In resident clinics, the transfer of patients at the end of each academic year has been noted to be a serious but largely unaddressed patient safety issue (9
). In a large pediatric residency clinic, we assessed resident perceptions of the importance of formal sign-out in ambulatory settings and of the adequacy of information they had when assuming care of a new primary care patients.
In our survey of resident perceptions, a large majority of our residents (87%) felt that it was important to receive sign-outs for medically complex patients, but only 35% felt it was important for patients with no significant issues. They particularly valued the medical summary and plan of care and gave less importance to a description of the patients’ social history and use of community resources. Residents indicated that having inadequate information on their new patients led to additional work (80%), delays or omissions in needed care (56%), and disruptions in continuity of care (58%). These findings suggest that improving the processes to transfer care of patients, particularly complex patients, represents a promising locus for quality improvement efforts.
Our study represents a starting point in the development of novel approaches for improving the quality of care transfers in academic ambulatory settings. The generalizability of our conclusions is limited by its single-site design. Future studies would benefit from collaboration between institutions, paralleling the efforts currently in progress for inpatient transfers of care (13
). At our institution, we have piloted a Patient Sign Out tool to facilitate the transfer of care of patients between graduating postgraduate year-3 (PGY-3) residents and incoming PGY-1 residents. The initial focus is on the most complex patients, those enrolled in our Pediatric Medical Home program. The Patient Sign-Out, which can be completed on paper or electronically, prompts residents to provide information in four categories: a brief medical summary, the child's current developmental and functional abilities, a social history, and a care plan [see Appendix
]. Future evaluations will assess whether such a tool leads to improvements in patient care and redresses the deficits in care transfers identified by the resident survey.
Trends in child health are creating a greater demand for caring for children with chronic illness (14
). For many years, observers have noted that training programs must evolve to meet this challenge (14
). Yet, specific curricular elements of such training have not been clearly articulated in the medical education literature. Training gaps in this area remain largely unexamined. A recent study exploring what pediatric residents are taught about children and youth with special health care showed relatively low levels of comfort in identifying community resources and collaborating with community agencies (21
). In our study, when assessing whether they had received adequate information when assuming care of patient with chronic conditions, only 17% reported receiving adequate information about community resources and social history, and only 30% reported receiving adequate information about functional abilities. In contrast, nearly 50% indicated they had adequate medical summaries and care plans.
Interestingly, residents also felt these categories were less important
– over 80% of residents indicated that receiving sign-out regarding the medical summary or care plan was somewhat or very important, but fewer than 60% felt similarly about social history or community resources. We noted a trend for giving decreasing importance to these areas by upper-level residents compared to first-year residents. For example, 82% of first-year residents felt that receiving sign-out regarding social history was somewhat or very important, in contrast to 60% of second-year residents and 30% of third-year residents (). These findings highlight the challenge of educating residents in caring for this population of children with complex care needs. Family-centered partnerships and integration into community-based system are core principles of the Patient-Centered Medical Home (10
). Yet, our findings suggest that residents may not prioritize these dimensions of primary care. Shifting the focus from acute, episodic care to chronic, systems-based care will require transforming medical education in a manner that addresses trainees’ knowledge, skills, and attitudes, as well as developing reliable methods to preserve continuity of care during transitions between caregivers.