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Improving quality on off-peak hours
Some hospitals are changing care delivery
The traditional hospital system in which physicians are staffed during the day and on call at night is not the only model. And certainly, as the health care industry becomes more aware of the quality of care for the traditional off-peak shifts, that model could change quite radically in the future.
There are some things hospitals can do now, and some challenges that cannot be overcome, says David Grace, MD, FHM, area medical officer for the Schumacher Group's Hospital Medicine Division and a hospitalist at Southwest Medical Center in Lafayette, LA. Among the latter, he says, is the fact that people sleep at night. During the day, patients have problems and can alert clinicians. "But very often if the patient is asleep, they'll sleep right through that event. So you lose your early warning system, which is the patient being able to tell you something is not right. And that I don't think we'll ever improve," he says.
Also, too often, nurses are uncomfortable calling physicians on call, when they know they are at home sleeping. "I've worked overnight shifts at hospitals over the years, and I've seen nurses discussing a bad lab result that came back missing. 'Hmm. I know that doctor who's on. I'm not calling him. He's going to yell at me. I'm going to wait til 7 a.m. when his partner comes back,'" thus delaying care that could be critical.
He's tracked data and found nurses are less likely to page a doctor who is at home versus a doctor who is up and working. "We end up with improved communication and therefore reduced errors and higher quality just by having a doctor awake in the hospital at night."
Grace suggests educating nurses to contact on-call physicians and not fear recrimination. It needs to be clear that it is unacceptable for doctors to be rude to a nurse for waking them up, he says.
One thing he's introduced that he says has been helpful is a standardized list that informs nurses, "if this happens, you should call the physician."
"I think what that does is it empowers the nurses a little bit more to say, 'I'm going to call him because this is what the standard order says. I need to call him if the heart rate is over 120 and this patient has a heart rate of 130, and if he yells at me, I'll just tell him it's in that order that they put in the chart." (See list, below.)
Call physician immediately for the following:
Southwest Medical Center in Lafayette, LA.
He says it has gained a lot of traction and empowered nurses, while still emphasizing that "if you have to think twice about whether you should call, you need to call."
As far as weekends, he says, "I think we see not the same phenomenon, but I think during weekends there's just less going on in hospitals. You know most of their departments aren't doing routine work. So I think patients are not watched quite as closely."
He says oftentimes weekends are staffed by agency nurses or per diem or part-time nurses who many not be as familiar with your setting.
He says he's seen many hospitals struggling but improving turnaround times on test results on weekends. Ten years ago, when he began his career as a hospitalist, he says it was difficult to get things such as MRIs or ultrasounds done on the weekend. Now that's changed. The impetus may be financial, to reduce length of stay, but the result does improve patient safety.
"Very often if there's a test we order, a lot of times we'll find something we didn't expect, and it alters the way care is delivered. If you introduce a delay on that or a delay in that diagnosis because it's a weekend and you just can't get the test result, I think that certainly translates into poor quality for the patients," he says.
One thing he's focused on is handoffs between day and night clinicians and identifying patients' major diagnoses, active problems, and any items on the to do list. "We catch a lot of things by doing a handoff that involves both an electronic or sort of durable written component and a verbal component," he says. Every patient is covered, and the process takes only about 10-15 minutes.
"I think that allows you to respond better. It's very difficult if you get woken up at 2 a.m. and a nurse is asking you somewhat complex questions about a patient you've never seen. You don't know what they're in for, you've never talked to their attending doctor, but now you're responsible for them during the night," he says.
As an example, he says, let's say patient A complains of chest pains about 10 times a day and is in for anxiety and asthma and has complained of chest pain for years, but every EKG has been fine.
"Well, when I get a call that night about this patient having chest pain from a nurse because I got a good checkout, the way I respond to that can be quite different if I never knew anything about the patient. I would probably give all the typical chest pain things. I would give them aspirin, give them a shot of a blood thinner, an EKG, a CT scan of the chest. Any of those can have complications. CT scans can cause renal failure. Anticoagulants can make you bleed. So they're not benign treatments and investigations. But just a little bit of a checkout procedure with my partner clears all that up, and now I don't go down that route, which can obviously provide not just cost savings but certainly some quality savings.
"You're not exposing the patient to as many risky things because you had a good checkout and you knew what was going on. So that makes quite a difference and that's usually when those issues come up nights and weekends. And I think a checkout can really boost quality for the hospitalized patients," he says.
Staffing intensivists 24/7
In his hospital "a big transition had taken place in the late '90s into 2000s," says Emmel Golden, MD, the medical director of the ICU at Baptist Memorial Hospital-Memphis in Tennessee. The hospital he had worked in had been a large downtown medical center with plenty of house staff. The hospital was closed, and what had been a community hospital was transformed into a tertiary care center with no house staff.
It took about a year to negotiate and form an enterprise, and in January 2003, the hospital began to staff its ICU with an intensivist from 6 p.m. to 7 p.m. 365 days a year. "And so the physician on location in the intensive care unit is available to assist in getting started on new admissions, most of which come out of the emergency department or the recovery room that time of night, or to deal with patients who become unstable in the intensive care unit and also in the hospital," he says.
The physician also backs up the rapid or emergency response team. Through observation and some monitoring, Golden says this has "moved codes from mainly being things that occurred on the floor to mainly being things that occurred in ICU, so it decreased the number of untoward arrests on the floor because we were able to move unstable patients a lot sooner. It definitely improved nursing satisfaction on the night shift because now there's a physician there and the physician can address whatever the issue is."
Other benefits? "The doctors that work at night literally have saved a lot of lives. People would be dead if we weren't here. I know that for a fact," he says.
Another thing "that happened on the legal side was that the suits against the hospital for wrongful death just about disappeared. Because it seemed a lot of those were evolving out of a patient who became unstable at an off-hour time and nobody did anything," Golden says.
Now when a doctor is paged, it usually is a conversation between the intensivist and the physician. "It's a peer-to-peer exchange, which is different from a doctor-to-nurse exchange. They may question us, but it's a different type of exchange that goes on with two doctors talking to one another, especially when one of the doctors is at the bedside with the patient. It moves to a different level very quickly," he says.
Length of stay at the hospital, which has a daily census of about 600-650, also has decreased from about seven days when the hospital began to staff intensivists at night to about four days.
Evening rounds are "very focused," he says. Why is this patient here? Are there any unresolved issues? And does this patient still need to be here?
If patients need to be moved even at night, the nighttime intensivist can consult with the daytime hospitalist, and if the patient is stable, he or she can be moved. "I did this to ensure better patient care and to improve patient outcomes and better patient safety. A side benefit [is a reduction] in nursing turnover and a lot better nursing satisfaction from the nurses who work at night," he says.