Hospitals Try Different Approaches to Improving Care at Night
Source: AMN Healthcare, Inc. – December 4, 2011
By: Debra Wood, RN, contributor
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Many patients come into the hospital after hours in critical condition, and others often “take a turn for the worse” during the overnight hours when hospitals are, typically, less well staffed with experienced nurses and physicians. But as health systems adapt to changing patient expectations and robust demands for patient safety, how they deal with night coverage is starting to change.
“Admissions do not stop at 5 o’clock,” said Christine White, M.D., MAT, assistant professor in the division of general and community pediatrics at Cincinnati Children’s Hospital Medical Center in Ohio, during the Institute for Healthcare Improvement’s presentation, “Night Talks & Nocturnists: New Interventions for the Hospital at Night.”
“Sometimes the least experienced personnel, especially in a teaching hospital, are there [at night],” added White, who reported her hospital found during a root cause analysis of adverse events that many of the incidents occurred at night, often due to people being afraid to call the attending and waiting until morning to notify the physician of a problem.
Winthrop Whitcomb, M.D., MHM, medical director of healthcare quality at Baystate Health in Springfield, Mass., added, “A lot of studies have shown patients do not do as well when the sun goes down or on weekends as they do during normal business hours.” In addition, he said that physicians have difficulties working all day and covering the hospital at night.
One solution is physician coverage by “nocturnists,” hospitalists who provide on-site coverage all night long to inpatients during the nighttime hours. He estimates about 16 percent of hospitals are using nocturnists full time.
“We’ve seen tremendous growth in hospitalist programs, and as they have grown, they have found it necessary to have someone in the building all night long,” Whitcomb said.
Nocturnists require a different skill set, he said. They must excel at caring for unstable patients and cross covering large numbers of patients. He acknowledged that it is difficult to recruit and retain physicians who want to work the overnight hours, and often the practice will pay the nocturnist more or require fewer hours for the same pay as a hospitalist staffing during the day.
“The night hospitalists tend to be more patient-care focused, by necessity, but they are doing hard work,” Whitcomb said. “The average night hospitalist fields 50 pages from nurses in the midst of doing their other work and puts in hundreds of thousands of orders.”
Healthcare consultant Ron Wince, CEO of Guidon Performance Solutions in Phoenix, added that the hospitalist concept is becoming more accepted and anticipates it will continue to grow.
“In the past, the culture believed that only a single physician [need] be in charge or make decisions with regard to patient care,” Wince said. “Now with regulatory changes and the complexity of cases, we are seeing more ‘team-based’ care--which means there needs to be robust communications between shifts and caregivers to insure a strong handoff.”
Cincinnati Children’s implemented a team solution. The hospital set up the Night Talks program, initially piloting it on a neurosurgical unit and now expanding to other medical services. Between 11:30 p.m. and midnight, the residents and charge nurse discuss each patient on that service. The charge nurse would have already asked each bedside nurse if the family or nurse had any concerns.
For those patients with concerns, the nurse, resident and ancillary staff members assess the patient and develop a plan for the night and then call the attending or pediatric hospitalist. Labs can be drawn, treatments started.
The hospital has assessed the number of days between near misses. Prior to establishing Night Talks, near misses sometimes occurred daily and the longest period without a near miss was 10 days. After implementation of Night Talks, the neurosurgical team went 201 days without a near miss.
As the program matured, the hospital has added some additional items to discuss. Residents complete handoffs between 8 p.m. and 9 p.m., in the presence of nurses. At 2 a.m. to 3 a.m., the hospital instituted “Coffee Talks,” which gives the team a chance to discuss new concerns, admissions and expected discharges.
Wince adds that medical school curriculums have changed to incorporate more communication and team skill building to allow for more collaborative care.
At the IHI event, David Gozzard, FRCP, FRCPath, MBA, a consultant in quality improvement in North Wales, United Kingdom, discussed the Hospital at Night program used by the National Health Service in 80 percent of its hospitals. They also have multidisciplinary teams who meet to deal with problems that come up over night. All of the residents work shifts that include day and nighttime hours. Handoffs have become more important.
Concern about quality of handoffs also is of concern in the United States, added White, and her facility and others are conducting research into the best way to make the transition from one resident’s care to the next.
“With the right process and workflow-centered approach and a robust electronic medical record, there is a great opportunity to mitigate the risks of the handoffs and improve outcomes,” Wince said.
All contents © 2012 AMN Healthcare, Inc. All Rights Reserved.
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