The Joint Commission is tired of fatigue-related events
New alert encourages attention
Almost everyone who has been in healthcare for long enough can tell a story about a tired physician or worn-out nurse who has either made a mistake or come this close to it due to fatigue. Studies have shown that nurses working longer than 12 hours and residents who worked multiple 24-hour shifts were involved in three times the fatigue-related adverse events than others. Overtired providers are also more likely to get injured on the job. The concern over the link between being tired and adverse events led The Joint Commission to issue a sentinel event alert on healthcare worker fatigue and patient safety in December.
In the alert, the JC recommends that organizations:
- assess fatigue-related risks such as off-shift hours, consecutive shift work and staffing levels;
- examine processes when patients are handed off or transitioned from one caregiver to another, a time of risk that is compounded by fatigue;
- seek staff input on how to design work schedules that minimize the potential for fatigue and provide opportunities for staff to express concerns about fatigue;
- create and implement a fatigue management plan that includes scientific strategies for fighting fatigue such as engaging in conversation, physical activity, strategic caffeine consumption and short naps;
- educate staff about good sleep habits and the effects of fatigue on patient safety.
Much of what is recommended is already in place in the Anne Arundel Health System, says Shirley Knelly, CPHQ, LCADC, MS, vice president of quality and patient safety for the Annapolis, MD-based system.
Productivity reports
Using the payroll program, they monitor employee hours every two weeks, with notations of every employee who works longer than 12-hour shifts. "That's the first line of defense: to know if they are scheduled for eight or 10 or 12 hours and work longer," she says. They look to see if there are particular staff members or units that are prone to this overwork, and whether it is a short-term occurrence or a long-term trend. Directors and managers then investigate what the reason is behind the longer shift.
Productivity reports for departments look at hours paid, the number of full-time employees (FTEs), and any variances. Knelly says these reports encourage managers and directors to look at whether a unit is consistently short-staffed. "If one is constantly over FTE, why are they over? Maybe they need more employees because you are working others too hard."
The organization also requires a review of employee hours as part of its root-cause analyses in any incident where harm occurred. This is done for all employees involved and includes how far into their shift they were, their individual patient loads, and staffing requirements for the units.
Anne Arundel is ahead of the curve on The Joint Commission's handoff recommendations, too, says Knelly. "We have a structured and standardized method," she says. Information is pooled from all parts of the patient record, shift reports have to be verbal — not just written — and they have begun doing bedside reporting with the patients, their families, and nurses all present.
The new alert will still have an impact: Knelly says they will pull together a team to look at what Anne Arundel has in place and do a gap analysis of that compared to The Joint Commission recommendations.
A task force will then create and put any new policies and procedures in place. At press time, the gap analysis meeting was scheduled but had not occurred.
One change already anticipated is to invite medical staff into the process as well. "We do not monitor the hours of non-employee physicians, but we think they should be part of the discussions, too," says Knelly.
On-call physicians
For physicians, the biggest issue is probably call, says Matthew Phillips, MD, president of Austin Heart, a Texas cardiology practice. "People always talk about the toll on residents to be up day after day, but no one talks about all the physicians who still work like that." He notes that half the cardiologists in the country are over 50 and often work all day, all night, and all the next day.
His practice includes 46 physicians covering an area of Texas the size of Maryland, including many small towns that have limited resources for complex heart patients. The sickest of the patients will be transferred to a tertiary care facility where they could end up under the care of a very tired physician, says Phillips.
Austin Heart implemented a program called Deep Night eight years ago. About three times a year, each cardiologist will spend a week — Sunday through Thursday — working from 6 p.m. to 7 a.m. They lose the daytime production by not working the day shift after the night shift, which means there is a cost to the individual physicians, and to the practice which essentially has to have an extra employee to make the program work.
Phillips says he doesn't know of other practices doing this — indeed, other cardiology groups in his market complain that Austin Heart does this at all. "We see patients often 12 hours earlier because we have a physician there, on site, every night. CMS says you have to see them within 24 hours, and other practices often won't go in during the night, but will wait until 8 a.m. the next morning. I'll see you at 8 p.m. when you come in."
The practice has a backup on-call physician who can come in if needed — for instance, if an invasive cardiologist is needed to put in a stent, then he or she will come in. Indeed, if necessary, any of the team will come in to assist if it is a particularly busy night.
How to measure?
One issue that organizations will face is how to measure fatigue. "It's individual for every person — one person may need six hours sleep to function, and another may need nine," Knelly says, adding that the best option is probably to look at various measures that surround fatigue — incident reports, hours worked, days in a row worked, staffing levels, and how busy a unit is. Employee satisfaction surveys might also help.
Knelly says Anne Arundel is looking at adding questions about fatigue to several surveys, including the safety culture survey and the annual nursing survey.
"This has always been a concern," says Knelly. "We are no different than any other hospital. If someone says they do not have this problem, I do not believe it. Every hospital has this issue." And it is one that not only affects patients, but staff. To that end, Anne Arundel also requires that staff take scheduled breaks and lunches, and staff members may not skip a break or lunch in order to leave early.
Austin Heart has used length of stay (LOS) measures to see if their program works. They have noted not only a shorter LOS for their patients, but Phillips thinks Austin Heart's heart attack death rate — the lowest in the nation — is at least in part due to the physicians seeing patients earlier and being completely awake and alert when they do. "You can't be awake every third night with a high-acuity patient and expect to be at your best," Phillips says.
But perhaps the best way to measure success is to look at how soon patients are seen compared to providers who do not have this kind of scheduling in place, he says. The difference is clear, and as any cardiologist will tell you, time is heart muscle.
Ask physicians what they hate, Phillips recommends. They'll probably all say call and the inhuman hours. His staffing program is certainly one way to address that. While it is dependent on independent practices implementing the change, it is certainly something that a hospital can suggest, or consider doing for their own employed physicians and other staff. Indeed, Phillips is concerned about the fatigue of ancillary staff members who assist cardiologists and might not be at their best in the middle of the night. The cost is worth it, he notes, in terms of improved patient safety and quality of life for providers.
For more information on this story, contact:
- Shirley Knelly, CPHQ, LCADC, MS, Vice President of Quality and Patient Safety, Anne Arundel Health System, Annapolis, MD. Email: [email protected].
- Matthew Phillips, MD, President, Austin Heart, Austin, TX. Email: [email protected].
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