John Q. Young

“July Effect”: Impact of the Academic Year-End Changeover on Patient Outcomes: A Systematic Review

BACKGROUND It is commonly believed that the quality of health care decreases during trainee changeovers at the end of the academic year. PURPOSE To systematically review studies describing the effects of trainee changeover on patient outcomes. DATA SOURCES Electronic literature search of PubMed, Educational Research Information Center (ERIC), EMBASE, and the Cochrane Library for English-language studies published between 1989 and July 2010. STUDY SELECTION Title and abstract review followed by full-text review to identify studies that assessed the effect of the changeover on patient outcomes and that used a control group or period as a comparator. DATA EXTRACTION Using a standardized form, 2 authors independently abstracted data on outcomes, study setting and design, and statistical methods. Differences between reviewers were reconciled by consensus. Studies were then categorized according to methodological quality, sample size, and outcomes reported. DATA SYNTHESIS Of the 39 included studies, 27 (69%) reported mortality, 19 (49%) reported efficiency (length of stay, duration of procedure, hospital charges), 23 (59%) reported morbidity, and 6 (15%) reported medical error outcomes; all studies focused on inpatient settings. Most studies were conducted in the United States. Thirteen (33%) were of higher quality. Studies with higher-quality designs and larger sample sizes more often showed increased mortality and decreased efficiency at time of changeover. Studies examining morbidity and medical error outcomes were of lower quality and produced inconsistent results. LIMITATIONS The review was limited to English-language reports. No study focused on the effect of changeovers in ambulatory care settings. The definition of changeover, resident role in patient care, and supervision structure varied considerably among studies. Most studies did not control for time trends or level of supervision or use methods appropriate for hierarchical data. CONCLUSION Mortality increases and efficiency decreases in hospitals because of year-end changeovers, although heterogeneity in the existing literature does not permit firm conclusions about the degree of risk posed, how changeover affects morbidity and rates of medical errors, or whether particular models are more or less problematic. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.

Cognitive Load Theory: Implications for medical education: AMEE Guide No. 86

Abstract Cognitive Load Theory (CLT) builds upon established models of human memory that include the subsystems of sensory, working and long-term memory. Working memory (WM) can only process a limited number of information elements at any given time. This constraint creates a “bottleneck” for learning. CLT identifies three types of cognitive load that impact WM: intrinsic load (associated with performing essential aspects of the task), extraneous load (associated with non-essential aspects of the task) and germane load (associated with the deliberate use of cognitive strategies that facilitate learning). When the cognitive load associated with a task exceeds the learner’s WM capacity, performance and learning is impaired. To facilitate learning, CLT researchers have developed instructional techniques that decrease extraneous load (e.g. worked examples), titrate intrinsic load to the developmental stage of the learner (e.g. simplify task without decontextualizing) and ensure that unused WM capacity is dedicated to germane load, i.e. cognitive learning strategies. A number of instructional techniques have been empirically tested. As learners’ progress, curricula must also attend to the expertise-reversal effect. Instructional techniques that facilitate learning among early learners may not help and may even interfere with learning among more advanced learners. CLT has particular relevance to medical education because many of the professional activities to be learned require the simultaneous integration of multiple and varied sets of knowledge, skills and behaviors at a specific time and place. These activities possess high “element interactivity” and therefore impose a cognitive load that may surpass the WM capacity of the learner. Applications to various medical education settings (classroom, workplace and self-directed learning) are explored.

Perioperative use of selective serotonin reuptake inhibitors and risks for adverse outcomes of surgery.

IMPORTANCE Single-site studies have described an association between use of selective serotonin reuptake inhibitors (SSRIs) and adverse outcomes of surgery. Multicenter studies including a broad range of surgical procedures that explore rare outcomes, such as bleeding and mortality, and that account for indications for administration of SSRIs are needed. OBJECTIVE To determine whether perioperative use of SSRIs is associated with adverse outcomes of surgery in a national sample of patients. DESIGN Retrospective study of patients 18 years or older who underwent major surgery from January 1, 2006, through December 31, 2008, at 375 US hospitals. We used multivariable hierarchical models to estimate associations between SSRI use and our outcomes. Pharmacy data were used to determine whether a patient received an SSRI in the perioperative period. SETTING Three hundred seventy-five US hospitals. PARTICIPANTS Five hundred thirty thousand four hundred sixteen patients 18 years or older. EXPOSURE Perioperative use of SSRIs. MAIN OUTCOMES AND MEASURES In-hospital mortality, length of stay, readmission at 30 days, bleeding events, transfusions, and incidence of ventricular arrhythmias. RESULTS Patients receiving SSRIs were more likely to have obesity, chronic pulmonary disease, or hypothyroidism (P < .001 for each) and more likely to have depression (41.0% vs 6.2%, P < .001). After adjustment, patients receiving SSRIs had higher odds of in-hospital mortality (adjusted odds ratio, 1.20 [95% CI, 1.07-1.36]), bleeding (1.09 [1.04-1.15]), and readmission at 30 days (1.22 [1.18-1.26]). Similar results were observed in propensity-matched analyses, although the risk of inpatient mortality was attenuated among patients with depression. Sensitivity analyses suggest that, to invalidate our results, an unmeasured covariate would have to have higher prevalence and be more strongly associated with mortality than any covariate included in our models. CONCLUSIONS AND RELEVANCE Receiving SSRIs in the perioperative period is associated with a higher risk for adverse events. Determining whether patient factors or SSRIs themselves are responsible for elevated risks requires prospective study.

The patient handover as an entrustable professional activity: adding meaning in teaching and practice

Major healthcare reform, including limits on work hours for health professionals and the involvement of multiple individuals, teams and settings have made handovers a common and frequent aspect of patient care. Research has shown that errors commonly occur during handovers, and can result in patient harm.1 ,2 As a result, healthcare systems, at the behest of regulatory agencies, must now ensure that handover processes are safe and reliable. Similarly, medical education programmes and credentialing bodies are required to monitor clinician competence with respect to handovers. Developing valid measures of clinician competence is a major challenge. The handover requires the application and integration of clinical and communication skills, and an understanding of the systems of care, which must come together in one, time-limited and highly constrained activity.3 ,4 Acquiring the ability to perform this activity well is, because of its complexity, not a simple linear process and requires years to perfect. A trainee cannot be asked to study it from a book, or practice in a course, with the expectation of a satisfactory score on a skills assessment. The quality of handing over patient information and responsibility is highly provider and context-dependent and case-specific. Because many doctors do it on a daily basis, it must be learned in training and the competence to do this should be assessed. Well trained physicians should be trusted to provide adequate information in handovers, and recipient doctors and other healthcare professionals must understand, accept and appropriately apply this information to guarantee optimal care. Policy makers and educators have called for added training of healthcare professionals to improve their skills and competence for conducting handovers. The European HANDOVER Project encompassed several initiatives to improve the education and training of healthcare professionals in this important area of patient safety and continuity of care. …

Improving resident education and patient safety: a method to balance initial caseloads at academic year-end transfer.

Purpose In outpatient continuity clinics, incoming trainees may receive caseloads that are unbalanced in terms of the mental workload required from each resident. When significant, these imbalances may compromise resident learning and patient safety. Using data from psychiatric outpatient continuity clinics, this study tested a method for balancing initial caseloads. Method Adapting prior research on mental workload, the authors developed and implemented a workload-balancing method to balance initial caseloads regarding factors contributing to mental workload: number of patients, number of acute patients, complexity/time demands outside clinic, visits per month, and collaboration demands. For academic years 2006–2007, 2007–2008, 2008–2009, and 2009–2010, they compared these balanced caseloads with those that would have been created by the clinics traditional method of largely preserving prior caseloads (with some redistribution to balance only the number of patients). The outcome measure was the intercaseload coefficient of variation for each of the chosen mental workload factors and for all factors combined. Results Compared with the traditional method, the workload-balancing method generated lower intercaseload variation for each mental workload factor. Also, this method reduced overall intercaseload variation for all factors combined by 50% to 61% in each of the intervention years. Conclusions The workload-balancing method evenly distributes among resident panels factors known to contribute to mental workload. This method may reduce errors and stress likely to occur when residents inherit unbalanced caseloads that are overly challenging and, thus, may improve patient safety and resident learning. This model could be applicable to other caseload situations.

Prevalence of behavioral health disorders and associated chronic disease burden in a commercially insured health system: findings of a case-control study.

OBJECTIVE The objective was to examine prevalence of behavioral health disorders (BHDs) and co-occurring chronic medical conditions in a 3.4 million-member integrated health system. METHOD Clinical databases identified 255,993 patients diagnosed with the most prevalent BHDs (cases): depression, anxiety, substance use, bipolar spectrum and attention deficit and hyperactivity (ADHD); non-BHD matched controls were created for all unique cases. Cases and controls were compared for prevalence of general medical conditions and specific chronic diseases and the Charlson Comorbidity Index (CMI). RESULTS The five most common BHDs were depression (58%), anxiety (42%), substance use (16%), bipolar spectrum (6%) and ADHD (4%). Compared to controls, patients with depression (80.1% vs. 66.3%), anxiety (78.0% vs. 63.0%), substance use (74.0% vs. 59.9%), bipolar (75.3% vs. 60.7%) and ADHD (60.6% vs. 53.1%; all P<.001) had significantly higher prevalence of any medical comorbidities. Excluding ADHD, BHD cases had higher prevalence of selected chronic diseases and average CMI. CONCLUSIONS BHDs in a largely commercially insured, employment-based health system are common and associated with a disproportionately higher burden of chronic medical disease and associated 10-year mortality risk rate. Given that co-occurrence of behavioral and medical conditions leads to elevated symptom burden, functional impairment, and healthcare costs, these findings highlight the importance of developing effective collaborative models of care in (nonpublic) employment-based health systems.

Unpacking the Complexity of Patient Handoffs Through the Lens of Cognitive Load Theory

Abstract Issue: The transfer of a patient from one clinician to another is a high-risk event. Errors are common and lead to patient harm. More effective methods for learning how to give and receive sign-out is an important public health priority. Evidence: Performing a handoff is a complex task. Trainees must simultaneously apply and integrate clinical, communication, and systems skills into one time-limited and highly constrained activity. The task demands can easily exceed the information-processing capacity of the trainee, resulting in impaired learning and performance. Appreciating the limits of working memory can help identify the challenges that instructional techniques and research must then address. Cognitive load theory (CLT) identifies three types of load that impact working memory: intrinsic (task-essential), extraneous (not essential to task), and germane (learning related). The authors generated a list of factors that affect a trainees learning and performance of a handoff based on CLT. The list was revised based on feedback from experts in medical education and in handoffs. By consensus, the authors associated each factor with the type of cognitive load it primarily effects. The authors used this analysis to build a conceptual model of handoffs through the lens of CLT. Implications: The resulting conceptual model unpacks the complexity of handoffs and identifies testable hypotheses for educational research and instructional design. The model identifies features of a handoff that drive extraneous, intrinsic, and germane load for both the sender and the receiver. The model highlights the importance of reducing extraneous load, matching intrinsic load to the developmental stage of the learner and optimizing germane load. Specific CLT-informed instructional techniques for handoffs are explored. Intrinsic and germane load are especially important to address and include factors such as knowledge of the learner, number of patients, time constraints, clinical uncertainties, overall patient/panel complexity, interacting comorbidities or therapeutics, experience or specialty gradients between the sender and receiver, the maturity of the evidence base for the patients disease, and the use of metacognitive techniques. Research that identifies which cognitive load factors most significantly affect the learning and performance of handoffs can lead to novel, contextually adapted instructional techniques and handoff protocols. The application of CLT to handoffs may also help with the further development of CLT as a learning theory.

Measuring cognitive load: mixed results from a handover simulation for medical students

IntroductionThe application of cognitive load theory to workplace-based activities such as patient handovers is hindered by the absence of a measure of the different load types. This exploratory study tests a method for measuring cognitive load during handovers.MethodsThe authors developed the Cognitive Load Inventory for Handoffs (CLI4H) with items for intrinsic, extraneous, and germane load. Medical students completed the measure after participating in a simulated handover. Exploratory factor and correlation analyses were performed to collect evidence for validity.ResultsResults yielded a two-factor solution for intrinsic and germane load that explained 50 % of the variance. The extraneous load items performed poorly and were removed from the model. The score for intrinsic load correlated with the Paas Cognitive Load scale (r = 0.31, p = 0.004) and was lower for students with more prior handover training (p = 0.036). Intrinsic load did not, however, correlate with performance. Germane load did not correlate with the Paas Cognitive Load scale but did correlate as expected with performance (r = 0.30, p = 0.005) and was lower for those students with more prior handover training (p = 0.03).ConclusionsThe CLI4H yielded mixed results with some evidence for validity of the score from the intrinsic load items. The extraneous load items performed poorly and the use of only a single item for germane load limits conclusions. The instrument requires further development and testing. Study results and limitations provide guidance to future efforts to measure cognitive load during workplace-based activities, such as handovers.

Applying Toyota Production System Principles to a Psychiatric Hospital: Making Transfers Safer and More Timely

BACKGROUND Health care organizations have increasingly embraced industrial methods, such as the Toyota Production System (TPS), to improve quality, safety, timeliness, and efficiency. However, the use of such methods in psychiatric hospitals has been limited. METHODS A psychiatric hospital applied TPS principles to patient transfers to the outpatient medication management clinics (MMCs) from all other inpatient and outpatient services within the hospitals system. Sources of error and delay were identified, and a new process was designed to improve timely access (measured by elapsed time from request for transfer to scheduling of an appointment and to the actual visit) and patient safety by decreasing communication errors (measured by number of failed transfers). Complexity was substantially reduced, with one streamlined pathway replacing five distinct and more complicated pathways. To assess sustainability, the postintervention period was divided into Period 1 (first 12 months) and Period 2 (next 24 months). RESULTS Time required to process the transfer and schedule the first appointment was reduced by 74.1% in Period 1 (p < .001) and by an additional 52.7% in Period 2 (p < .0001) for an overall reduction of 87% (p < .0001). Similarly, time to the actual appointment was reduced 31.2% in Period 1 (p < .0001), but was stable in Period 2 (p = .48). The number of transfers per month successfully processed and scheduled increased 95% in the postintervention period compared with the pre-implementation period (p = .015). Finally, data for failed transfers were only available for the postintervention period, and the rate decreased 89% in Period 2 compared with Period 1 (p = .017). DISCUSSION The application of TPS principles enhanced access and safety through marked and sustained improvements in the transfer processs timeliness and reliability. Almost all transfer processes have now been standardized.

Advancing the next generation of handover research and practice with cognitive load theory

Improving patient safety during handovers has become a public health priority.1 Over the past decade, a number of best practices have emerged, which, taken together, represent the first generation of handover interventions. Largely adapted from industries (such as aviation and railroad) in which transition errors have high consequences,2 these first-generation best practices aim to reduce information loss and distortion via structured communication protocols such as face-to-face and written sign-out that use mnemonics and standardised templates, interactive questioning and distraction-free environments.1 These efforts have been fruitful. Interventions that bundle these practices have yielded improvements in educational and clinical outcomes.3 Yet, while these protocols improve safety, handovers still remain an important source of medical error and potential harm to patients. Accordingly, we must now choose how best to identify strategies that improve upon these first-generation interventions. In our view, since handovers are a complex cognitive task, these efforts will require deeper appreciation of human cognitive abilities. The sender and receiver must simultaneously apply and integrate multiple sets of (clinical, communication and systems) knowledge, skills and attitudes into one, time-limited and highly constrained activity.4 As a result, the task demands can easily exceed the information-processing capacity of the clinicians, resulting in impaired learning and performance, errors and harm to the patient.5 To date, handover research and practice has not explicitly applied cognitive theories of learning and information processing to address these cognitive limitations. One such theory, cognitive load theory (CLT), has received increased attention in the medical education literature,5 ,6 and, in a recent study, has been used to unpack the complexity of handovers.7 By highlighting the constraints of human beings’ working memory, we believe that CLT identifies specific cognitive limitations highly relevant to handovers, and can help guide a second generation of handover …