Residents’ clinical rotation has little effect on length of patient hospital stays

While clinical rotation has long been part of training for hospital residents, its resulting discontinuity of care has raised concerns about the practice’s impact on patients. But a recent study finds the effect is minimal, at least as measured by length of patient stay.

The study’s purpose was twofold. The first was to see whether patients exposed to end-of-rotation resident changeover have longer hospital stays than those not exposed to a changeover. The second was to test the effectiveness of separating changeover days for residents from those of attending physicians—a strategy for mitigating the care discontinuities caused by resident changeover.

The authors examined admission and discharge data for about 95,000 patients at four teaching hospitals affiliated with the University of Toronto, Canada between July 2010 and June 2019. The changeover day of the week was the first Monday of the month at all four sites until July, 2013, when the changeover day was moved for attending physicians.

The primary outcome measured was length of hospital stay. Secondary outcomes were transfers to critical care facilities, in-hospital deaths and rate of discharge per 100 patients on “index day”—the first Monday after the day of the patient’s admission if the Monday was a resident changeover day.

The results showed resident changeover day to be associated with an increase in the mean lengths of patient hospital stays from 6.5 to 6.7 days, along with a decreased likelihood of patient discharge on changeover day. Separating resident and attending physician changeover days didn’t significantly affect those outcomes.

Among secondary outcomes, the results revealed virtually no differences between patients who were or weren’t exposed to end-of-rotation changeovers.

The authors provide three possible explanations for the slightly increased length of stay for patients exposed to changeovers: hesitation to discharge an unfamiliar patient on the first day, loss of diagnostic momentum, and lack of time to discharge a patient safely while acclimating to a new group of patients.

They caution that the absence of any clinical impact of staggering the changeover days of resident and attending physicians is not a reason to eliminate the practice, since it is “an intuitive, inexpensive and adaptable solution to increase care continuity.” Moreover, the practice could have additional benefits for both patients and trainees, including improved communication, patient comfort, sense of team belonging, and support at the start of a new rotation.

The study, “Analysis of Resident and Attending Physician End-of-Rotation Changeover Days and Association With Patient Length of Stay” was published March 23, 2023 on JAMA Network Open.