Friday, March 6, 2009

Transfer of Care

At almost all hospitals, interns and residents go through rotations that last about 4 weeks at a time. That means at the end of the four weeks, you transfer care to another team. Like I mentioned in the previous post, at Pennsylvania Hospital, we use a night float system. So what happens at the end of a rotation, one team signs out to night float with a paper signout describing all their patients (like a normal night) and the next morning, the new team picks up the paper signout with news about whatever happened overnight from the night float person. As the night float intern takes care of about 100 patients (or more) a night, they don't know any of these patients in detail unless they're pretty sick, so they don't really have any details to hand off to the new team in the morning. There is really no verbal communication between the new intern and the old intern regarding the patients. The best continuity comes from the resident of the team, who is on for about 4 days before the interns switch, so they know the patients at least to some small degree, although they often do not know the small details, or the really complex patients well.

As a result, the new intern is really dependent on the paper signout for active issues and things to do for the patients. In addition, if a patient has been admitted for a relatively long time (on the order of weeks to months), there should be an end-of-service note written by the previous intern for the new intern. Usually if all these things are done well, there are no problems.

However, I cannot believe how angry I was at the start of one of my months. I had 4 long-term patients, none of which had an end-of-service note. The paper signout I received from night float, who had been given this signout by the previous intern, was horrendous - it was lacking in detail, disorganized, and did not point out what the active issues were. It didn't feel appropriate to me to approach the other intern personally, but I did contact the chief resident and hopefully the importance of these notes will be emphasized. I also think instituting a verbal signout, in which one intern calls the other intern to verbally tell them about the patients and what's going on would be a great idea. It wouldn't take that long and I think it would go a long ways towards improving continuity of care.

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