of 23 hand-off sessions, involving 262 patients in the intensive care unit (ICU) at Kingston General Hospital in Ontario, Canada. The physicians turned over between six and 23 patients in each of nearly two dozen hand-off sessions. While the physicians spent, on average, 2.5 minutes per patient, this varied significantly. The researchers report that for physicians who were handing off medium-sized groups of 11 patients, the average time spent per case steadily declined as the physicians moved down the list of patients to be handed off.1
Consider 'the portfolio effect'
While this study involved patients in the ICU, Cohen says that the findings should apply to hand-offs in the ED as well as other hospital units. Regardless of the unit or setting, people tend to rush at the end, an observation that should be familiar to people who regularly attend other types of meetings, he says.
However, hospital hand-offs can have a major impact on patient care, particularly in the early parts of a shift. More than a billion of these hand-offs happen in the United States every year, according to the researchers. And they say the number has increased substantially in recent years, as administrators have become more focused on enforcing work-hour regulations.
While patient safety breakdowns during hand-offs have received considerable attention among researchers and quality experts, Cohen points out that most of the training in this area focuses on how to hand off a single patient as opposed to groups of patients. He suggests a better approach would take into consideration the fact that most hand-offs happen in batches. And the results, which he calls "the portfolio effect," can adversely impact patient safety.
Cohen says he has observed hand-offs in which key details were left out of the conversation about a patient. Indeed, the Institute of Medicine reports that preventable medical errors cause as many as 98,000 deaths each year, and studies show that hand-off miscommunications are a major contributing factor. Considering the hundreds of millions of hospital hand-offs that occur every year, Cohen argues that even a slight improvement in hand-off communications could prevent a huge number of injuries and deaths.
Try simple remedies
Cohen points out that informal observations suggest that the problem is "very widespread," but he says it is easy to assess whether it is happening, and there are a number of relatively simple remedies. "The key point is for the off-going physician to begin the [hand-off] session identifying the cases that need the most time," says Cohen, noting that these cases can then be taken at the beginning of the session. "The whole patient list can be ordered by the time required, or time can be preserved later on for the cases that need it."
While the changes required are not difficult, Cohen stresses that participants, whether they are physicians or nurses, need to become mindful of how much time they have to allocate across all the cases so that they can then put in the time where it is most needed.
- Cohen M, Ilan R, Garrett L, et al. The earlier the longer: Disproportionate time allocated to patients discussed early in attending physician handoff sessions. Archives of Internal Medicine 2012 [Epub ahead of print]
Michael Cohen, PhD, Professor of Complex Systems, Information, and Public Policy, University of Michigan, Ann Arbor, MI. E-mail: email@example.com.