Published in the August 2011 issue of Today’s Hospitalist
SINCE 2004, the Joint Commission has required doctors and nurses performing procedures and surgeries to take a mandatory timeout. The idea is to provide a short bit of breathing space so everyone can agree that they have the right patient and they’re doing the right procedure.
That concept raises an interesting question. Why not require short timeouts during the rest of a patient’s hospital stay?
A new study did exactly that by putting brief timeouts into nonprocedural settings to avoid misunderstandings that can jeopardize patient safety at high-risk times during a hospitalization. The study, which refers to those timeouts as "critical conversations," appeared in the April 2011 Journal of Hospital Medicine.
Researchers at the University of California, San Francisco (UCSF) identified three nonprocedural events where direct communication is critically important to reduce patient harm: admission, changes in clinical condition and discharge.
"We knew that transitions were high-risk times," says Niraj Sehgal, MD, MPH, the study’s lead author. "Yet there was no real structure around the need for direct communication at those times."
Critical conversations “at least those at admission and during status changes “consist of direct communication (either face to face or on the phone) between a physician and the bedside nurse. At discharge, timeouts may also include a social worker or case manager. Some of these conversations, the study makes clear, last no more than 60 seconds.
At each juncture, says Dr. Sehgal, "We give four or five bullet points emphasizing the types of things that should be discussed. The hope was that codifying these times made the communication more efficient."
Bullet points that should be covered at admission, for example, include the admitting diagnosis; the immediate treatment plan; medications that have been ordered, particularly those that are new ones for that patient; priorities for completing various admitting orders; and who should be notified if the patient’s condition changes.
Dr. Sehgal admits that initially, some clinicians worried that these rapid-fire conversations would eat up valuable time. But once the plan was in place, he says, clinicians found that "having that very quick discussion saved time."
"Engaging in these conversations," he explains, "actually reduced the number of pages physicians received to clarify orders or new medications or find out if the patient already went to radiology for a chest X-ray."
Dr. Sehgal talked to Today’s Hospitalist about the study and how it can help hospitalists.
How did you get doctor and nurse buy-in?
The buy-in came from having frontline providers identify and develop the foundation for these conversations. They understood how important it was to have direct communication at these three junctures. Although these are high-risk times, we had very haphazard, unstructured communication around them.
As a result, most of our frontline providers were part of the solution, rather than just being told, "This is a new mandate, and we need you to communicate at these times because we think it’s important."
Who initiated these conversations, doctors or nurses?
It was a balance. During admission, the physician many times initiated the call. But there were times they got busy and then the bedside nurse tried to reach the physician “"Hey, your patient just arrived, I see the admitting orders" “and that initiated the critical conversation.
We didn’t explicitly say who should make the call. We realized that there were times when having the conversation was more important than who initiated it.
How is information exchanged during timeouts different than what’s discussed at handoffs or in multidisciplinary rounds?
Handoffs and interdisciplinary rounds are largely driven by providers’ need for information when they’re transferring care responsibilities or sharing the basic plans for the day at designated times.
While information passed during handoffs is based on what you want the covering provider to be aware of, timeout conversations are driven by those times at which patients are at greatest risk for errors from communication failures “at admission, during a change in clinical condition and at discharge. They’re not mutually exclusive sets of information, but the goals of exchanging information are different.
With the shift to electronic records, are timeouts like these becoming more or less important?
Before we had electronic health records, our medical unit often looked like air traffic control in the early afternoon. You had multiple providers running around looking for the charts. This created numerous informal opportunities for providers to talk about shared patients.
Today, if you walk into our medical unit at two or three in the afternoon, it can look like a ghost town. Nurses are sitting in front of computers in little hideaways, and physicians are sitting in front of computers doing their documentation a couple floors away. As we put more people in front of computers, the need to have more direct communication is probably greater.
What was the purpose of creating checklists for the conversations?
We tried to create a general structure of what these conversations should entail, with the understanding that they may be different in different circumstances. Our experience was that codifying the discussions during these timeouts made the communication more efficient and directed.
As hospitals in the future become more and more electronic, it’s going to be a challenge to ensure direct communication and avoid over-reliance on "It’s in my note" or "They can just look it up in the EHR." Certainly, mobile devices, tablets and other IT tools may help advance communication efforts like these in creative ways.
Did you track how many fewer pages doctors received after they began these conversations?
We didn’t formally evaluate that outcome. However, when we talked to clinicians, several themes emerged. One was that these conversations helped them clarify the plan of care and prioritize competing tasks. The timeouts also seemed to improve teamwork and made for more effective use of resources.
Other themes came through stories shared at our multidisciplinary case conference. A bedside nurse stated that nothing’s worse than meeting a patient for the first time at admission and not being able to answer why he or she was admitted. It gives the impression that we don’t talk to each other, so a critical conversation can help us avoid the perception of mixed messages or lack of teamwork.
Contrast that with a physician comment that discharge always seems chaotic, with everyone racing to fill out forms. Invariably, you have to fix, change or add new information to the discharge process that would have easily been averted by having a brief conversation with the bedside nurse or case manager.
Laura Putre is a freelance health care writer based in Lakewood, Ohio.