Associations between early handoffs, length of stay and complications in internal medicine wards: A retrospective study


      • Early handoff was independently associated with an increased length of stay.
      • Major complications were more frequent after early handoff.
      • Early handoff had no impact on use of resources.



      In US healthcare system, handoffs are associated with an increase in medical error and in hospital length of stay. In non-US healthcare systems, this phenomenon has not been well studied. We studied the association between early handoffs (EH) in a non-US internal medicine ward with length of stay (LOS), use of resources, major complication (MC) and discharge to post-acute care (PAC) facility.


      We conducted a retrospective cohort study on patients admitted to the general internal medicine division. Patients with EH (defined as a transfer of responsibility between primary teams within the first 72 h) were compared with patients without EH. The primary outcome was LOS in the general internal medicine division. Secondary outcomes were the use of resources, the incidence of MC (transfer to intensive care, to intermediate care or death) and discharge to a PAC facility.


      We included 11,869 patients, 38% of whom were in the EH group. Patients were 67.7±16.6 years old and 53% were males. EH was independently associated with an increase of LOS (+6.4% [95% CI, 3.5%–9.5%], P < .001) and with an increased rate of MC (OR 1.3 [95% CI, 1.1–1.7], P = .012). In our subgroup analysis, the association between early handoff and LOS and MC rate were not statistically significant when the admission occurred on public holidays and weekends.


      Among patients admitted in our general internal medicine division, early handoffs were associated with significantly higher length of stay and major complication rate, but not in patients admitted during week-ends.


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        • Arora V.
        • Johnson J.
        A model for building a standardized hand-off protocol.
        Joint Comm J Qual Pat Saf. 2006; 32: 646-655
        • Denson J.L.
        • Jensen A.
        • Saag H.S.
        • et al.
        Association between end-of-rotation resident transition in care and mortality among hospitalized patients.
        JAMA. 2016; 316: 2204-2213
        • Petersen L.A.
        • Brennan T.A.
        • O'Neil A.C.
        • Cook E.F.
        • Lee T.H.
        Does housestaff discontinuity of care increase the risk for preventable adverse events?.
        Ann Intern Med. 1994; 121: 866-872
        • Lofgren R.P.
        • Gottlieb D.
        • Williams R.A.
        • Rich E.C.
        Post-call transfer of resident responsibility: its effect on patient care.
        J Gen Intern Med. 1990; 5: 501-505
        • Ryan S.
        • O'Riordan J.M.
        • Tierney S.
        • Conlon K.C.
        • Ridgway P.F.
        Impact of a new electronic handover system in surgery.
        Int J Surg. 2011; 9: 217-220
        • Vidyarthi A.R.
        • Arora V.
        • Schnipper J.L.
        • Wall S.D.
        • Wachter R.M.
        Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out.
        J Hosp Med. 2006; 1: 257-266
        • Kitch B.T.
        • Cooper J.B.
        • Zapol W.M.
        • et al.
        Handoffs causing patient harm: a survey of medical and surgical house staff.
        Joint Comm J Qual Patient Saf. 2008; 34: 563-570
        • Horwitz L.I.
        • Moin T.
        • Krumholz H.M.
        • Wang L.
        • Bradley E.H.
        Consequences of inadequate sign-out for patient care.
        Arch Intern Med. 2008; 168: 1755-1760
        • Starmer A.J.
        • Sectish T.C.
        • Simon D.W.
        • et al.
        Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.
        JAMA. 2013; 310: 2262-2270
        • Rudiger-Sturchler M.
        • Keller D.I.
        • Bingisser R.
        Emergency physician intershift handover - can a dINAMO checklist speed it up and improve quality?.
        Swiss Med Wkly. 2010; 140w13085
        • Hess D.R.
        • Tokarczyk A.
        • O'Malley M.
        • Gavaghan S.
        • Sullivan J.
        • Schmidt U.
        The value of adding a verbal report to written handoffs on early readmission following prolonged respiratory failure.
        Chest. 2010; 138: 1475-1479
        • Ong M.S.
        • Coiera E.
        A systematic review of failures in handoff communication during intrahospital transfers.
        Joint Comm J Qual Pat Saf. 2011; 37: 274-284
        • Pezzolesi C.
        • Schifano F.
        • Pickles J.
        • et al.
        Clinical handover incident reporting in one UK general hospital.
        Int J Qual Health Care. 2010; 22: 396-401
        • Toson B.
        • Harvey L.A.
        • Close J.C.
        New ICD-10 version of the Multipurpose Australian Comorbidity Scoring System outperformed Charlson and Elixhauser comorbidities in an older population.
        J Clin Epidemiol. 2016 Nov; 79 (PMID 27101889): 62-69
        • Rich E.C.
        • Gifford G.
        • Dowd B.
        The effects of scheduled intern rotation on the cost and quality of teaching hospital care.
        Eval Health Prof. 1994; 17: 259-272
        • Tsugawa Y.
        • Jena A.B.
        • Orav E.J.
        • Jha A.K.
        Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study.
        Bmj. 2017; 356: j273
        • Volpp K.G.
        • Rosen A.K.
        • Rosenbaum P.R.
        • et al.
        Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform.
        JAMA. 2007; 298: 984-992
        • Horwitz L.I.
        • Meredith T.
        • Schuur J.D.
        • Shah N.R.
        • Kulkarni R.G.
        • Jenq G.Y.
        Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care.
        Ann Emerg Med. 2009; 53: 701-10 e4
        • Starmer A.J.
        • Spector N.D.
        • Srivastava R.
        • et al.
        Changes in medical errors after implementation of a handoff program.
        N Engl J Med. 2014; 371: 1803-1812
        • Kuhn E.N.
        • Davis M.C.
        • Agee B.S.
        • Oster R.A.
        • Markert J.M.
        Effect of resident handoffs on length of hospital and intensive care unit stay in a neurosurgical population: a cohort study.
        J Neurosurg. 2015; : 1-7
        • Aylin P.
        • Yunus A.
        • Bottle A.
        • Majeed A.
        • Bell D.
        Weekend mortality for emergency admissions. A large, multicentre study.
        Qual Saf Health Care. 2010; 19: 213-217
        • Shih Y.N.
        • Chen Y.T.
        • Shih C.J.
        • et al.
        Association of weekend effect with early mortality in severe sepsis patients over time.
        J Inf. 2017; 74: 345-351
        • Thakkar R.N.
        • Kim D.
        • Knight A.M.
        • Riedel S.
        • Vaidya D.
        • Wright S.M.
        Impact of an educational intervention on the frequency of daily blood test orders for hospitalized patients.
        Am J Clin Pathol. 2015; 143: 393-397
        • Gottlieb D.J.
        • Parenti C.M.
        • Peterson C.A.
        • Lofgren R.P.
        Effect of a change in house staff work schedule on resource utilization and patient care.
        Arch Intern Med. 1991; 151: 2065-2070
        • Burke R.E.
        • Juarez-Colunga E.
        • Levy C.
        • Prochazka A.V.
        • Coleman E.A.
        • Ginde A.A.
        Patient and hospitalization characteristics associated with increased postacute care facility discharges from US hospitals.
        Med Care. 2015; 53: 492-500
        • Chen A.Y.
        • Zagorski B.
        • Parsons D.
        • Vander Laan R.
        • Chan V.
        • Colantonio A.
        Factors associated with discharge destination from acute care after acquired brain injury in Ontario, Canada.
        BMC Neurol. 2012; 12: 16
        • Louis Simonet M.
        • Kossovsky M.P.
        • Chopard P.
        • Sigaud P.
        • Perneger T.V.
        • Gaspoz J.M.
        A predictive score to identify hospitalized patients' risk of discharge to a post-acute care facility.
        BMC Health Serv Res. 2008; 8: 154