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Quality of care during off-peak hours: Are you monitoring this?
Research shows deaths, complications more likely in off-peak hours
From about 7 a.m. to 7 p.m. Monday to Friday a hospital is a busy place with a host of clinical and administrative staff and department chairs and chiefs. But on nights and weekends, it's often quite different. It's quieter. Hospital leaders are not there, senior managers are off, and nurse/patient ratios are lower, says David Shulkin, MD, president of Morristown Memorial Hospital, part of Atlantic Health, and previously president and CEO of Beth Israel Medical Center in New York City. In an article in the New England Journal of Medicine, Shulkin wrote, the results of such "service deficiencies" in off-peak hours include increased mortality and readmission rates as well as additional surgical complications and medical errors.1
The disparity between these "two hospitals" is getting a lot of attention these days. With funding from the Robert Wood Johnson Foundation, Patti Hamilton, RN, PhD, has been studying the discrepancy in care as co-lead of the interdisciplinary nursing quality research initiative. (See www.nursingopen247.com.)Hamilton, formerly a nurse, is now dean of graduate studies, John and Nevils Wilson Professor at Midwestern State University in Wichita Falls, TX.
Hamilton's research began with neonates and mortality in off-peak shifts. The team "found that your biggest off-peak increase in mortality didn't happen in your big hospitals or it didn't even happen in your tiniest hospitals. The hospitals most likely to have differences in mortality rates were the middle-sized hospitals." She hypothesizes that bigger hospitals have more staff 24/7. The smaller hospitals can transport high-risk patients to tertiary care centers. "Those middle-sized hospitals tended to maybe hold on to patients they should have referred elsewhere or got into trouble because they didn't have enough staff to staff with equal expertise and skill 24/7. They put all their resources in the peak periods and were left a little bit deficient on the off-peak period," she says.
Assessing patient safety during off-peak hours
Her research has included discussions with nurses about their workflow and concerns on off-peak hours. "When you add together all of the night shifts and the weekend shifts, that's the majority of the week. So really 64% of [nurses'] work hours are off-peak, meaning they're at a hospital doing something when the staffing and the resources are at the lowest ebb, which surprised me. I at first was thinking of it as being a minority of time, but it is not. It is the majority, and I just never have thought of it that way."
Complications and other untoward events are not the only price to pay for inadequate staffing, communication, and clinical evaluation seen during off-peak hours. Often, Hamilton says, patients admitted during these times have longer lengths of stay, incurring greater costs for the hospital.
Both Shulkin and Hamilton urge quality improvement directors to begin to look at discrepancies in care between peak and off-peak shifts.
"The very first thing I would recommend that people do is become sensitive to the fact that so much of what happens in hospitals happens at night and on the weekend. And plan accordingly... [W]e come up with policies and plans and workflow plans that work well during the day when everyone is there or the physician can be reached readily through their office, and we forget that it doesn't work that well the rest of the time," Hamilton says.
She suggests including staff who work off-peak hours nurses, radiology technicians, respiratory therapists, occupational therapists, and physical therapists on the decision-making team for any workflow or operational initiatives.
"One of the best suggestions I can make is for people to become aware that the majority of care delivered is delivered during off-peak periods. So that's No. 1," she says.
"The second one is that we don't gather data in a way that would allow us to know how we're operating differently peak and off-peak. Very often, our core measures or our nursing-sensitive indicators or those things that we're measuring, we aggregate either over an entire day, an entire week, or an entire month. And when you do that, when you start talking about the average nurse/patient ratio, that may give you a picture that is not the same as if you had gathered the data and said, 'Now here's my peak nurse/patient ratio and here's my off-peak nurse/patient ratio.'"
She says it's important to gather the data that can answer the question: Are there differences between peak and off-peak hours?
Shulkin recommends that you look at your hospital's sentinel event and serious event data to see if an event occurred at night or on the weekend. "Just beginning to look for this issue and see whether lack of communication, lack of availability of staff or equipment contributed to the event, I think is important," he says.
He says oftentimes when you trace an event, you'll find the error actually occurred during an off-peak time. For example, if a patient has a cardiac arrest at 11 a.m., when you trace the event you might find that a critical lab value was missed at 3 a.m. or staff failed to note the patient's blood pressure began to drop at 4 a.m.
"From a quality improvement perspective, bringing that into the formal root-cause analysis and the formal evaluation of the way care is evaluated will be eye-opening to many people," he says.
And off-peak hour vulnerabilities are not solely staffing issues. "There's so many more systems that are functional in regular hours than off hours that you really need to look at it from a clinical perspective. How was the situation handled on off-hours versus how it would be handled on regular hours?" he says.
Hamilton suggests hospitals use the SWAN tool, developed by Shulkin while he was at Beth Israel to assess their weekend and night care delivery. (You can find the tool at http://davidshulkin.com/swan.asp.)
Shulkin says QI directors can play a big role in looking at hospital functions and the problem of "off-peak" care. "[B]y letting people understand how this particular issue impacts their hospital with data and real events that could potentially be prevented, I think that's very powerful. I think the quality director has a lot of opportunity to share that information and to get decisions made upon that," he says.
Work on handoffs, communication
Improving handoffs between day and night staff and strengthening communication among off-peak staff can make a "big difference" in quality of care, Shulkin says. He and Hamilton have had multiple discussions with nurses about their workflow and concerns. Shulkin says often seemingly small but consequential things can be uncovered.
"I think being aware of the communication problem is hugely important. We've known in health care that communication is a problem. But it becomes a very big problem off-peak, especially in those hospitals where say it's not a teaching institution and there's not a hierarchy of residents and interns and fellows and those sorts of things somewhere around 24/7. Community hospitals where the nurses are working and the physicians are off-site run into lots of problems with communication," says Hamilton.
One easily fixed problem Shulkin found in talking to off-peak staff was that they felt the person in the pharmacy was unresponsive to calls. At night, one person staffs the pharmacy, and it turned out there was no phone in the room where that person mixed chemicals. In the daytime, it wasn't a problem, but at night if he was the only one staffed and he was in the back, he didn't hear the phone.
"You find all sorts of small issues that frankly you wouldn't think about when you work in the hospital during the day but if you take the time to really look at the issues at night and talk to people, you find all sorts of things that you can begin to start doing to make it a better place," he says.
Shulkin is beginning to employ "nocturnists" as in-house night staff. He says many hospitals are used to 24/7 coverage within OB/GYN, anesthesiology, trauma care, and in the emergency department. "So those are the five areas where the standard really is to have 24-hour physician care. But I think that we're moving toward that in a broader way. It's a challenge because not many physicians look for jobs that keep them up all night, but I think that if you have a sensitivity around this issue and you're looking to improve from your current performance, this is certainly an area that's worth looking at."