‘Warm handoffs,’ rapid response calls

Summaries from ACP Hospitalist Weekly.

Residents report that ‘warm handoffs' enhance patient safety

Most internal medicine residents who tried a warm-handoff protocol reported that it was worth the extra time and safer for patients than prior handoff techniques.

The protocol was implemented at a university-based residency program with three training sites. At the end of a ward rotation, the incoming and outgoing residents met at the hospital to sign out and jointly rounded on sicker patients using a bedside-rounding checklist. Researchers surveyed eligible residents, who were in their second and third postgraduate years, to compare the protocol to prior handoff strategies, which were nonstandardized and typically included signing out by phone or email.

About 10 months after implementing the warm handoffs, researchers sent eligible residents an eight-question survey and randomly selected six residents to participate in face-to-face open-ended interviews. Questions addressed patient safety, residents' familiarity with patients, and whether the intervention was worthwhile. Results were published online on Aug. 14 by the Journal of General Internal Medicine.

Of 99 eligible residents, 60 responded to the survey. Compared to prior handoff techniques, 85% of residents reported that they perceived warm handoffs to be safer for patients (P<0.001), and 98% thought warm handoffs improved their knowledge and familiarity of patients on the first day of an inpatient rotation (P<0.001).

Warm handoffs took additional time, and 75% (95% CI, 58% to 85%) of residents reported spending an extra hour or more to perform a warm handoff. However, 88% (95% CI, 80% to 95%) of residents felt that warm handoffs were a worthwhile use of their time.

In qualitative interviews, all six residents reported that seeing patients in person was a major advantage of warm handoffs, and half of them said that face-to-face sign out decreased misinformation and improved communication between physicians. They also discussed such disadvantages of warm handoffs as interruptions and time limitations.

The authors noted limitations to the study, such as its retrospective and single-center design, and that there was no monitoring or supervision of warm handoffs. “Lastly, our study does not look at patient outcomes; thus, there is no way to measure what impact, if any, warm handoffs may have on patient outcomes, which will be important to estimate in future studies,” they wrote.

Rapid response calls decrease overnight, followed by an early morning spike in mortality

Rapid response teams (RRTs) are called less frequently during the early morning hours, and this is followed by a spike in mortality in the 7 a.m. hour, a study found.

Photo by Thinkstock
Photo by Thinkstock

To determine whether RRT calls are less frequent overnight and how this is associated with patient outcomes, researchers designed a retrospective analysis of the American Heart Association Get With The Guidelines-Medical Emergency Team database, which tracked RRT calls from 2005 to 2015.

The primary outcome was in-hospital mortality. Patient and event characteristics between the hours with the highest and lowest mortality were compared, and multivariable models were adjusted for patient characteristics. The study was published online by Critical Care Medicine on July 22 and appeared in the October issue.

A total of 282,710 RRT calls from 274 hospitals were included. The lowest frequency of calls occurred from 1 a.m. to 6:59 a.m., with 266 of 274 (97%) hospitals having lower than expected call volumes during those hours. Mortality was highest during the 7 a.m. hour and lowest during the noon hour (18.8% vs. 13.8%; adjusted odds ratio, 1.41; 95% CI, 1.31 to 1.52; P<0.001). Compared with calls at the noon hour, those during the 7 a.m. hour had more deranged vital signs, were more likely to have a respiratory trigger, and were more likely to have greater than two simultaneous triggers.

According to the authors, the results suggest that failure to rescue deteriorating patients is more common overnight and strategies aimed at improving RRT utilization during these vulnerable hours may improve patient outcomes.

“These findings demonstrate that RRTs are subject to the same diurnal trends in patient contact as the usual hospital care they are meant to supplement, which highlights an important deficiency in these systems,” the authors wrote. “Improving the recognition of impending critical illness and the rate of RRT calls at nighttime could have a large potential benefit for the care of hospitalized patients.”

The authors suggested that increased frequency of monitoring in high-risk patients paired with universal use of evidence-based early warning scores could lead to automated notification of the RRT when vital signs become deranged and allow for prompt recognition of clinical deterioration at all hours of the day or night.