The floors are quiet, patients are asleep, and residents are trying to either catch some shut-eye or catch up on paperwork. The rush of the evening hours in the emergency department has ended. Yet the wee hours of the morning — 4 a.m. to 7 a.m. — are when doctors think the hospital is at its least safe, according to a new study.1
Jed Gonzalo, MD, and his colleagues surveyed physicians and nurses and looked at reports of adverse events and misses during overnight hours at a university-affiliated hospital in Pennsylvania. Results were published in the December issue of the Journal of Hospital Medicine.1 They wanted to know what providers thought was the least safe time of day and why, particularly since there had been changes made to ensure that there was adequate oversight and nurse-patient ratios in the recent past that might make many think that issues previously brought up — not enough people to deal with problems, no senior doctors on site to deal with decompensating patients — had been adequately solved.
They looked at issues of quality of care delivery, communication and coordination, staffing and supervision, patient transfers, and consulting services issues. Perceived mismanagement of patient care and personal/relational tensions were also measured. The most common of the seven parameters questioned was mismanagement of patient care, with 97 of the 332 survey responses including issues with this. Next most frequent was quality of delivery, with 63 responses; communication and coordination, with 50; staffing and supervision with 39; patient transfers with 38; consulting services with 18; and professionalism/relational tension with 17.
Among the lowest-rated items were timeliness and safety issues with patients from the emergency department, timeliness of consults, and physician staffing levels. There seemed to be much less issue with things like medication ordering and processing, getting lab results, and communications between physicians.
The authors think the issues surrounding ED admissions are the most concerning, particularly since when the study was conducted, the hospital in question had a nocturnist on staff who was supposed to make such transitions smoother. Another issue was how differently people with no night shift experience viewed the quality of care delivered at night from the people who did have such experience, and the authors note that many of those who have those negative perceptions are making decisions that directly affect care delivered at night. Figuring out what they view as “wrong” and why could be important to future delivery of care.
Lastly, they found that everyone agreed that the last part of the shift was the most dangerous — that period from 4 a.m. to 7 a.m., which does not coincide with the busiest time at the hospital (usually between 6 p.m. and 9 p.m.) when most admissions are happening. Gonzalo and his peers note they have no idea why this is so — fatigue, getting ready for shift transition — only that it is a nearly universal feeling among nurses and physicians that those hours are the most dangerous.
This study came out of a larger work on nocturnists and outcomes, Gonzalo told HPR. “I spent a lot of times on night shifts as a fellow and wanted to look at those hours when half the patients come into the hospital.”
The idea is not to compare day to night, and it’s hard to frame it so that it is not such a comparison. The first thing people will say is that staffing is down and that’s why it’s unsafe, he says, or there is less supervision. But those things have been improved. Now, with nocturnists to supervise and better nurse-patient staffing ratios, it should be the same. Yet it is not.
Most, if not all, quality staff work during the day, Gonzalo says, and may not think of the hospital in terms of how it works at night. Beyond the increase in admissions, there are things that are just different — such as communications coordination, how things move from one place to another.
It might be a good idea to come to the hospital late one evening to see what’s different, or in the wee hours of the morning, he says. “The things you come up with for daytime may not apply at night. There are nuances you just may not think of. I just want to ask you to think about what you are doing and how it might impact the people who are working at night.”
For more information on this topic, contact Jed Gonzalo, MD, Director of General Internal Medicine, Penn State Hershey Medical Center, Hershey, PA. Email: firstname.lastname@example.org.
- 1. Gonzalo J, Moser E, Lehman E, Kuperman E. Quality and safety during the off hours in medical units: a mixed methods study of front-line provider perspectives. J Hosp Med. 2014 Dec;9(12):756-63.