Whenever possible I make a point of rounding on patients with their nurses present. I rely on nurses to be my eyes and ears when I’m not at the bedside. I need their input to confirm patient self-reports of everything from bowel and bladder habits to pain control, not to mention catching early warning signs of infection, mental status changes, or lapses in safety awareness. Oftentimes patients struggle to recall bathroom details, and they can inadvertently downplay pain control needs if they don’t happen to be in pain when I visit them. A quick check with their nurse can clarify (for example) that they are asking for pain medicine every 2 hours, that they have missed therapy due to somnolence, that their wound incision looks more red, and/or that they haven’t had a bowel movement in a dangerously long time. All critical details that I wouldn’t necessarily know from talking to the patient alone. Some of this information is not accurately captured in the electronic medical record either.
On a recent trip to a new facility, I asked the head nurse when change of shift occurred. She was visibly perplexed and asked why I wanted to know. I explained that I planned to attend nursing sign out so that I’d be up to date on how my patients were doing. She raised her eyebrows to their vertical limit and responded, “I haven’t seen a doctor do nursing rounds in 30 years.”
That was one of the saddest things I’d heard in a long time. How is it that one of the fundamental features of medical care (doctors and nurses visiting patients together) has gone the way of the dinosaur? Most of my colleagues say they don’t round with nurses because they “don’t have time for that stuff” or that they can “flag down a nurse when there’s an issue” without needing scheduled communication. While I can sympathize with the fear of yet another “time suck” during a busy hospital day, I believe that rounding with nurses can actually save time, reduce medical errors, and head off developing problems at earlier stages (e.g. wound infections, intestinal obstructions, delirium, over/under medication and unwanted medication side effects).
You may think that coordinating nursing rounds with medical rounds is an insurmountable logistical nightmare, and if you have patients scattered throughout various floors of a hospital, that will certainly make things more difficult. But I have found ways to overcome these barriers, and highly recommend them to my peers:
1. Attend nursing sign out at change of shift if possible. Do not disrupt their hand-off process, but ask for clarification (or offer clarification) at key points during patient presentation.
2. Listen to the change of shift recording. Some nurses have their night shift team record their observations and findings in lieu of a 1:1 hand-off process during busy morning hours. This has its advantages and disadvantages. The good thing is that relaying information becomes asynchronous (i.e., like email vs a phone call – you don’t have to be present to get the info), the bad thing is that you can’t ask for clarification from the person delivering the information. If the nurses know in advance that the patient’s doctor is also listening in, they will leave targeted medical questions and concerns for you on the recording.
3. Do your rounds at times when medications are most commonly delivered. You will be more likely to run into a nurse in the patient’s room and can coordinate conversations as well as perform skin checks together.
4. Communicate with nurses (between rounds) when you are about to order a series of tests or dramatically change medication regimens. Explain why you’re doing it so they will be able to plan to execute your orders more efficiently (i.e. before the patient leaves for a radiologic study, etc.) This open communication will be appreciated and will be reciprocated (and may help to spark interest in joining you for regular rounds).
5. Invite nurses to round with YOU. If you can’t join their change of shift, consider having them join your medical rounds. You’ll need to negotiate this carefully as the goal is to streamline rounding processes, not double them.
A recent study published in the New England Journal of Medicine described a sign out process that reduced medical errors by 30%. This communication strategy involved 1:1 transfer of information about patients in a structured team environment (including nurses in some physician meetings). I anticipate that further investigation will reveal that interdisciplinary rounding (with nurses and doctors together) is a critical piece of the error reduction process. For all our advances in technology and digital information tracking, “old school” doctor-nurse rounds may prove to be more important in reducing errors and keeping our patients safe than other far more costly (and exasperating) interventions.
One of my biggest pet peeves is taking over the care of a floor-full of complicated patients without any explanation of their current conditions or plan of care from the physician who most recently treated them. Absent or inadequate verbal and written “handoffs” of patient care are alarmingly common in my experience. I work primarily as a locum tenens physician, traveling across the country to “cover” for my peers on vacation or when hospitals are having a hard time recruiting a full-time MD. This type of work is particularly vulnerable to gaps in continuity of care, and has heightened my awareness of the prevalence of poor sign-outs.
Recent research suggests that communications lapses are the number one cause of medical errors and adverse events in the healthcare system. An analysis published in the Archives of Internal Medicine suggests various kinds of consequences stemming from inadequate transfer of information, including missed diagnoses, incomplete work ups, ICU admissions, and near-miss errors. I have personally witnessed all manner of problems, including medication errors (the patient’s full list of medical conditions was not known by the new physician), lack of follow up for incidental (though life-threatening) findings discovered during a hospital stay, progression of infection due to treatment delay, inappropriate antibiotic therapy (follow up review of bacterial drug resistance results did not occur), accidental repeat fluid boluses in patients who no longer required rehydration (and had kidney or heart failure), etc.
It has long been suspected, though not unequivocally proven, that sleep deprivation (due to extended work hours and long shifts) is a common cause of medical errors. New regulations limiting resident physician work hours to 80 hours a week have substantially improved the quality of life for MDs in training, but have not made a remarkable difference in medical error rates. In my opinion, this is because sleep deprivation is a smaller contributor to the error problem than incomplete information transfer. If we want to keep our patients safe, we need to do a better job of transferring clinical information to peers assuming responsibility for patient care. This requires more than checklists (made popular by Atul Gawande et al.), it’s about creating a culture of carefulness.
Over the past few decades, continuity of care has been undermined by a new “shift worker” or “team” approach. Very few primary care physicians admit patients to local hospitals and continue to manage their care as inpatients. Instead, hospitalists are responsible for the medical management of the patient – often sharing responsibility as a group. This results in reduced personal knowledge of the patient, leading to accidental oversights and errors. The modern shift-worker model is unlikely to change, and with the rise of locum tenens physicians added to the mix – it’s as if hospitalized patients are chronically cared for by “float staff,” seeing the patient for the very first time each day.
As a physician frustrated with the dangers of chronically poor sign-outs, these are the steps that I take to reduce the risk of harm to my patients:
1. Attend nursing change of shift as much as possible. Some of the most accurate and best clinical information about patients may be obtained from those closest to them. Nurses spend more face-to-face time with patients than any other staff members and their reports to one another can help to nip problems in the bud. I often hear things like, “I noticed that Mr. Smith’s urine was cloudy and smelled bad this morning.” Or “Mrs. Jones complained of some chest pain overnight but it seems to be better now after the Percocet.” These bits of information might not be relayed to the physician until they escalate into fevers, myocardial infarctions, or worse. In an effort to not “bother the physician with too much detail” nurses often unwittingly neglect to share subtle findings that can prevent disease progression. If you are new to a unit or don’t already know the nursing staff well, join their morning or evening sign out meeting(s). They (and you) will be glad you did.
2. Pretend that every new patient needs an H&P (complete history and physical exam). When I pick up a new patient, I comb through their medical chart very thoroughly and carefully. I only need to do this once, and although it takes time, it saves a lot of hassle in the long run. I make note of every problem they’ve had (over the years and currently) and list them in a systems-based review that I refer to in every note I write thereafter.
3. Apply the “trust but verify” principle. I read other physicians’ notes with a careful eye. Electronic medical records systems are notorious for “copy and paste” errors and accidentally carrying over “old news” as if it were an active problem. If a physician notes that the patient has a test or study pending, I’ll search for its result. If they are being treated empirically for some kind of infection, I will look for microbiologic evidence that the bug is sensitive to the antibiotics they are receiving. I’ll ask the patient if they’ve had their radiology study yet, and then search for the result. I’ll review the active medication list and see if one of my peers discontinued or started a new medicine without letting me know. I never assume that anything in the medical record is correct. I try my best to double check the notes and data.
4. Create a systems-based plan of care, reconcile it each day with the active medication list. I like to organize patient diseases and conditions by body systems (e.g. cardiovascular, endocrine, gastrointestinal, neurologic, dermatologic, etc.) and list all the diseases/conditions and medications currently being offered to treat them. This only has to be done thoroughly one time, and then updated and edited with additional progress notes. This helps all consultants and specialists focus in on their particular area of interest and know immediately what is currently being done for the patient (both in their system of interest and as a whole) with a glance at your note. Since medications often have multiple purposes, it is also very helpful to see the condition being treated by each medication. For example, if the patient is on coumadin, is it because they have a history of atrial fibrillation, a prosthetic heart valve, a recent orthopedic procedure, or something else? That can easily be gleaned from a note with a systems-based plan of care.
5. Confirm your assessment and plan with your patient. I often review my patients’ medication and problem list with them (at least once) to ensure that they are aware of all of their diagnoses, and to make sure I haven’t missed anything. Sometimes a patient will have a condition (otherwise unmentioned in their record) that they treat with certain medications at home that they are not getting in the hospital. Errors of omission are not uncommon.
6. Sign out face-to-face or via phone whenever possible. These days people seem to be less and less eager to engage with each other face-to-face. Texting, emailing, and written sign-outs often substitute for face-to-face encounters. I try to remain “old school” about sign-outs because inevitably, something important comes up during the conversation that isn’t noted in the paper record. Things like, “Oh, and Mr. Smith tried to hit the nursing staff last night but he seems calmer now.” That’s something I want to know about so I can preempt new episodes, right nursing staff?
7. Create a culture of carefulness. As uncomfortable as it is to confront peers who may not be as enthusiastic about detailed sign-outs as I am, I still take the initiative to get information from them when I come on service and make sure that I call them to provide them with a verbal sign-out when I’m leaving my patients in their hands. By modeling good sign offs, and demonstrating their utility by heading off problems at the pass, I find that other doctors generally appreciate the head’s up, and slowly adopt some of my strategies (at least when working with me). I have found that nurses are particularly good at learning to tell me everything (no matter how small it may seem at the time) and have heard time and again that things “just run so much more smoothly” when we communicate and even “over-communicate” when in doubt.
“The Devil is in the details.” This is more true at your local hospital than almost anywhere else. Reducing hospital error rates is possible with some good, old-fashioned verbal handoffs and a small dose of charting OCD. Let’s create a culture of carefulness, physicians, so we don’t get crushed with more top-down bureaucratic rules to solve this problem. We can fix this ourselves, I promise.
At one time, a hospital would be called a 24-hour institution but now it’s a business. Within this business are shift workers that include nurses, technicians, clerical staff and even hospital employed doctors who are now called hospitalists. In a teaching hospital resident physicians also work in shifts so the responsibility of patient care is always being transferred from one group of healthcare providers to another. Do they always communicate effectively? Regrettably, “no.”
Sign-outs, handoffs, shift changes, nurses’ report. These are the multiple names for the process where a departing provider is responsible for letting the arriving provider know what’s going on with the patient. According to statistics, 80% of medical mistakes occur during shift changes and 50 to 60% of them are preventable. Listed below is an excerpt from The Smart Mother’s Guide to a Better Pregnancy that teaches pregnant moms what things should be known during a shift change. Read more »
*This blog post was originally published at Dr. Linda Burke-Galloway*
Welcome to Change of Shift!
We have some old friends and some new additions. Our submissions cover the best of nursing and the most difficult moments. Some share successes, others could use some collegial support.
So grab a latte, put your feet up, and enjoy…
Change of Shift: Volume 5, Number 4
I love adding nursing blogs to my blogroll! This week, thanks to his CoS submission, I’ve found Stephen at A Nurse Practitioner’s View, where he presents Team Work. When it comes to patient care, check our egos at the door.
Some teams we chose and some we’re born into, as noted in this heart-warming story from Keith at Digital Doorway, We’re All in This Together.
Nurses are expected to be super-humanly objective and non-judgmental. As this honest post from Nurse Me shows, there are limits, and don’t forget to Always Look Behind the Curtain First. Read more »
*This blog post was originally published at Emergiblog*
One of the most dangerous times for a patient is during the transition, or “handoff,” between providers. This is due to a number of reasons. First, the original provider(s) may not relay all the information he or she knows about the patient to the next provider(s). Second, the accepting team may take it for granted that everything is known about the patient, and therefore not take a complete history or perform an adequate physical examination. Third, if the patient initially looks good, the accepting providers may be lulled into a false sense of security, and not anticipate a deterioration in the patient’s condition.
We know this problem to exist in the hospital setting. Survey of doctors-in-training suggests that handoffs may commonly lead to patient harm. Last year (2008) in September, there was a blog written by Elizabeth Cooney in the Boston Globe that stated, “a 2006 survey of resident physicians at Massachusetts General Hospital found that handoffs commonly lead to patient harm, according to an article in The Joint Commission Journal on Quality and Patient Safety.” More than 50 percent “of the 161 medical or surgical residents who responded to the anonymous survey said they recalled at least one occasion in their last month-long rotation when a patient suffered from flawed handoffs.” Approximately “one in nine said the harm that resulted was significant.” The respondents said that “if the patient was coming from the emergency department or from another hospital, problematic handoffs were more likely.”
This holds true in the field. Unless the new treatment team makes the assumption that they need to begin their assessment of the patient’s condition from scratch, they are more likely to make a mistake. Obviously, such caution depends on the possible severity of the patient’s condition and the rescue/environmental situation. If I can get a decent handle on a patient’s condition, and there is little or no risk of me missing something, I will tailor my questioning and examination to suit the circumstances. However, I always start from the position that something has been hidden from me, of course not intentionally, and that the patient’s initial assessment has underestimated the problem(s).
I cannot begin to tell you how many times I have found something that was missed, or have accepted the care of a patient just as he or she began to “crash.” This is in no way a criticism of others, just a common fact of medical care. Previous rescuers may have been tired, the conditions may not have been conducive to a full examination, the patient may have been withholding information, or the situation may have just taken its natural course and worsened. Regardless, it’s my responsibility to learn what I can as quickly as I can about my patient, so that nothing slips through the cracks.
Here are some simple rules to follow:
1. If the situation permits, ask your new patient to repeat his or her history. If they are reticent to engage in a long conversation, at least try to get them to relate current relevant events.
2. Repeat as much of the physical examination as you can. Explain to the patient that you have assumed their care, and that in order to do the best that you can on their behalf, it’s important for you to understand their issues and to be able to monitor their progress based up the exam.
3. Assume that until you have talked to the patient or otherwise obtained a comprehensive history, and performed a physical examination with your own hands, eyes, and ears, that you do not know as much about your patient as you could.
4. If a patient is under your care for a prolonged time, or if you are managing a situation prone to rapid or undetected deterioration, interview and examine your patient as often as is necessary and practical. If you must be absent from a patient for a longer period than is prudent between examinations, delegate the responsibility to someone else.
image of leg splinting courtesy of www.princeton.edu
This post, Dropping The Ball In Patient Care: Provider Handoffs, was originally published on
Healthine.com by Paul Auerbach, M.D..