Exploring Physician Perspectives of Residency Holdover Handoffs: A Qualitative Study to Understand an Increasingly Important Type of Handoff

Abstract

Background: The term “holdover admissions” refers to patients admitted by an overnight physician and whose care is then transferred to a new primary team the next morning. Descriptions of the holdover process in internal medicine are sparse. Objective: To identify important factors affecting the quality of holdover handoffs at an internal medicine (IM) residency program and to compare them to previously identified factors for other handoffs. Design: We undertook a qualitative study using structured focus groups and interviews. We analyzed data using qualitative content analysis. Participants: IM residents, IM program directors, and hospitalists at a large academic medical center. Main Measures: A nine-question open-ended interview guide. Key Results: We identified 13 factors describing holdover handoffs. Five factors—physical space, standardization, task accountability, closed-loop verification, and resilience—were similar to those described in prior handoff literature in other specialties. Eight factors were new concepts that may uniquely affect the quality of the holdover handoff in IM. These included electronic health record access, redundancy, unwritten thoughts, different clinician needs, diagnostic uncertainty, anchoring, teaching, and feedback. These factors were organized into five overarching themes: physical environment, information transfer, responsibility, clinical reasoning, and education. Conclusions: The holdover handoff in IM is complex and has unique considerations for achieving high quality. Further exploration of safe, efficient, and educational holdover handoff practices is necessary.