by Dutra,
Mariana; Monteiro, Mariana V.; Ribeiro, Karina B.; Schettino, Guilherme P.;
Kajdacsy-Balla Amaral, Andre Carlos
Objectives: Handovers are associated with
medical errors, and our primary objective is to identify missed diagnosis and
goals immediately after a shift handover. Our secondary objective is to assess
clinicians’ diagnostic accuracy in anticipating clinical events during the
night shift.
Design: Single-center prospective
observational cohort study. Setting: Thirty-bed tertiary ICU in Sao Paulo,
Brazil.
Patients: Three-hundred fifty-two patient
encounters over 44 day-to-night handovers.
Interventions: None.
Measurements and Main Results: We used a multimethods approach to
measure transmission of information among staff physicians on diagnoses and
goals for the night shift. We surveyed clinicians immediately after a handover
and identified clinical events through chart abstractions and interviews with
clinicians the next morning. Nighttime clinicians correctly identified 454 of
857 diagnoses (53%; 95% CI 50–56) and 123 of 304 goals (40%; 95% CI, 35–46).
Daytime clinicians were more sensitive (65% vs 46%; p < 0.01) but less
specific (82% vs 91%; p < 0.01) than nighttime clinicians in anticipating
clinical events at night, resulting in similar accuracy (area under the
receiver operating characteristic curve, 0.74 [95% CI, 0.68–0.79] vs 0.68 [95%
CI 0.63–0.74]; p = 0.09). The positive predictive value of both daytime and
nighttime clinicians was low (13% vs 17%; p = 0.2). Gaps in diagnosis and
anticipation of events were more pronounced in neurologic diagnoses. Conclusions: Among staff intensivists,
diagnoses and goals of treatment are either not conveyed or retained 50–60% of
the cases immediately after a handover. Clinicians have limited ability to
anticipate events, and the expectation that anticipatory guidance can inform
handovers needs to be balanced against information overload. Handovers among
staff intensivists showed more gaps in the identification of diagnostic
uncertainty and for neurologic diagnoses, which could benefit from
communication strategies such as cognitive checklists, prioritizing discussion
of neurologic patients, and brief combined clinical examination at handover.
