Work Hour Limits for Medical Residents Spur Otolaryngologists to Rethink Patient Handoffs

It was the beginning of an overnight shift, and the junior resident was the only one in house. He had been briefed about the group of patients he was responsible for, and one patient—who had a complex cancer and underlying cardiac issues and had just come out of a long surgery—had been prescribed a specific antibiotic following the procedure. But what step would the resident take next, when the patient developed a cardiac arrhythmia due to intraoperative blood loss or fluid shifts at 2 a.m.? Would it be something the junior resident had decided on the fly, or had a senior attending physician already envisioned this possibility and discussed how to respond, hours before?

How well these questions are answered depends on how the patient handoff—the information the day’s group of doctors presented to the overnight shift—went earlier in the shift. The handoff procedure is a crucial part of patient care, and standards to strengthen it were implemented in 2011 by the Accreditation Council for Graduate Medical Education (ACGME). In light of the 2003 resident duty hour restrictions—limiting residents to working 80 hours a week, overnight shifts every third or fourth night and at least 10 hours off between shifts—most people admitted to a medical center for care will be seen by at least two shifts of health care workers as one group takes over for the next.

For residents, knowing how to communicate crucial handoff details is a skill learned on the job. Those details boil down to two questions: 1) What is the bottom line for each patient? and 2) What are the potential interventions if a patient deviates from what is expected? With more groups of people overseeing patients in an era of restricted medical resident work hours, the potential for missed details has increased.

How should handoffs work? “There is a basic expectation that physicians transfer relevant information to colleagues in instances in which they are not available to their patients 24/7,” said Ingrid Philibert, PhD, MBA, ACGME’s senior vice president of the department of field activities. “This predated the duty hour limits, but the limits increased the frequency of handoffs and made the consequences of no, or suboptimal, handoffs much more prominent.” With additional people taking over responsibility for patients over any given day or week, there are “more opportunities for missed, erroneous or distorted information being transferred during these handoffs,” she added.