We have discussed in several columns the increased incidence of adverse events and poor outcomes in the hospital at night and on weekends (see our February 26, 2008 Patient Safety Tip of the Week “Nightmares….The Hospital at Night” and our What’s New in the Patient Safety World columns for October 2008 “” and September 2009 “After-Hours Surgery – Is There a Downside?”).
We discussed the presentation “The Hospital at Night Program: Reducing Risks at Our Most Vulnerable Time of the Day” by David Gozzard and Carol Haraden given at an IHI annual meeting. This described a redesign of hospital structure and processes in anticipation of a significant limitation of work hours imposed by the European Union (the European Working Time Directive). They collected data on the tasks performed off-hours and found that many tasks performed by doctors at night could be redistributed to nonmedical staff and that many tasks could be performed during daytime hours. For instance, leaving space in the OR schedule for emergencies reduced delays in regularly scheduled cases and reduced the likelihood of doing overflow cases at night. They also focused on communication and handoffs and made greater use of SBAR and written reports that were discussed verbally. And they made better use of the MEWS (Modified Early Warning System) to identify patients at risk of deterioration. Preliminary, largely anecdotal, experiences with the program were positive. However, the first report of outcomes of this project, available at the Hospital at Night project website, showed outcomes to have been modest.
In the September 2009 “After-Hours Surgery – Is There a Downside?” we noted that some surgical outcomes are worse or more adverse events may be seen when cases are done “after-hours”. We pointed out that the operating team after-hours is likely different from your daytime team. All members of that team (physicians, nurses, anesthesiologists, techs, etc.) may not have the same level of expertise as your regular daytime team and the team dynamics between members is likely to be different. The post-surgery recovery unit is likely to be staffed much differently after-hours as well. The staff may be more likely to be unfamiliar with things like location of equipment. And some of the other hospital support services (eg. radiology) may have lesser staffing after-hours. Just as importantly, many or all of the “on-call” staff that make up the after-hours surgical team have likely worked a full daytime shift that day so fatigue enters as a potential contributory factor.
Interestingly, our focus in the above columns was always on the professional staff. But some recent research has given us an “aha!” moment. Nursing researcher Patti Hamilton recently talked about her research at INQRI’s annual meeting and pointed out what should have been obvious to us: there are fewer non-nursing staff on the weekends. That means fewer support staff to answer phones, handle administrative tasks, or retrieve necessary medical supplies. So who ends up doing these tasks? Yes – nurses! And all those extra tasks and responsibilities take them away from direct patient care.
Hamilton noted “What we’re finding is that many, many small troubles pile up during off-peak shifts. There is rarely one big crisis situation. It’s usually an accumulation of little barriers that keep nurses from doing their jobs as effectively as during peak times.”. Sometimes the nurses end up doing tasks such as transporting patients or even mopping floors. There is also less dietary and nutrition support, pharmacy and imaging services, physical therapy, patient teaching, and social services. She also points out that they may spend more time on the phone trying to track down doctors on weekends. So nurses end up doing many more tasks that they do not normally perform during regular “day” hours and they do not have as much time to do patient care and bedside nursing.
The net result is that reported nurse staffing ratios may give us a very misleading sense of security at certain times of the day or week. Many studies have demonstrated better patient outcomes and fewer adverse events when nurse:patient ratios are more favorable. But it is clear from the above that the same nurse:patient ratio is really very different at night and on weekends than on the day shift.
And what do we usually do in the C-suite when facing a budget crunch? We, of course, all say “We can’t cut clinical staff! Our cuts will have to come from non-clinical staff.” So we cut those non-clinical positions and the tasks they used to perform still have to be done. Only now we are asking our higher-cost clinical personnel to carry out those functions – all at the cost of taking them away from patient care. We often shoot ourselves in the foot when we make these decisions. (As an aside, we also remember a story about a new CEO attempting to do a hospital turnaround. That CEO reduced the housekeeping staff as part of the budget cuts. Infection rates increased, with resulting increased lengths of stay and increased pharmacy costs.)
The moral of the story: every person who works in a hospital provides some function that is vital to patient outcomes – even those people you think of as “non-clinical”. Your non-clinical people can contribute greatly to your quality improvement and patient safety programs. Every time we have done a root cause analysis at a hospital regarding long turnaround times for radiology reports, the person most likely to know the root causes (and consequently the solutions) – the unit secretary! And we use our medical records staff to help us identify practices that put our patients at risk. And our housekeeping staff can help us save lives and dollars (see our November 10, 2009 Patient Safety Tip of the Week “Conserving Resources…But Maintaining Patient Safety”).
It is only when you do the kind of research that Patti Hamilton does – talking to frontline staff and observing people doing tasks at different times of the day – that you get a real feel for how a hospital runs! That’s a great lesson. When you do your Patient Safety Walkrounds or your Executive Walkrounds, make sure you don’t just do them on the day shift. You’ll learn a lot more if you do them at night or on a weekend. And your staff will have a totally different impression of you when they see you out there on a weekend!
Robert Wood Johnson Foundation. INQRI Researcher Patti Hamilton Explores Why the "Weekend Effect" is Putting Patients at Risk. Robert Wood Johnson Foundation. Publications and Research. September 30, 2009