Department of Internal Medicine, Bellevue Hospital Center, New York University School of Medicine, New York.
Department of Emergency Medicine, New York University School of Medicine, New York.
Am J Med. 2015 Sep;128(9):994-1000. doi: 10.1016/j.amjmed.2015.03.023. Epub 2015 Apr 8.
Medical errors occur following handoff-related miscommunication. Data regarding the effect on patient-centered outcomes, specifically mortality, are lacking. Our objective was to investigate handoff-related mortality and the effect of duty-hour regulations.
Retrospective cohort study of adult medical patients at a public, university-affiliated hospital from 2010 to 2012. Patients were divided into 2 cohorts: handoff group (discharged within 7 days following a change in resident physician team) vs control group (discharged the 3 weeks of each 4-week rotation before resident service change). The primary outcome was unadjusted and adjusted hospital mortality rate. As a secondary prespecified analysis, we examined the effect of 2011 Accreditation Council for Graduate Medical Education (ACGME) duty-hour changes.
Among 23,736 patients, unadjusted hospital mortality during the handoff group was higher than the control group (2.68% vs 2.08%, respectively; P = .007; odds ratio [OR] 1.30; 95% confidence interval [CI], 1.08-1.57). Following adjustment, this association remained statistically significant (adjusted OR 1.34; P = .003; 95% CI, 1.10-1.62). Similarly, pre-duty-hour unadjusted hospital mortality was higher in the handoff group vs control group (2.87% vs 2.01%, respectively; P = .006; OR 1.44; 95% CI, 1.11-1.86), which remained statistically significant following adjustment (adjusted OR 1.50; P = .002; 95% CI, 1.16-1.95). However, this association lost statistical significance following duty-hour revision with respect to both unadjusted (2.48% vs 2.15%, respectively; P = .30; OR 1.16; 95% CI, 0.88-1.53) and adjusted mortality (OR 1.18; P = .26; 95% CI, 0.89-1.56).
Resident transition in care was significantly associated with an increase in unadjusted and adjusted hospital mortality. Although improved by 2011 ACGME duty-hour amendments, a trend toward higher mortality remained following resident handoff.
交接班相关的沟通失误会导致医疗差错。目前缺乏与以患者为中心的结局（尤其是死亡率）相关的数据。我们的目标是研究交接班相关的死亡率和工时法规的影响。
回顾性队列研究，纳入了 2010 年至 2012 年在一家公立大学附属医院的成年住院患者。患者被分为 2 个队列：交接班组（在主治医生团队变更后 7 天内出院）和对照组（在主治医生变更前的 3 周内出院，每个 4 周轮转周期）。主要结局是未调整和调整后的医院死亡率。作为次要的预设分析，我们研究了 2011 年毕业后医学教育认证委员会（ACGME）工时变化的影响。
在 23736 例患者中，交接班组的未调整医院死亡率高于对照组（分别为 2.68%和 2.08%；P =.007；比值比[OR]1.30；95%置信区间[CI]1.08-1.57）。调整后，这种关联仍然具有统计学意义（调整后的 OR 1.34；P =.003；95% CI，1.10-1.62）。同样，在调整前，交接班组的未调整医院死亡率高于对照组（分别为 2.87%和 2.01%；P =.006；OR 1.44；95% CI，1.11-1.86），调整后仍然具有统计学意义（调整后的 OR 1.50；P =.002；95% CI，1.16-1.95）。然而，在工时改革后，这种关联在未调整（分别为 2.48%和 2.15%；P =.30；OR 1.16；95% CI，0.88-1.53）和调整后的死亡率（OR 1.18；P =.26；95% CI，0.89-1.56）方面均失去了统计学意义。
主治医生交接时的患者护理变更与未调整和调整后的医院死亡率增加显著相关。尽管 2011 年毕业后医学教育认证委员会的工时修正案有所改善，但主治医生交接后仍存在死亡率升高的趋势。
