Computer system helps nurses in care delivery
System first implemented with residents
A computerized sign-out system at Jacobi Medical Center in Bronx, NY, has improved physician-nurse communication and positively affected the ability of nurses to care for their patients, according to staff surveys following the implementation of the system.1
Communication problems among health care workers are a common, preventable source of hospital-related morbidity and mortality. In fact, poor communication among health care professionals is the root cause of nearly seven of 10 sentinel events, according to the Joint Commission on Accreditation of Healthcare Organizations.
The system at Jacobi Medical Center, first launched with internal medicine residents in February 2003, was incorporated into the facility’s electronic medical record and physician order entry system. This new system was specifically developed to improve the quality of information transfer between cross-covering residents. In August 2004, after acceptance by the residents, a pilot study was initiated to explore the potential benefits of offering inpatient nurses access to this sign-out data, and the system was made available to inpatient nursing staff. This was also, in part, an effort to respond to complaints by nurses about insufficient communication between nurses and house officers.
A sign-out module was incorporated into the computerized health record; it was designed to screen the electronic record and automatically populate fields with patient demographic and admit-discharge-transfer data; medical team information; allergies; active medication lists; and resuscitation status. Internal medicine house officers were required to use the program’s printout during face-to-face transfer of patient care responsibility at the change of every morning and evening shift, and the program was available at every computer in the hospital.
In the pilot program, nursing staff members were provided electronic access to the residents’ sign-out information. Nurses received printouts of the computerized signouts at the start of each shift and were asked to use the sign-out program as a basis for their care plans and nursing change-of-shift "report."
A big improvement
Prior to the implementation of the new system, information transfer between house staff used to take place using notes written on pieces of paper during shift changes, recalls Robert Sidlow, MD, associate professor, department of medicine, and lead author of the paper. "It was very disorganized, yet this is an incredibly vulnerable aspect of hospital care of patients," he notes. "Cross-coverage is a time fraught with potential danger for patients."
Since Jacobi already had an enterprisewide electronic record, he reasoned, "why not leverage that and integrate it into the actual health record of the patient?" Now, is it an actual submenu of the system, he explains.
Training, says Sidlow, was straightforward. "We met with house staff and said, This is how you’re going to do it from now on,’ and it took off like wildfire; within a month-and-a-half all the residents were using it."
The residents, he says, viewed the new system "as an incredible boon. The system automatically drops in your patient list from the order entry system —- allergies, active meds, where the patient is located, when they were admitted, as well as all demographic information that previously had to be entered manually." The fields that need to be edited are the traditional information fields that are handed over — active issues, potential problems the patient might experience overnight, what the clinical issues are that are facing this patient, Sidlow explains.
Moving into nursing
Making the system available to nurses made sense, says Sidlow, because "communication between doctors and nurses is also incredibly vulnerable. Nurses change shifts every 12 hours at 7:00, and now they have the physician sign-outs, so they can align the care plans in a much more streamlined, standardized fashion. Before, they would either have to decide things intuitively or go through the chart; now, they can sit there and have it all on one piece of paper."
The nurses agreed. The 19 (of 20) nurses who completed the survey said that using the resident sign-out program positively affected their ability to care for their patients. In addition, the intervention improved nurses’ understanding of the patients’ reason for admission, helped to improve communication between physicians and nurses, and raised nursing morale.
One of the more surprising benefits on the new system, says Sidlow, was this boost in nursing morale. "These days, you are really challenged to create a good work environment for nurses who are so stressed out — how can you make their lives and time a bit easier and keep them on staff?" he says. "This gave them a feeling of control over their patients that they did not have before. Still, it’s surprising that such a simple intervention boosted their morale. They just felt they had a better handle on their patients, and we were thrilled."
This initiative, which began as a pilot project on one floor in internal medicine, has now spread throughout the facility. "There are novel enhancements that health care organizations should consider when implementing the rollout of an electronic medical record," says Sidlow. "There are ways to think outside the box and stretch and use the information flow that’s going on in novel ways that had not been thought of before — and this is one of them."
- Sidlow, R, Katz-Sidlow RJ. Using a Computerized Sign-Out System to Improve Physician-Nurse Communication. Joint Commission Journal on Quality and Patient Safety; Volume 32, Number 1, January 2006: 32-36(5).
For more information, contact: Robert Sidlow, MD, Assistant Professor, Department of Medicine (General Internal Medicine), Jacobi Medical Center, 1400 Pelham Parkway South, Room 159, Bronx, NY 10461. Phone: (718) 918-4606. Fax: (718) 918-4607. E-mail: firstname.lastname@example.org.