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23-08-2011 | Article

Novel method developed to ease hospitalist handovers


Free abstract

MedWire News: Researchers have developed a patient acuity rating (PAR) scale, which they say could ease the transition between on- and off-duty clinicians as they convey complex assessments of at-risk patients, and lead to improved patient outcomes.

The team believes that proposed further limits on resident duty hours will result in increased frequency of these clinician "handoffs", but that "an ideal way to quickly transfer complex medical information on numerous patients remains to be identified."

Dana Edelson (University of Chicago, Illinois, USA) and colleagues explain that "the benefits of well-rested physicians are theorized to be offset by increased harm associated with discontinuous care, especially in high-risk patients."

Therefore, the team developed the PAR, hypothesizing that clinicians would be able to quantify their judgments regarding the stability of their inpatients and that this measure would correlate with impending clinical deterioration.

The PAR is a 7-point Likert scale where a score of 1 corresponds to extreme unlikelihood of suffering a cardiac arrest or requiring transfer to the intensive care unit (ICU) within the subsequent 24 hours, and a score of 7 corresponds with extreme likelihood of these events occurring.

For their study, Edelson et al asked 140 clinicians (interns, residents, attending, and midlevel providers) to complete the PAR once per 2 to 4 days at the end of their work day, during a 6-month period in 2008.

Overall, and from 6034 individual PAR scores from 3419 patient-days, the average PAR was 2.9. A total of 2.2% of the patient-days ended in cardiac arrest or patient transfer to the ICU.

Using a cut-off value of 5 or higher on the PAR, the scoring system had 62.2% sensitivity and 84.6% specificity at accurately predicting the likelihood that a patient would experience either of the two defined adverse outcomes. Lowering the threshold to a PAR score of 4 or higher increased the sensitivity to 82.4% but reduced the specificity to 68.3%, report the researchers.

Interestingly, physician-specific area under the receiver operator characteristic curve analysis scores to predict cardiac arrest or transfer to the ICU ranged from 0.69 for residents to 0.84 for attendings, remark Edelson and co-investigators.

"One explanation may be that clinical judgment optimally requires both experience and 'at-the-bedside' data. While attendings have the most experience, the amount of time interns spend at the bedside collecting data may offset their relative inexperience," note the authors.

"We have developed a simple tool for quantifying provider judgment, which yields moderate inter-rater reliability, and good accuracy in predicting which floor patients may suffer cardiac arrest or emergent ICU transfer," concludes the team in the Journal of Hospital Medicine.

They add that based on their PAR scoring system, evaluating all patients with a score of 4 or higher would require assessing one-third of all patients, but would identify 82% of all subsequent deteriorations.

By Sarah Guy