Exploring Ward Team Handoffs of Overnight Admissions: Key Lessons from Field Observations

Background: The diagnostic process is a dynamic, team-based activity that is an important aspect of ward rounds in teaching hospitals. However, few studies have examined how academic ward teams operate in areas such as diagnosis in the handoff of overnight admissions during ward rounds. This study draws key lessons from team interactions in the handoff process during ward rounds. Objective: To describe how ward teams operate in the handoff of patients admitted overnight during ward rounds, and to characterize the role of the bedside patient evaluation in this context. Design: A qualitative ethnographic approach using field observations and documentary analysis. Participants: Attending physicians, medical residents, and medical students on general medicine services in a single teaching hospital. Approach: Thirty-five hours of observations were undertaken over a 4-month period. We purposively approached a diverse group of attendings who cover a range of clinical teaching experience, and obtained informed consent from all ward team members and observed patients. Thirty patient handoffs were observed across 5 ward teams with 45 team members. We conducted thematic analysis of researcher field notes and electronic health record documents using social cognitive theories to characterize the dynamic interactions occurring in the real clinical environment. Key Results: Teams spent less time during ward rounds on verifying history and physical examination findings, performing bedside evaluations, and discussing differential diagnoses than other aspects (e.g., reviewing patient data in conference rooms) in the team handoff process of overnight admissions. Several team-based approaches to diagnosis and bedside patient evaluations were observed, including debriefing for learning and decision-making. Conclusions: This study highlights potential strengths and missed opportunities for teaching, learning, and engaging directly with patients in the ward team handoff of patients admitted overnight. These findings may inform curriculum development, faculty training, and patient safety research.