Maintaining quality care on nights and weekends

Patients with time-sensitive medical problems may be particularly vulnerable in off hours.

Making sure that patient care doesn't suffer after the sun sets, or the week stretches past Friday, requires a heightened degree of attention to everything from maximizing available staff to communication during shift changes, hospitalists say.

When physicians work nights or weekends, they might cope with less access to subspecialists, some tests, and the social services support that can ease patient transitions between units or out of the hospital.

Photo from Thinkstock
Photo from Thinkstock.

Whether those challenges impact patient care is unclear, with studies yielding mixed findings. But a recent study indicated that patients with time-sensitive medical problems might be vulnerable. For patients seeking care for a heart attack at night or over the weekend, the risk of death is 5% higher in the hospital and within 30 days after discharge, compared to those seeking care during the weekday, according to a meta-analysis of 48 studies published online Jan. 21, 2014, in BMJ.

An off-hours deterioration in patient care, though, is by no means a given, and hospitalists can take steps to guard against it, said Kenneth R. Epstein, MD, FACP, chief medical officer for Hospitalist Consultants. “I think the potential exists for not providing the same level of care,” he said. “I wouldn't say that the care is poorer, but that the risk is higher of care being poorer.”

Dr. Epstein suggests establishing protocols when feasible, such as developing guidelines in advance for when a hospitalist should call in a subspecialist during the wee hours. Other creative staffing and patient rounding approaches can help avoid missing a deteriorating patient or other medical crises amid the cycle of shift changes and patient discharge pressures, said Stella Fitzgibbons, MD, FACP, a hospitalist practicing at several Houston hospitals.

It's also imperative that temporary doctors are backed up when they are brought in to cover difficult-to-fill gaps in the night schedule, Dr. Fitzgibbons said. Those doctors, who might be moonlighting at several hospitals, should be supported to the max with the patient information they require and the authority to take charge, she said.

“They might be young doctors who haven't quite cottoned to the fact that they are in the driver's seat and should behave accordingly,” Dr. Fitzgibbons said. “They are trying not to make waves. They don't want the doctor who they are effectively working for to come in on Monday and say, ‘Why the hell did you call him?’”

Mixed results

Nineteen percent of all admissions begin on a Saturday or a Sunday, according to a statistical brief by the Agency for Healthcare Research and Quality based on 2007 data. The analysis, which looked at 39.5 million hospital stays, found treatment delays during off-hours care, with 36% of weekend patients getting a needed procedure on the day of admission, compared with 65% of those admitted on a weekday.

The BMJ meta-analysis also found that off-hours care was common and delayed, with several studies showing that two-thirds of heart attacks flare during night or weekend hours. Patients who arrived at the hospital during off-hours with an ST-elevation myocardial infarction waited nearly 15 minutes longer for a percutaneous coronary intervention, the BMJ analysis found. While they didn't look at cause and effect, the authors cited evidence that such a delay in door-to-balloon time could increase mortality by 10% to 15%.

Extrapolating a 5% mortality increase across 900,000 U.S. heart attack patients annually, given that roughly two-thirds arrive during off hours, the researchers projected an excess 3,800 deaths each year. “We wanted to quantify the population impact because we know that the incidence of heart attack is so high, and the risk of death by heart attack is also high,” said Atsushi Sorita, MD, ACP Member, the study's lead author and a senior fellow in preventive medicine and public health at the Mayo Clinic in Rochester, Minn.

Not all studies of off-hours care are so gloomy. Another study conducted at Northwestern University, comparing on- and off-hours outcomes for 824 general medicine admissions, found no evidence of worse outcomes among the off-hours patients, said Raman Khanna, MD, lead author of the study, which was published in 2011 in the Journal of Hospital Medicine. The hospitalist, who conducted the research while at Northwestern, is now an assistant professor at the University of California, San Francisco (UCSF).

The timing of a patient's hospitalization might be more likely to influence how he or she fares when the medical problem requires rapid treatment by a subspecialist physician, such as with heart attack or stroke, said Gregg Fonarow, MD, professor of medicine and co-chief in the division of cardiology at the University of California, Los Angeles.

Dr. Fonarow, who studied the impact of admission timing on heart failure care, hasn't identified a similar concern with that condition. The average 3.8% in-hospital death rate did not vary based on what day the heart failure patient was admitted or discharged, according to the findings, published in 2008 in Circulation: Heart Failure.

But the length of stay was affected. Patients who were hospitalized on a Thursday or a Friday were more likely to stay longer, according to the analysis, based on 48,612 patients at 259 U.S. hospitals. Patients admitted on Tuesdays had the shortest stays of 5.39 days; the longest admissions, 5.88 days, occurred on Fridays.

Along with the level of physician staffing, another weekend-related factor might be the more limited access to support services, Dr. Fonarow said. “Some of that might have to do with the availability of social workers and others involved in the transition of care or arranging home nursing or home visits,” he said.

Shift-related strategies

In order to best use their scarce time, hospitalists rounding on weekends should prioritize which patients they see first, Dr. Fitzgibbons suggested.

In hospitals with intensive care specialists, ICU patients typically should be dropped to the bottom of that list, as they will probably have been seen by critical care doctors, who tend to round quite early in the day. “So why see them early?” she said. “Let's see those patients at 3 p.m. in the afternoon, when no doctor has been by, the night is coming, and make sure they are still as stable as they were when ‘Dr. Pulmonary’ came by.”

Similarly, patients who are stable and are being monitored can wait, she said, such as the older man admitted with a blood clot who is doing well but can't be discharged until the anti-clotting medication reaches therapeutic levels.

“That leaves the lady who had gallbladder surgery yesterday and this morning started running a fever,” Dr. Fitzgibbons said. “That leaves the heart failure patient who insists on going outside to smoke and had wheezes yesterday. It leaves the patients you really need to worry about.”

During nights, many hospital medicine groups are using nocturnists to cover their patients. Nearly half of groups who only treat adult patients employ at least some nocturnists, according to a Society of Hospital Medicine 2012 survey.

At some hospitals, work limits on nocturnists may mean that they leave partway through the night or have a cap on how many patients they can admit per shift, Dr. Fitzgibbons said. Meanwhile, day physicians are under pressure to discharge patients by late morning.

That cycle can delay patients admitted overnight from getting the history and physical they need. “Just to lay eyes on them, and make sure they are doing okay, to make sure that the emergency room doctor who wrote orders for them didn't leave out something necessary,” said Dr. Fitzgibbons.

One strategy is to hire a part-time physician to come in during the early morning and knock out as many history and physicals as feasible by noon. That way the overnight patients are all seen amid the morning flurry to discharge other patients, she said.

Boosting communication

Of course, adding another physician to the mix raises another challenge of off-hour coverage: ensuring that key components of a patient's treatment are not lost during handoffs. At Northwestern University and UCSF, patients are presented by the residents and the night staff to the day staff who will assume their care, Dr. Khanna said.

If the day staff is only relying on the overnight physician's notes, it's more difficult to ask follow-up questions. Also, they might miss an emphasis on particular points that a doctor might subtly stress if verbally describing the patient's situation. “Medicine is a narrative science. The more you tell the story, the better you understand it,” Dr. Khanna said.

On the other end of the day, every effort should be made to fully update the night doctor, particularly if a vulnerable patient is involved, Dr. Epstein said. “One of the risks that comes up is the night doctor is covering more patients, none of [whom] he knows,” he said.

Any patient who is considered unstable, or whose next treatment step is dependent upon outstanding test results, should be specifically signed off to the night doctor, with explanation of any concerns and proposed treatment once results come in, Dr. Epstein said.

Hospitalist programs should also develop protocols between the night doctors and key subspecialists to head off potential conflicts in advance. For example, if a patient is admitted overnight with an intracranial bleed, surgery is typically not needed, but the patient or family may expect to see a neurosurgeon.

One approach, Dr. Epstein said, is for hospitalists to agree to admit such patients as long as they have confidence that the neurosurgeon will see the patients within 8 hours.

In other circumstances, when hospitals don't have a 24-hour on-site intensivist or pulmonologist, a protocol can be hammered out regarding when a hospitalist is expected to manage a critically ill patient overnight versus when a specialist should be contacted to come in, Dr. Epstein said. “So you leave less to the judgment of the hospitalist at night to say, ‘Should I or shouldn't I call a pulmonologist?’” he said.

“The more you work out those protocols ahead of time, the less problems you run into,” he continued. “The worst time to reach an agreement on these protocols is in the middle of seeing a patient at 11 o’clock at night.”