February 26, 2008 Nightmares….The Hospital at Night
A new study (Peberdy et al 2008) using data on CPR voluntarily submitted by 507 participating hospitals demonstrated that patients were less likely to survive in-hospital cardiac arrest that occurred at night or on weekends. The only areas of the hospital not having this time-of-day disparity were the emergency room and the trauma service. The disparity persisted even after adjustment for numerous patient and hospital variables. The disparities were more pronounced for arrest in non-monitored patients, unwitnessed arrests, and arrests with asystole as the original rhythm documented. All these suggest delays in recognizing patients in trouble may play role.
Another recent study (Chan et al. 2008) had shown almost a third of in-hospital cardiac arrests had delays in defibrillation. That study had shown after-hours occurrence as one of several variables associated with delayed defibrillation.
Two new studies (Jeffrey 2008) have also confirmed the observation of previous studies that the mortality rates for patients with stroke are higher if they are admitted at night or on weekends. Even after adjustment for demographic and socioeconomic factors, patient characteristics and hospital characteristics, the relationship between “off-hour” admission and mortality remained significant. The relationship was more pronounced for hemorrhagic stroke.
Other studies have shown medical errors to be more frequent at night and studies on accidents in other industries reveal that some of the most famous disasters have occurred “off-hours” (eg. Bhopal, Piper Alpha, Chernobyl, Three Mile Island). Car crashes are more likely to occur between midnight and 6AM. Our August 28, 2007 Tip of the Week “Lessons Learned from Transportation Accidents” talked about some of the contributory factors in the ValuJet accident, which included many issues related to maintenance work done at night.
Our November 27, 2007 Patient Safety Tip of the Week “More on Rapid Response Teams” mentioned the NICE Guideline “Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital” recommendation that patients should not be transferred back to wards between 22:00 and 07:00 unless absolutely necessary. This was an evidence-based recommendation, though most of the studies were done in the UK, Canada, Australia, or countries other than the United States.
One of the presentations at IHI’s Annual National Forum on Quality Improvement this past December was “The Hospital at Night Program: Reducing Risks at Our Most Vulnerable Time of the Day” by David Gozzard and Carol Haraden. 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). As part of the redesign 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 have been positive. It will be most interesting to see the effect of this program on hard outcome measures.
Some of the principles in The Hospital at Night Project sound much like some of the principles from the Toyota Production System/Lean Thinking approach (removal of unnecessary tasks, reducing duplication, etc.).
Of course, physiological changes that have circadian rhythms may result in patient deterioration after-hours. However, the more easily modifiable factors have to do with the systems we practice in within hospitals.
It is more likely that physiological changes and circadian rhythms in care providers, such as fatigue and inattention, may play a role. There are plenty of studies now demonstrating deterioration in cognitive and physical skills with sleep deprivation. These, and some well publicized incidents such as the Libby Zion case, have led to the restriction of work hours for physicians in training. The Bell Commission, which developed the original residency workhour restrictions in New York in the 1980’s, cited the more frequent occurrence of hospital incidents at night and on weekends as a sign of work-related fatigue. Of course, those are also times when there is more cross-coverage of patients and the covering physicians generally have less knowledge about the patients they cover. So the debate has ensued as to which is worse: errors related to fatigue or errors related to handoffs. It is fairly clear we must avoid fatigue as much as possible by adherence to workhour restriction rules. So focusing on improvement of handoffs and other communication issues becomes an important patient safety activity.
Handoffs are one of the critical processes subject to errors that may result in incidents with adverse outcomes. Considerable research done in other industries (Lardner 1996) has some lessons for healthcare. Information at handoffs should be repeated by more than one method. For example, the communication may be written but then should be conveyed by a second method, such as a face-to-face verbal communication. Cues such as speech inflection and body language may convey important messages during such face-to-face communications, enhancing memory of the salient points. The verbal face-to-face contact also provides the opportunity for 2-way communication and feedback, both of which are essential in ensuring that both parties understand the information conveyed. Adding structure to written documents and defining what should be included in handoffs are very helpful. Hence, the popularity of techniques like SBAR (Situation-Background-Assessment-Recommendation). And eliminating unnecessary information may be very important. Lastly, training and education in handoffs should be a priority for organizations, as should providing adequate time for such handoffs.
Of interest is that some industries have found that 12-hour shifts appear to be associated with better handoffs. Presumably this is because the same two individuals are participating together in most of the handoffs here. We are unaware of any studies done in healthcare settings where 12-hour shifts have been compared to 8-hour shifts (eg. in emergency rooms) with hard outcome measurements.
Staffing patterns for a variety of healthcare workers (nurses, pharmacists, physicians, lab technicians, radiology staff, etc.) tend to be lower at night. Environmental factors such as poor lighting may contribute to medication errors and other errors. Ironically, our empathetic response to “let the patient get some sleep” may even be a contributory factor in some adverse events.
So one can see that there are multiple factors that make “off-hours” in a hospital times when patients are especially vulnerable. A lot more research is needed to continually focus attention on those factors which are modifiable.
Peberdy M, Ornato JP, Larkin GL, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008;299:785-792
Chan PS, Krumholz HM, Nichol G, et al. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med 2008; 358:9-17
Jeffrey S, Barclay L. Deaths Higher for Strokes Treated at Night, on Weekends. Medscape New Article. February 22, 2008
Gozzard D, Haraden C.The Hospital at Night Program: Reducing Risks at Our Most Vulnerable Time of the Day. Report from IHI’s 19th Annual National Forum on Quality Improvement in Health Care, December 9-12, 2007, Orlando, Florida
Lardner R. Offshore Technology Report – OTO 96 003. Effective Shift Handover – A Literature Review. Health & Safety Executive, 1996
Update: See October 2008 What’s New in the Patient Safety World “Hospital at Night Project”