Even before the 80-hour work week, shift work was part of a physician’s and resident’s training. Now, it’s just more prominent. Residency programs have adapted, introducing night teams for their patients, various types of “floats” (night, day, root beer) who take over for a resident–or often an entire team of residents–when one set must go home because of hour restrictions.
In some ways, this is a good adaptation — and even if it’s not, it seems to be staying. I don’t care how tough and hardcore you are, you wouldn’t want a sleep-deprived resident (equivalent to an intoxicated resident) making health care decisions about your mother, let alone operating on her. (Having alcohol while on call or in the hospital would be a major violation, but sleep deprivation is inherently part of the system. Funny.)
In other ways, shift work is bad for patients: I know Mrs. Jones much better than the colleague I’m signing her out to, because she’s told me her whole story, her emergency contact, and how to reach her daughter’s cell phone if the first three numbers don’t work. Thoroughly complicating this issue is hospital overcrowding, especially in the ED when patients can be waiting for beds for days, and end up being handed off to a new physician every 8 hours. This knowledge differential between my colleague and I — he coming on shift, me going off shift — somehow must change, because the shift work world isn’t going to. Younger physicians are wanting shift work.
We know that most errors come about through errors of communication and often during shift changes. We KNOW that.
We owe it to our patients that we safely and correctly do hand-offs. We should be relying on a system that is designed to minimize communication errors, prioritize information and patients, and eliminate ambiguity while being as efficient as possible.
I’m not exactly sure what this system looks like. Maybe it means that we have some computer system that somehow collects important information about the patient and puts together a summary based on the electronic medical record.
I certainly know when I come across a piece of information that I know will be vital to sign-out, but sometimes I struggle at signout to remember it. Maybe it means that we carry around voice recorders and make memos to ourselves.
Maybe it means that we follow a cue from the nursing playbook and devote an hour to “shift change” in the name of patient safety. We review the patients in order of severity or likelihood something will come up, and in an order of importance: Patient Name, Age, Admission Diagnosis, Code Status, Active Problems, Active Plan, Anticipatory Guidance.
Maybe it means we teach physicians about conditional orders, and allow them to be carried out even if the physician is signed out. Things like:
IF (Troponin #3 = Normal AND Social Work Note AND Dispo = Complete AND Patient Has Outpatient Medications Ready AND IV is out) THEN (discharge home)
I’m not a communications expert, and I’ve fallen too far down the rabbit hole to probably even see where my own communication errors are. Perhaps that’s the problem right there — we don’t even know when or how we failed. Maybe the first step is to discuss it happening: along with M&M, how about a communication version? W&W? Words and Warnings?
As I’ll repeat throughout this series: if we as physicians don’t step up to the plate and do something about it ourselves, someone else will. And often that “someone else” isn’t caring for patients and doesn’t know what they’re doing. Being proactive about this stuff will help us in the long run.