A new multifaceted study examines the implications of end-of-rotation transitions by resident students on the health of patients at 10 university-affiliated US Veterans Affairs hospitals. The findings of an unrestricted analysis suggest that there is a significant increase in the amount of in-hospital deaths related to end-of-rotation transitions; however, in a restricted analysis, similar results were not found.
Recently, there has been an increase in the amount of evidence that suggests that transitions between attending resident physicians at the end of shifts can result in miscommunication leading to negative consequences in regards to patient care. The effects of a specific type of transition known as end-of-rotation transition, where the patient is transferred to a new team for further care, is particularly intriguing because its effects on the patient, specifically their mortality, is largely unknown. Recent research published in the Journal of the American Medical Association explored whether there was a link between end-of-rotation transitions and higher mortality rates. In addition, they wanted to determine if there was indeed a link, whether the 2011 regulation changes by the Accreditation Council for Graduate Medical Education (ACGME) which restricted the amount of hours worked by first-year residents, also known as interns, had any effect on this relationship.
The investigators of this study looked at patients who were at least 18 years of age, that were discharged from one of the 10 university-affiliated US Veterans Affairs hospitals in New York, between the years 2008 and 2014. Based on the data recovered from these patients, the researchers devised two separate analyses. The first, or main analysis, consisted of individuals that had been admitted into the hospital and experienced an end-of-rotation transition and then were ultimately discharged or died within 7 days of the transition. Of a total of 230,701 discharged patients 25,938 experienced an intern-to-intern transition, 26,456 experienced a resident-to-resident transition, and 11,517 patients experienced care from both a resident and an intern. These patients which composed the experimental group were all matched to control individuals who did not experience a change in care providers. The second, or alternative analysis, looked at individuals that were admitted to the hospital within 2 days of an end-of-rotation transition and compared them to individuals who were admitted 2 weeks later. The results of the study yielded conflicting results. The results from the main analysis found that there was a significantly increased risk of in-hospital mortalities in patients that were exposed to an end-of-rotation transition in comparison to the control individuals. Furthermore, this correlation was found to have strengthened after the regulation change that occurred in 2011. Conversely, when studying the results from the alternative analysis, researchers determined that there was no significant increase in mortality rates between experimental and control individuals.
These findings suggest that there could be an increase with regards to in-hospital mortality rates following end-of-rotation transitions. However, because the results from the two analyses were conflicting, it is beneficial to examine their limitations. For example, the alternative analysis consisted of a much smaller sample size and therefore, could have limited the ability of the analysis to show any effects on mortality. While the results are interesting, more studies will have to be conducted to yield more solid evidence as to the effects of transitions on mortality rates. Future results may impact the way that hospitals are run, in order to decrease the effects of these transitions on patient health.
Written By: Sonia Parmar, HBSc