Former CIR National President Simon Ahtaridis, MD, MPH describes observing a chaotic scene as a med. student on rotation:

Who has the patient in 832? Their pressure is seventy over palp and they are maxed out on Levo.”

The cluster of residents gathered in the small backroom began to frantically shuffle through note cards, scraps of paper, and folded sign outs, a scene that would not inspire confidence. […]

The overhead speaker blared to life, “code in 832.” Everyone abandoned their sheets and ran to the room finding a morbidly obese gentleman being moved with great difficulty onto a board.

“Who’s patient is this?”

“What’s his code status?”

“What’s going on? Who found him?”

“What did he come in with?”

“What does he have, what meds is he on?”

“Is anyone running this code?”

“Where is his chart?” “Does anyone know anything about this patient?”

Silence.

This example brings to light a dangerous reality in medicine: Even though the transfer of care of a patient from one physician to another is a daily occurrence, the process receives little attention and  is far from standardized across and even within medical institutions. Additionally, resident physicians receive very little training on the process.  

It is important for patient safety that a greater focus is placed on examining and improving patient hand-offs. Hours Watch includes an excellent “Best Practice” example related to patient hand-offs, which includes a checklist for the safe transfer of care.

Sign-outs should, at a minimum, comply with JCAHO standards and:

• be both written and oral 
• occur face-to-face
• be interactive, with time for questions, responses, confirmation, and feedback
• be supervised by higher levels of the team and involve as much of the team as possible
• be inter-specialty, where appropriate
• be interdisciplinary (e.g. include RNs, PAs and other professionals) when feasible and include notice to RNs of changed coverage and responsibilities
• be standardized within and, as much as possible, across departments
• be computerized
• be done in coordination with electronic access to patient records and data
• occur in a location and at a time free of interruptions
• be a formally trained and evaluated skill (including experiential workshops and didactics) that includes monitoring the quality of the process
• result in identifying the sickest patients and giving notice to RNs and other staff so they can anticipate problems
• be subject to regular re-evaluation and improvement
  

As we move to a shorter work hour standard, it is increasingly important that we evaluate how the process of patient hand-offs can be improved. Some opponents of work hours reform have tried to use the risk inherent in increased patient hand-offs as an  excuse to resist reducing hours. However, a randomized control trial published in the New England Journal of Medicine in 2004 showed that the error rate associated with fatigue outweighed the error rate associated with increased hand-offs (Landrigan et al., NEJM, 2004, Oct 28; 351(18):1838-48).

Nonetheless, improving the patient hand-off process is an imperative patient safety goal that deserves more attention.

How are patient hand-offs done in your hospitals? What are your thoughts on the subject, and how it could be improved? 

All night call is a hallmark of residency training, but hardly a pleasant experience. While numerous studies demonstrate how the fatigue that results from all night call effects patient safety, it is also important to look at the psychological and emotional effects such schedules have on residents physicians.

 In an excellently written piece originally appearing in the Hartford Courant, Jenny Blair, MD illustrates what young doctors face when on-call. She writes:

4:30 a.m. Beepbeepbeepbeep. Another resident stirs in the adjoining bed. “It’s just my alarm,” you murmur aloud. You twist around, turn it off and lie back down in the dark.

Dimly, a thought arises… maybe someone paged me.

You sit up, nauseated, trying to remember what to do. Dial. The nurse’s voice is brisk and alert. Bed 4, whom you decided a few hours ago not to intubate, is getting worse. “I’ll come see him,” you say huskily. Slip stinking feet into loafers. Take white coat off the bedpost. Breathe slowly. The air seems to burn in the chest.

At that hour, the brain works differently. Some filter that stratifies things by importance is lost. The eye wanders to handwriting on a chart, a torn piece of paper, the patient’s dry-skinned knee, just as easily as it does to the vital signs or heaving chest. This makes it difficult to make decisions.

In the 24th hour of your working day, on half-an-hour of sleep, you sedate a desperately ill person, open his mouth with a metal instrument and put a breathing tube down his windpipe.

 Later on, Dr. Blair concludes:

There is a sensation of physical outrage that washes over one in the wee hours when one has had little or no sleep and is faced with the task of caring for sick human beings. There is a wrongness to it, a sense of betrayal of both oneself and the patient. The instinctive need to decline the responsibility and lie down is so strong that rage wells up when there is no way to do so. In a profession where sloppy work is never excusable, residents on call are set up to fail.

[…]

During some of the worst moments on call, when I dragged myself to my tasks, and patients’ families looked to me with hope and trust, it gradually became clear that none of them had any idea of the condition I was in. I often fantasized of saying to them, “Hello. I’m Dr. Blair. I’ve been awake since 4:30 yesterday morning. How can I help you today?” I never did, but still can’t help thinking: If they only knew.

 
What is/was call like for you during residency? What type of psychological or emotional effect did it have on you? Do you have a call horror story? Please share your answers in the comments below.