Published in the July 2006 issue of Today’s Hospitalist
When it came to getting up-to-date information about patients, the nurses on the medical units at Jacobi Medical Center were frustrated. Because the 500-plus bed hospital in the Bronx, N.Y., doesn’t have centralized wards, medical patients can be admitted to one of six different nursing units in the hospital, depending on their individual needs and bed availability.
For a large hospital like Jacobi that’s trying to maximize its bed capacity, decentralizing the wards “and putting patients wherever there is room “is a fairly common solution. And while physicians may complain about sore feet from so much time spent walking the halls, an even bigger problem is the effects on physician-nurse communication.
Because physicians are coming and going throughout the day, nurses often have trouble getting the information they need to develop a care plan or talk to patients and their families. With physicians often nowhere to be found, nurses feel like they’re left in the dark about what’s going on with their patients.
During departmental meetings, in fact, nurses often complained that they weren’t getting enough information about changes in areas like diagnostic testing, discharge planning and DNR status.
As hospital leaders searched for a solution, they had a brain¬storm: Why not give nurses access to the electronic sign-out system already being used by housestaff?
Extending electronic sign-outs
The hospital was in a position to do just that because it had implemented an electronic sign-out system for its housestaff in February of 2003. That system was quickly embraced by interns and residents, in large part because the hospital required them to use printouts from the system during shift changes.
About 18 months after the sign-out system was put into place, Jacobi gave nurses on a general medical unit access to the sign-out system as part of a pilot project. Nurses also received a printout of the computerized sign-outs at the beginning of their shifts so they could refer to the information easily throughout their shift.
Nurses were asked to use the printouts to create care plans for their patients. They were also encouraged to use the printouts during shift changes to make hand-offs go more smoothly, much like interns and residents were already doing.
Robert Sidlow, MD, a hospitalist and associate medical direc¬tor of the North Bronx Healthcare Network, says that the nurses taking part in the test agreed that it made a big difference in how they received information about patients. (See “How a sign-out system gave nurses access to patient information,” right, for more information.)
In an article published in the January 2006 issue of the Joint Commission Journal on Quality and Patient Safety, Dr. Sidlow and colleagues concluded that nurses with access to the sign-out system had a markedly improved understanding of their patients’ reason for admission, current clinical status and overall care plan. The system also improved nursing morale, which the study points out may be an important factor in nursing satisfaction and retention.
Not a substitute for “real” communication
“The nursing staff took to it enthusiastically because we have such a geographical spread of our house officers throughout the hospital,” Dr. Sidlow explains. “Nurses were really having difficulty integrating with the physicians’ workflow in a meaningful way.”
While Dr. Sidlow notes that the system was not intended to replace what he calls “real” communication, he says that it paradoxically led to more person-to-person communication.
“Having access to the sign-out system really boosted the nurses’ self-confidence in their own work, and it ultimately improved their interactions with the doctors,” Dr. Sidlow says. “Nurses now feel more empowered to ask questions and engage with the doctors because they have a better understanding what is going on in the minds of the physicians taking care of the patients.”
Dr. Sidlow admits that in an ideal world, physicians and nurses would simply talk to each other. But as any hospitalist knows, what transpires in the hospital setting is often far from ideal.
“You might say that this is really a crutch for what should be taking place on patients together, such as interdisciplinary rounds where nurses actually round on patients together on a regular basis,” he acknowledges. “The unfortunate reality for most people who work in hospitals is that things just don’t happen that way anymore.”
A “low-stress” solution
One of the reasons the initiative worked so well is that existing tools were simply expanded. Dr. Sidlow says that hospitals with electronic sign-out systems could do the same thing without much effort.
“It’s a low-stress way of leveraging information that is already floating around the hospital,” he explains.
The project was so successful, in fact, that after the pilot study was completed, the hospital gave access to the electronic sign-out system to nurses in all of its medical and subspecialty wards, including all intensive care units. Care managers and social workers on the medical service were also given access to the data.
There are some caveats, however. For example, Dr. Sidlow acknowledges that a key to the initiative’s success is making sure that the sign-out system is well-used by the residents. If they don’t regularly update the information in the system, the nurses will still be working with bad data.
One downside of the sign-out system, he says, is that audits have found that about 10 percent of the information is not as current as it should be. While much of the sign-out information is automatically downloaded from the electronic medical record, clinicians are still responsible to update the “active problems” and “to-do” list manually.
“Sometimes the information entered into the system is delayed a bit,” Dr. Sidlow says. “It might reflect what happened on the last shift. Until the house officers get around to updating that information, there might be a delay of a few hours or so.”
Also, while the system identifies the team responsible for individual patients, it doesn’t identify the individual physician. When nurses ranked improvements in communication that were enhanced by the sign-out system, this area received the lowest score. Dr. Sidlow says this finding highlights an opportunity for improvement.
Concerns about information accuracy
He also acknowledges that not every hospital has an EMR and a sign-out system. Most hospitals, he says, instead use word processing documents to pass along information.
Could hospitals using that more traditional form of sign-outs share information with nurses? Dr. Sidlow is skeptical, primarily because these documents typically aren’t integrated into an electronic medical record. That could lead to problems with the integrity of the information being passed around.
“One of the main priorities we had was ensuring the accuracy of the information being shared,” he explains. “Most important is having an accurate medication list for patients.”
Because the electronic sign-out system at Jacobi is integrated into the computerized medical record, the “active medication and infusion” list is always refreshed and current. In addition, the sign-out system automatically downloads information about patients’ drug allergies, DNR status, and current location “all critical information to have on hand in the middle of the night.
Any other type of system, Dr. Sidlow says, could be subject to transcription error. “I would be wary about sharing information if it’s been scribbled by hand on a paper note or entered into a word processing document willy-nilly,” he explains. “I wouldn’t necessarily want to share that with nurses because I wouldn’t be able to verify its accuracy.”
Edward Doyle is Editor of Today’s Hospitalist.
