Quality and safety during the off hours in medicine units: A mixed methods study of front‐line provider perspectives

Abstract

BACKGROUND Hospital off‐hours care is associated with poor outcomes. Mutual conceptualization among provider groups may facilitate improvement efforts. Provider‐perceived threats to quality are unreported. OBJECTIVES The objectives of this study were to identify perceived off‐hours quality and safety issues, assess the most significant, and evaluate differences between nurses, and attending and housestaff physicians, and providers with day and night experience. DESIGN Prospective, sequential, exploratory mixed‐methods study. MEASURES Open‐ended descriptions of adverse events/near misses occurring overnight (n = 190) were analyzed using thematic analysis. From these results, a survey was developed to assess perceptions of quality/frequency of each issue (7‐point scale, 7 = the highest rating) and highest‐quality overnight period (7–10 pm, 10 pm−1 am, 1–4 am, 4–7 am). RESULTS Primary issues related to mismanagement, delivery processes, and communication/coordination. Of 214 surveys, 160 responses (75%) were received. Least‐optimal issues related to “communication” (2.93) and “timeliness/safety” (3.89) of emergency department transfers; most‐optimal issues related to timely lab reporting (4.70). On the 7‐point scale, comparisons among nurses, and attending and housestaff physicians revealed differences in quality of “communication between physicians” (4.29 vs 6.00 vs 5.14) and “communication between consultants–primary providers” (3.46 vs 5.75 vs 4.35, P < 0.001). Comparisons between day–night providers revealed lower ratings from day providers in 12/24 items (P < 0.05), including “communication during emergency department transfers” (4.81 vs 3.86). All groups ranked 4 to 7am lowest in quality. CONCLUSIONS Nurses, and attending and housestaff physicians lack a shared mental model of off‐hours care. Several issues, including emergency department transfers and timeliness of consults, were identified by all providers as problematic, meriting further investigation and intervention. Journal of Hospital Medicine 2014;9:756–763. © 2014 Society of Hospital Medicine

Parent-Provider Miscommunications in Hospitalized Children

“…Communication breakdowns between interprofessional team members (eg, physicians and nurses 10,58 or primary and consulting services 59,60 ) may occur as the day progresses and be transmitted to parents. 52,61,62…”

Communication and Shared Understanding Between Parents and Resident-Physicians at Night

“…This represents a lost opportunity for parents to serve as key partners in ensuring the safety and quality of hospital care. This may be particularly true at night, when parents are often at their children’s bedside and hospitals typically have decreased staffing 5,6,29 and busier providers who may not know patients as well. 9,30 In addition to affecting safety, lack of shared understanding at night may affect parent experience because communication with nighttime providers is associated with overall parent experience of hospitalization.…”

Night Physician–Nurse Collaboration: Developing the Scale of Physicians’ Difficulties and Exploring Related Factors in Acute Care Hospitals

“…9,10 Many studies have documented challenges in communication or collaboration between physicians and nurses in this process; however, these barriers remain in clinical practice. [11][12][13] In addition, a previous scoping review regarding nighttime detection and response to clinical deterioration identified a gap in research concerning nighttime interprofessional communication and collaboration in response to deteriorating patients. 14 Accordingly, knowledge development that focuses on nighttime interprofessional collaboration may help address the challenges of responding to clinical deterioration at night.…”