Background: As a result of the 2011 ACGME duty-hour policies, many residencies have transitioned to a shift-work system, where swing and overnight residents admit patients for handoff to a new primary team the following morning. In our Internal Medicine residency program, up to 70% of admitted patients are handed off in this fashion. These “holdover handoffs” occur early in a patient’s admission, often before a diagnosis is solidified. They are prone to loss of information; one study found that overnight trainees failed to report 40% of clinically important issues during morning handoffs and 86% of these issues were not recorded in the medical record. Another study described the unique aspects of this complex handoff, including the importance of avoiding anchoring and conveying information efficiently. To our knowledge, no curricula targeting this handoff has been reported.
Purpose: To design a curriculum that teaches residents how to efficiently and effectively take over care of these holdover patients utilizing an approach to chart review and critically appraise the clinical reasoning of the admitting physician.
Description: We designed an innovative case-based flipped classroom workshop where senior residents receive a standardized handoff on a holdover patient. Working in groups, residents decide what additional pieces of data they need from the patient and medical record to confirm the conclusions of the admitting physician and determine next steps for workup and treatment. Using these cases, residents critically evaluate their process for receiving this handoff and recognized key pitfalls that can occur. Residents were then encouraged to formulate a checklist of their process that could be disseminated to new interns. All residents who participated in the workshop filled out a 5-question survey regarding their experiences.
Conclusions: Of the 28 residents who completed the workshop, 26 (93%) reported increased confidence in their ability to efficiently and safely pick up a holdover handoff. All of the residents (28/28) felt this workshop should be given to future resident classes. Free-text responses about the most useful part of the workshop fell into three categories: group discussion (46%), case-based format (32%) and creating a chart review checklist (28%). Overall, standardizing an approach to holdover handoffs through a case-based flipped classroom workshop increased resident confidence in their ability to safely pick up these patients. This approach includes an efficient way to review the patient’s data in the morning and critically appraise the decision making overnight to avoid anchoring. More research is needed to see if this translates into improved patient outcomes.