CONFESSIONS FROM THE INTENSIVIST: HAND-OFFS ARE FUN AND MORE THAN A SHIFT WORKER SARAH TABBUTT MD PHD DIRECTOR CARDIAC INTENSIVE CARE BENIOFF CHILDREN’S HOSPITAL UNIVERSITY OF CALIFORNIA SAN FRANCISCO

24/7 attending coverage: models Two attendings for 7 days, alternate nights Two attendings for 7 days, one for days and one for nights One attending for 7 days, multiple attendings on nights and weekends

two attending for 7 days, alternate night coverage model: post-call attending goes home after rounds (30 hours on, 18 hours off) advantages: hand-off occurs during detailed bedside rounds hand-off to someone well acquainted with patients improved continuity nights less stressful as patients are familiar move patient care forward at night disadvantages: 100 to 115 hours/week of service

Advantage HLHS undergoes Norwood Primary attending cared for patient preoperatively Primary attending goes to OR Primary attending gets handover from surgeons and anesthesia Primary attending examines baby several times an hour Primary attending longitudinally watching hemodynamics, NIRS, rhythm, lab results Primary attending more likely to be confident of late evening extubation

Disadvantage Fatigue Sustainable?

LONGER HOURS ASSOCIATED WITH INCREASED MEDICAL ERRORS BY INTERNS IN THE ICU Greater than 5 times reduction in diagnostic errors, P < 0.001 Greater than 20% reduction in medication errors, p = 0.03 Landrigan et. al. NEJM, 2004

LONGER HOURS ASSOCIATED WITH INCREASED MEDICAL ERRORS BY INTERNS IN THE ICU Greater than 5 times reduction in diagnostic errors, P < 0.001 Greater than 20% reduction in medication errors, p = 0.03 Landrigan et. al. NEJM, 2004 No data for attending staff. Does training with long work hours improve effective practice when fatigued?

one attending for 7 days with multiple attendings on night and weekends Advantages: 60 to 85 hours/week of service Disadvantages: multiple hand-offs to multiple caretakers

Scenario HLHS undergoes Norwood Night attending picks up service at 5pm Hand-off from daytime attending: no change in drips (epinephrine 0.01, dopamine 5, milrinone 0.25, fentanyl 1), lactate down to 2 Surgeon walks through unit and says patient is “fine” Night attending examines patient and reviews labs Nurse and fellow hand-offs at 7pm

Scenario Next several hours fellow has given volume x 2, gradually increased epinephrine to 0.05, blood gases stable Night time attending focused on another critically ill patient At 9pm, bedside nurse goes on break At 9:15pm, patient with desaturation and decision is to suction with fellow at bedside Bradycardia with suctioning, E-CPR

HAND-OFF PROTOCOLS REDUCE MEDICAL ERRORS ON PEDIATRIC INPATIENT WARDS I-PASS Illness severity Patient summary Action List Situation awareness and contingency plans Synthesis by the receiver Starmer et. al. NEJM, 2014

Night time attending was not in the OR and does not receive handover from surgery and anesthesia: difficulties with induction, airway, arch reconstruction, shunt placement, coming off bypass, coronary air HLHS undergoes Norwood Night attending picks up service at 5pm Hand-off from daytime attending: no change in drips (epinephrine 0.01, dopamine 5, milrinone 0.25, fentanyl 1), lactate down to 2 Surgeon walks through unit and says patient is “fine” Night attending examines patient and reviews labs Nurse and fellow hand-offs at 7pm

Night time attending does not have longitudinal knowledge of subtle changes in exam, hemodynamics, rhythm, oxygenation, NIRS, all fundamentally important to provide optimal care HLHS undergoes Norwood Night attending picks up service at 5pm Hand-off from daytime attending: no change in drips (epinephrine 0.01, dopamine 5, milrinone 0.25, fentanyl 1), lactate down to 2 Surgeon walks through unit and says patient is “fine” Night attending examines patient and reviews labs Nurse and fellow hand-offs at 7pm

No newborn immediately following a Norwood procedure is “fine” No newborn immediately following a Norwood procedure is “fine”. This reassurance can lead to false sense of security for the ICU team. HLHS undergoes Norwood Night attending picks up service at 5pm Hand-off from daytime attending: no change in drips (epinephrine 0.01, dopamine 5, milrinone 0.25, fentanyl 1), lactate down to 2 Surgeon walks through unit and says patient is “fine” Night attending examines patient and reviews labs Nurse and fellow hand-offs at 7pm

Entire team turns over between within two hours as the patient is approaching its predictable low cardiac output syndrome HLHS undergoes Norwood Night attending picks up service at 5pm Hand-off from daytime attending: no change in drips (epinephrine 0.01, dopamine 5, milrinone 0.25, fentanyl 1), lactate down to 2 Surgeon walks through unit and says patient is “fine” Night attending examines patient and reviews labs Nurse and fellow hand-offs at 7pm

Is the night time attending less engaged or more distracted as covering other patients? Is supervision of the fellows looser at night? Next several hours fellow has given volume x 2, gradually increased epinephrine to 0.05, blood gases stable Night time attending focused on another critically ill patient At 9pm, bedside nurse goes on break At 9:15pm, patient with desaturation and decision is to suction with fellow at bedside Bradycardia with suctioning, E-CPR

Perfect storm: covering nurse not experienced with newborns following complex surgery, RT new to CICU, attending unable to get to bedside for what the bedside team felt was an urgent need for suctioning. Next several hours fellow has given volume x 2, gradually increased epinephrine to 0.05, blood gases stable Night time attending focused on another critically ill patient At 9pm, bedside nurse goes on break At 9:15pm, patient with desaturation and decision is to suction with fellow at bedside Bradycardia with suctioning, E-CPR

REASONABLE WORK HOURS LEADS TO LESS CONTINUITY OF CARE AND MORE HAND-OFFS

REASONABLE WORK HOURS LEADS TO LESS CONTINUITY OF CARE AND MORE HAND-OFFS WE ARE WELL TRAINED TO CARE FOR THE CRITICALLY ILL PATIENT, BUT NOT WELL TRAINED TO HAND-OFF THE CRITICALLY ILL PATIENT

Can a modified I-PASS type hand-off protocol be effective in the CICU setting? Should the night time attending shift start when the complex patient arrives from the operating room? Should hand-offs be extended to several hours or as needed based upon patient acuity? Should shift changes be staggered between attending, fellow/resident and nurse? Should the night team be more experienced than the day team? LCOS often occurs at night. Should the night attending jointly develop the care plan with the day attending to provide more ownership of the patient? Will patient care become more driven by numbers than by human factors?

MILL VALLEY