1. 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

2. 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

3. 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

4. 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

5. Disadvantage
Fatigue
Sustainable?

6. 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

7. 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?

8. 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

9. 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

10. 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

11. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

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

22. 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

23. 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?

24. MILL VALLEY