A retrospective chart review to explore the impact of evening shift change admissions on safety events and handoffs

Objective: This study’s purpose was to provide valuable insights into patient outcomes at shift change to guide the development of future guidelines and protocols that enhance patient care during nursing shift changes at a 4-hospital healthcare system.
Methods: A retrospective case-control design assessed whether the timing of admissions during evening shift changes influenced patient care, including safety events and handoffs. The sample comprised of 150 patient records (75 cases transferred during the PM shift change and 75 controls transferred at other times, avoiding the shift change), matched on month, hospital unit, admitting diagnosis, age, and gender, between October 2023 and September 2024. Data collection, electronic reports, and individual patient chart review were de-identified for statistical comparison, and chi-square tests determined whether there was a significant difference between safety events and handoffs.
Results: The study found that admissions during evening shift changes were associated with a significant increase in Rapid Response Team (RRT) calls (p = .043) and post-transfer handoffs (p = .003), suggesting higher risk and communication challenges during these periods. These findings highlight the need for improved protocols, such as minimizing shift change admissions and enhancing handoff communication. Hospital throughput teams should consider these results, along with others, when developing plans to encourage discharges and admissions earlier in the day to avoid admissions during shift change.
Conclusions: Ongoing research on improved throughput to avoid shift-change admissions is paramount. Larger, prospective studies are recommended to validate and expand these results.