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Texas Tech University Health Sciences Center (TTUHSC), in 2018, transitioned from a traditional 24-hour surgeon on-call shift to a 12-hour one, in part to help promote physician well-being and reduce burnout. Researchers have now looked at some patient and fiscal outcomes that occurred after this transition (Caballero 2019). They chose to look at patients admitted with acute appendicitis, because that is the most frequent condition for which the on-call surgeon would provide urgent surgery.
Patients treated by surgeons in the 12-hour shift model had an average length of stay of 0.73 days vs. 2 days for those treated under the traditional 24-hour model and had no reported cases of organ space infection vs. a rate of 7.1 percent in the traditional group. On average, ACS patients were seen by a surgeon more than an hour sooner after they arrived at the hospital: 2 hours, 9 minutes vs. 3 hours, 14 minutes. Per-patient costs with the 12-hour model were $1,452 vs. $9,834 per patient. They also found a decrease in perforation rates of appendicitis with the shorter surgeon on-call shift (ACS 2019).
Subjectively, faculty satisfaction was better with the new model. They also felt that continuity of care was improved, mainly because when the attending surgeon is working 12-hour shifts on consecutive days, he/she is more likely to be in the hospital and follow-up with the patient on the day after surgery than he/she would be doing 24-hour call. Also, the handoff between surgeons and surgical teams is more efficient with the 12-hour shift.
We’ve discussed some of the logistical and personnel issues that may lead to worse outcomes for surgery done “after hours” (see list below). The 12-hour surgeon on-call shift does improve upon several of those factors. It would also be interesting to know how other members of the surgical team (nurses, OR techs, anesthetists, etc.) were deployed when urgent cases were done under the new protocol. Additionally, we suspect factors pertinent to the rest of the team might be less impacted for general surgery cases, like acute appendicitis. It would be very interesting to see whether the 12-hour surgeon on-call shift also improves outcomes for other surgical specialties, where composition of the surgical team is more complicated.
This is a very interesting finding and merits consideration for other surgical specialties.
Some of our previous columns on “after-hours” surgery:
· September 2009 “After-Hours Surgery – Is There a Downside?”
· October 2014 “What Time of Day Do You Want Your Surgery?”
· January 2015 “Emergency Surgery Also Very Costly”
· September 2015 “Surgery Previous Night Does Not Impact Attending Surgeon Next Day”
· October 4, 2016 “More on After-Hours Surgery”
· August 15, 2017 “Delayed Emergency Surgery and Mortality Risk”
· October 24, 2017 “Neurosurgery and Time of Day”
Caballero B, Puckett Y, Chung C, et al. Improved Patient Outcomes and Reduced Cost in Treating Acute Appendicitis with a Shift-Based Acute Care Surgery Model Compared with Traditional General Surgery Call. Scientific Forum Abstracts. J Am Coll Surg 2019; 229(4 Supplement 1): S99
ACS (American College of Surgeons) Press Release. Surgeons report that 12-hour shifts improve patient outcomes, lower costs vs. 24-hour call shifts. American College of Surgeons October 30, 2019
In this month’s What's New in the Patient Safety World column “Surgeon On-Call Shifts” we noted how the length of a surgeon’s on-call shift can impact patient outcomes and costs of care. It turns out that shifts of hospitalists, likewise, are important in influencing patient outcomes.
A recent study showed that patients receiving care from hospitalists with schedules that promote inpatient continuity of care may experience better outcomes of hospitalization (Goodwin 2019). Goodwin and colleagues note that discontinuous schedules, such as 24 hours on and 48 hours off, result in several hospitalists providing care during a patient’s hospital stay and hypothesized that poor continuity of care during hospitalization may be associated with poor patient outcomes. They then did a retrospective study, using a formula with a weighted mean of schedule continuity for the treating hospitalists, assessed as the percentage of all their working days in that year that were part of a block of 7 or more consecutive working days,
In the lowest quartile for continuity, hospitalists providing care worked 0% to 30% of their total working days as part of a block of 7 or more consecutive days, compared to 67% to 100% in the highest quartile for continuity. Compared to those in the lowest quartile, admitted patients cared for by hospitalists in the highest quartile had lower 30-day mortality after discharge (adjusted odds ratio 0.88), lower readmission rates (adjusted odds ratio 0.94), higher rates of discharge to the home (adjusted odds ratio 1.08), and lower 30-day post-discharge costs (−$223). The findings were consistent in several sensitivity analyses.
Hospitalists offer several important contributions to patient care. Since they are in the hospital, they are particularly good at steering patients through the complex world of testing and consults, thus promoting more efficient care and shorter lengths of stay. They also are more readily available to attend promptly to changing patient conditions and to interact with families of hospitalized patients. But, at the same time, several studies have shown care by hospitalists compared with care by primary care physicians is associated with higher readmission rates, higher costs after discharge and lower rates of discharge home (we discussed one of those papers by Kuo and Goodwin (Kuo 2011) in our September 2011 What's New in the Patient Safety World column “Shiftwork and Patient Safety”).
Handoffs are critical when inpatient hospital care is rendered by someone other than the physician who will be primarily managing the patient after discharge. A good hospitalist keeps the PCP (or other physician who will have primary responsibility after discharge) apprised of the patient’s status not just at discharge, but throughout the course of the hospitalization. We’ve also noted the critical importance of communicating tests pending at discharge so that significant test results do not “fall through the cracks”. Also, in our December 20, 2016 Patient Safety Tip of the Week “End of Rotation Transitions and Mortality” we speculated that an increase in mortality was noted for patients hospitalized around the end of rotation for medical housestaff might also be seen with similar transitions for hospitalists.
Note that it’s not just continuity
through shift assignments that may impact patient outcomes. How patients are assigned
to hospitalists may also play a role. A recent study looked at the impact of geographic
cohorting on hospitalist activity (Kara
2019). By geographic cohorting we mean assigning hospitalists to patients
on one or two units. The researchers hypothesized that geographic cohorting
would increase direct patient interactions, a positive phenomenon, but would
also increase interruptions, a negative phenomenon. They then did a time-motion
study study that proved them to be right. Geographic cohorting was associated
with longer durations of patient visits. Interruptions were pervasive. Morning
interruption rates were comparable between the two groups, but the highest
interruption rate of once every eight minutes in the afternoon was noted in the
geographic cohorting group (compared to once every 17 minutes in the
non-geographic cohorting group). However, they also found changes in workload
might have a significant impact. Increasing patient loads were associated with
shorter visits, but geographic cohorting, increasing patient loads, and
increasing numbers of units visited were associated with increased indirect
care time. Geographic cohorting hospitalists were observed spending 56% of
the day in computer interactions vs 39% for non-geographic cohorting
hospitalists. The percentage of time spent multitasking was 18% for geographic
cohorting hospitalists and 14% for non-geographic cohorting hospitalists.
We also discussed the impact of hospitalist workload on patient care and costs in our May 2014 What's New in the Patient Safety World column “Hospitalist Workload Impact on Care and Cost”.
Kuo Y-F, Goodwin JS. Association of Hospitalist Care with Medical Utilization After Discharge: Evidence of Cost Shift From a Cohort Study. Ann Intern Med 2011; 155: 152-159
Kara A, Flanagan ME, Gruber R, et al, A Time Motion Study Evaluating the Impact of Geographic Cohorting of Hospitalists. J Hosp Med 2019; Published Online First November 20, 2019
A patient with difficulty swallowing had a nasogastric tube inserted for feeding (Kang-chun 2019). He pulled out his nasogastric tube. After the tube was reinserted, an X-ray examination was performed, and the patient’s gastric juices were also tested for acidity in accordance with the prevailing protocol at the hospital. “No abnormalities were detected,” said the hospital spokeswoman. Nasogastric tube feeding was restarted on the same night and in the early hours of the next morning. But the patent subsequently developed cardiac arrest and had to be sent to the intensive care unit after resuscitation by clinical staff. It was at this stage that the earlier X-ray results were reviewed, and it was found that the nasogastric tube was inserted into the patient’s left lung. The patient’s condition deteriorated and he died.
In our November 1, 2011 Patient Safety Tip of the Week “So What’s the Big Deal About Inserting an NG Tube?” we noted numerous reports from the UK’s NPSA of incidents and bad outcomes related to NG (nasogastric) tubes and we mentioned some of our own observations. NG tube insertion is viewed by many as a simple and routine procedure. But we have seen NG tubes in patient’s lungs, the pleural space, and even in a cerebral ventricle! So, we have a great respect for proper NG tube insertion.
Then, our October 2016 What's New in the Patient Safety World column “AACN Alert on Feeding Tube Placement” discussed American Association of Critical-Care Nurses practice alert “Initial and Ongoing Verification of Feeding Tube Placement in Adults”. And our June 2019 What's New in the Patient Safety World column “Guidelines for NG Tube Placement” discussed a new systematic review (Metheny 2019) of guidelines and recommendations to distinguish between gastric and pulmonary placement of nasogastric tubes.
We’ve stressed that particular attention be paid to the x-ray requisition, which should clearly state the x-ray is for determination of tube placement. All too often we still see x-ray requisitions filled out with something like the admission diagnosis rather than the real reason for the x-ray. And you need to make sure that the person doing the interpretation is appropriately credentialed to do so (for example, if someone other than the radiologist is doing the interpretation). And feeding should not be commenced via that tube until the radiologist (or appropriately credentialed person) has documented the tube is in the correct location. We’ve also noted that correct placement of a blindly inserted small-bore or large-bore tube should be confirmed with a radiograph that visualizes the entire course of the tube prior to its initial use for feedings or medication administration. Once correct tube placement is confirmed, the exit site from the patient’s nose or mouth should be immediately marked and documented to assist in subsequent determinations of tube location. After feedings are started, tube location should be checked at four-hour intervals.
A hospital trust in the UK undertook a performance improvement project after it had 2 incidents of NG tube misplacement (Earley 2019). They first performed a gap analysis and found nursing and medical staff sometimes worked in silos without necessarily understanding each others’ responsibilities. There was a lack of standardized documentation. There was no formally agreed dataset to audit compliance with practice. They also found that 90% of advanced nurses and doctors who were involved in confirming the NG tube position on X-ray had received no specific training. They also noted lack of an escalation process for challenging decisions.
After the gaps were identified, they took a multicomponent implementation approach that included education and training, development of a new e-learning tool designed to educate staff and assess their competence, standardization in the approach to care for patients with an NG tube, and monitoring and reporting systems to assure the trust’s board. One of their educational strategies is our old favorite – stories, not statistics. They included the story from relatives of a deceased patient who had experienced a never event.
But one interesting approach they took was development and use of a novel mnemonic to make things easier and more memorable for staff, The mnemonic was “NEX, 2C’s and 2D’s” to highlight the required areas to review on chest X-ray:
NEX = Nose to Ear to Xyphoid process measurement
2C’s = anatomical landmarks Carina, Clavicle
2D’s = Diaphragm and Deviation
Documentation of these findings was standardized, first as a sticker in the notes and later digitally as part of the electronic patient record.
Several parameters of the training improved after implementation, and satisfaction with the e-learning tool was high. They also implemented rigorous monitoring and reporting. The e-learning tool has subsequently been adopted by several other trusts in the National Health Service.
Obviously, a culture change and staff buy-in were key elements of success.
It’s too bad when it takes a “never event” related to NG tube insertion and placement to get the attention of a hospital’s staff. Use of NG tubes is ubiquitous in most hospital settings, yet you’d be surprised at how often we see lack of knowledge, training, and standardization regarding NG tube insertion and verification of accurate placement. Do you know what gaps exist in your organization?
See our prior columns on NG tube placement and positioning:
November 1, 2011 “So What’s the Big Deal About Inserting an NG Tube?”
October 2016 “AACN Alert on Feeding Tube Placement”
June 2019 “Guidelines for NG Tube Placement”
Kang-chun N. Patient in Hong Kong hospital dies after medical tube wrongly inserted into his lung. South China Morning Post 2019; November 27, 2019
AACN (American Association of Critical-Care Nurses). Feeding Tubes Require Initial and Ongoing Verification to Minimize Complications. American Association of Critical-Care Nurses updates Practice Alert on feeding tube placement. Press Release 15-Sep-2016
AACN (American Association of Critical-Care Nurses). AACN Practice Alert: Initial and Ongoing Verification of Feeding Tube Placement in Adults. CriticalCareNurse 2016; 36(2): e8-e13 April 2016
Metheny NA, Krieger MM, Healey F, Meert KL. A review of guidelines to distinguish between gastric and pulmonary placement of nasogastric tubes. Heart & Lung 2019; 48(3): 226-235
Earley T. Improving safety with nasogastric tubes: a whole-system approach. Nursing Times 2019 [online]; 115: 12, 50-51 December 2019
Two of the most trusted and respected patient safety organizations have agreed to join forces. ISMP (Institute for Safe Medication Practices) and ECRI Institute announced on November 13, 2019 an affiliation agreement, which is expected to become effective January 2, 2020 (ISMP 2019). ISMP will become an ECRI Institute subsidiary, Current leadership of both organizations is expected to remain active after the affiliation becomes formalized.
The two nonprofit organizations have long been pillars of the patient safety movement. While both organizations will retain their core missions, it is expected that their pooled resources will allow them to share even more vital information with the healthcare community.
Our best wishes to both organizations. Continue the great work you’ve been doing for years!
ISMP (Institute for Safe Medication Practices). ECRI Institute and Institute for Safe Medication Practices Join Forces to Enhance Patient Safety. ISMP News Release November 13, 2019
ISMP (Institute for Safe Medication Practices)
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