Development of a handoff continuity score to improve pediatric ICU physician schedule design for enhanced physician and patient continuity

INTRODUCTION: Few studies investigate the benefits of familiarity or continuity during physician-to-physician handoff of inpatients. Factors such as how recently physicians (MDs) have worked and successive days caring for patients increase continuity, and thus could lead to enhanced handoff efficiency. Evaluating the efficacy of MD scheduling to enhance continuity is currently subjective. METHODS: An MD group consisting of 9 attending physicians and 7 fellows redesigned its pediatric intensive care unit (PICU) coverage schedule with the goal of enhancing continuity of care. The attending PICU MDs were formally surveyed to rate the impact of the schedule change on continuity and efficiency (5 point Likert scale: 1 = worse, 3 = no change, 5 = better). A Handoff Continuity Score (HCS) was developed and used to analyze the 30-bed PICU MD schedule for continuity and handoff efficiency. MD service and call schedules were evaluated for 6-month periods before and after the schedule redesign. The HCS for each schedule was calculated by considering every shift change, or handoff, in the scheduling horizon, and assigning scores to oncoming physicians based on previous days worked. Specifically, for each handoff, each oncoming MD receives a score between 0 and 1, calculated as the summation of a series of 'familiarity factors', one for each recent day worked. The scores for all oncoming MDs are averaged to determine the score for that specific handoff, and the HCS is the average of all handoff scores. The HCS was incorporated into an integer programming (IP) model for scheduling MDs to maximize continuity. A z-test was used to assess the significance of improvement in the HCS. RESULTS: The HCS before and after redesign was 0.57 and 0.68, respectively (19% increase, p < 0.01). Mean MD rating was 4.22 ± 0.56 for continuity, and 4.00 ± 0.65 for efficiency. With the goal of further improving the HCS and (partly) automating and streamlining the scheduling process, the IP was developed to populate physician service and night-call schedules while conforming to scheduling constraints; IP-generated schedules improved the HCS to 0.79 (39% increase). CONCLUSIONS: The increased HCS was associated with the MD qualitative assessment of enhanced continuity and efficiency after implanting a schedule change. The IP identified the potential for additional scheduling improvements.