The Case

A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine resident—for routine follow-up. The resident was in his final month of training, and would leave the institution for fellowship at the completion of his residency.

After discussion, the provider sent off a prostate-specific antigen (PSA) test to screen the patient for prostate cancer. The patient's past PSA tests had always been normal. Unfortunately, this time his PSA returned markedly elevated at 83 ng/ml—a level at which cancer is a near certainty. The patient was not immediately notified as the electronic alert (via an existing electronic health record) was sent to the patient's primary care provider. However, because this provider had graduated and left the program before the alert returned, and there was no system to ensure smooth handoffs to oncoming residents, the alert went unread.

Eight months later, the patient presented with new onset low back pain. Imaging tests confirmed metastatic prostate cancer and also uncovered the missed follow-up of the elevated PSA.

The Commentary

Background

Transfers of patient care from one physician to another, known as "handoffs," are pervasive.(1) Failures in these communication processes are common (2,3) and can lead to medical errors and patient harm.(4-6) These risks prompted the Institute of Medicine (7) to recommend and the ACGME to require, as of July 2011, enhanced training for residents in safe transitions in care.(8) Similarly, The Joint Commission mandates a standardized approach to handoff communications.(9)

Until recently, research has focused on transitions necessitated by transfer to a different setting of care (e.g., discharge from the hospital) or by a provider's end-of-shift. Few studies have examined the safety risks presented by the type of handoff in this case—the academic year-end transfer that occurs every July and affects hundreds of thousands (if not millions) of outpatients in the United States when residents advance to a higher level of training or graduate.(10) Family medicine, internal medicine, pediatrics, and psychiatry are the most frequently affected specialties because their trainees spend significant time in ambulatory-based continuity clinics.

While year-end handoffs resemble other types of handoffs in many regards, there are important distinguishing features.(11) First, the year-end transfer often terminates a long-term treatment relationship that can be experienced by patients as a significant loss, and lead to increased symptoms.(12-14) This potentially heightened acuity makes monitoring even more critical during the transition. Second, residents stationed in continuity clinics have often accumulated large panels of patients. As a result, the year-end transfer requires unique organizational processes capable of seamlessly transitioning a high volume of patients at one time. Without such processes in place, there is a higher probability of patients or important clinical information "falling through the cracks" compared with other types of transfers. This case demonstrates how information loss can delay a workup and lead to devastating outcomes. Third, patients are transferred from experienced trainees to those with much less experience and skill. This experience gradient can be significant and warrant slower caseload growth, enhanced supervision, and specialized didactics for new providers early in their training.(15) Fourth, the year-end handoff is a permanent provider change rather than the more customary cross-coverage handoff. This requires the incoming clinician to immediately assume responsibility for each patient's care, often without access to the previous provider, even though many of these patients will not be seen for weeks to months. Finally, patient factors such as adherence to and engagement in treatment plans are more problematic in the ambulatory setting. It's not always clear what follow-up instructions a patient was given by an outgoing clinician, or whether a patient failed to initiate follow-up. Handoffs in which the patient resides in the clinical setting (e.g., nursing homes, acute hospital) do not face this challenge.

Given these features, the academic year-end transfer poses significant patient safety risks as well as educational challenges. Studies have drawn on the existing handoff literature to propose features of a safe year-end transfer process.(10,11)

• I. Identify and Prioritize Higher Risk Patients. Because incoming clinicians often receive a large panel of patients in the academic year-end transfer, programs should identify patients whose acuity, complexity, or both require priority attention. These patients should be scheduled proactively by the clinic for longer appointments during the first weeks of the new academic year. A recent study showed that a simple categorical designation of "acute" or "non-acute" by the outgoing residents effectively predicted those patients more likely to require hospitalization or have significant symptoms during the transition period. This process facilitated nearly 90% of acute patients being seen in the first month.(16)
• II. Communication Processes. The handoff should be organized with a structured written and verbal sign-out for the resident (and the attending as well, if he or she is also changing). For the written sign-out, programs should use computer-based templates that ideally pre-populate with information from the electronic medical record. As with other types of handoffs, the written sign-out should identify active issues, pending lab tests (such as the PSA in this case), and recent significant changes in clinical status. Additional types of ambulatory-specific information may be relevant, such as long-term goals (e.g., smoking cessation or weight loss) or communication and motivational strategies that work best with the patient. The verbal sign-out should ideally be face-to-face but logistical considerations may require transfer sessions via telephone. Depending on the panel sizes, the verbal sign-out may need to be limited to "acute" patients. In addition, the verbal sign-out should occur in a quiet setting with the written sign-out in hand and the opportunity to ask clarifying questions and take notes. A psychiatry program implemented a face-to-face and written sign-out process for the academic year-end transfer by using the half day normally set aside for didactics. The quality of handoff communication as perceived by the incoming residents improved substantially.(16)
• III. Create Balanced Initial Caseloads. Resident panels in continuity clinics can develop differently over time. For reasons of administrative simplicity, the traditional method has largely preserved prior caseloads (i.e., incoming resident A receives all of outgoing resident B's patients). This can lead to significant variability in acuity and complexity between caseloads. A recent study adapted mental workload theory to develop a method for constructing balanced outpatient caseloads during the year-end transfer. This intervention successfully reduced inter-caseload variability by 50% in key domains of mental workload.(15)
• IV. Attend to the Patient. Patients experience the year-end handoff as stressful.(13) Mechanisms should be developed to help prepare the patient for the transfer and to navigate care during the transitional period. Effective strategies include a letter from the outgoing clinician notifying the patient of their new clinician (13) or a phone call from the new clinician during the first days or weeks (with a template phone note that guides the trainee and facilitates documentation).(16) This kind of strategy may have prompted or helped the patient in our case to initiate contact earlier with his new clinician.
• V. Provide Handoff Training. In order to facilitate learning safe handoff practices during the academic year-end transfer, it is important to provide trainees with didactics and dedicated learning opportunities. These may include specialized transition curricula, training in communication skills for giving and receiving sign-out, structured verbal and written sign-out tools, augmented supervision, and requirements for incoming clinicians to make immediate phone contact with their new patients. Additional educational topics may include how outgoing residents prepare patients for the transfer or determine which patients are "acute" and how incoming residents should approach the initial visit, prioritize tasks, and establish a new therapeutic relationship. All of these complementary strategies are potentially useful but they also may need adaption, depending on the specialty and type of training program.

For all types of handoffs, little is known about the impact of handoff interventions on clinical outcomes. Future research is needed to test the impact of such interventions on key clinical outcomes, including rates of hospitalization, clinical decompensation, errors, and medication adherence. In the meantime, the principles above should be used to guide the development of handoff processes that better protect patients and educate residents during the academic year-end transfer.

Take-Home Points

• The academic year-end transfer of outpatients in resident continuity clinics affects a large number of patients each July and poses significant patient safety risks.
• The academic year-end transfer of outpatients has a number of unique features compared with traditional handoffs, including the experience gradient between outgoing and incoming clinicians, and the large volume of patients being transferred simultaneously.
• Steps can be taken to enhance patient safety during the academic year-end transfer, including identifying and scheduling acute patients on a priority basis, requiring standardized written and verbal sign-outs, balancing initial caseloads, notifying the patients, and providing handoff training to the residents.

John Q. Young, MD, MPP Assistant Professor Associate Program Director, Residency Training Program Department of Psychiatry, UCSF School of Medicine

References

1. Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1:257-266. [go to PubMed]

2. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14:401-407. [go to PubMed]

3. Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166:1173-1177. [go to PubMed]

4. Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med. 2006;145:488-496. [go to PubMed]

5. Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34:563-570. [go to PubMed]

6. Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121:866-872. [go to PubMed]

7. Ulmer C, Wolman DM, Johns MME, eds. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, Institute of Medicine. Washington, DC: The National Academies Press; 2008. ISBN: 9780309127721. [Available at]

8. ACGME Duty Hours. Chicago, IL: Accreditation Council of Graduate Medical Education; 2011. [Available at]

9. National Patient Safety Goals. Oakbrook Terrace, IL: The Joint Commission; 2011. [Available at]

10. Young JQ, Wachter RM. Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue. JAMA. 2009;302:1327-1329. [go to PubMed]

11. Young JQ, Eisendrath SJ. Enhancing patient safety and resident education during the academic year-end transfer of outpatients: lessons from the suicide of a psychiatric patient. Acad Psychiatry. 2011;35:54-57. [go to PubMed]

12. Mischoulon D, Rosenbaum JF, Messner E. Transfer to a new psychopharmacologist: its effect on patients. Acad Psychiatry. 2000;24:156-163. [Available at]

13. Roy MJ, Herbers JE, Seidman A, Kroenke K. Improving patient satisfaction with the transfer of care. A randomized controlled trial. J Gen Intern Med. 2003;18:364-369. [go to PubMed]

14. Roy MJ, Kroenke K, Herbers JE Jr. When the physician leaves the patient: predictors of satisfaction with the transfer of care in a primary care clinic. J Gen Intern Med. 1995;10:206-210. [go to PubMed]

15. Young JQ, Niehaus B, Lieu SC, O'Sullivan PS. Improving resident education and patient safety: a method to balance initial caseloads at academic year-end transfer. Acad Med. 2010;85:1418-1424. [go to PubMed]

16. Young J, Pringle Z, Wachter R. Academic year-end outpatient transfers: identifying and improving follow-up of high risk psychiatry patients in resident continuity clinics. Jt Comm J Qual Patient Saf. 2011;37:300-308. [Available at]