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Trial of shift scheduling with standardized sign-out to improve continuity of care in intensive care units*

Emlet, Lillian L. MD, MS; Al-Khafaji, Ali MD, MPH; Kim, Yeon Hee MS; Venkataraman, Ramesh MD; Rogers, Paul L. MD; Angus, Derek C. MD, MPH, FRCP

doi: 10.1097/CCM.0b013e3182657b5d
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Background: Since 2003, the Accreditation Council for Graduate Medical Education requires residency programs to restrict to 80 hrs/wk, averaged over 4 wks to improve patient safety. These restrictions force training programs with night call responsibilities to either maintain a traditional program with alternative night float schedules or adopt a “shift” model, both with increased handoffs.

Objective: To assess whether a 65 hrs/wk shift-work schedule combined with structured sign-out curriculum is equivalent to a 65 hrs/wk traditional day coverage with night call schedule, as measured by multiple assessments.

Design: Eight-month trial of shift-work schedule with structured sign-out curriculum (intervention) vs. traditional call schedule without curriculum (control) in alternating 1–2 month periods.

Setting: A mixed medical–surgical intensive care unit at a tertiary care academic center.

Subjects: Primary subjects: 19 fellows in a Multidisciplinary Critical Care Training Program; Secondary subjects: intensive care unit nurses and attending physicians, families of intensive care unit patients.

Interventions: Implementation of shift-work schedule, combined with structured sign-out curriculum.

Measurements: Workplace perception assessment through Continuity of Care Survey evaluation by faculty, fellows, and nurses through structured surveys; family assessment by the Critical Care Family Needs Index survey; clinical assessment through intensive care unit mortality, intensive care unit length of stay, and intensive care unit readmission within 48 hrs; and educational impact assessment by rate of fellow didactic lecture attendance.

Main Results: There were no statistically significant differences in surveyed perceptions of continuity of care, intensive care unit mortality (8.5% vs. 6.0%, p = .20), lecture attendance (43% vs. 42%), or family satisfaction (Critical Care Family Needs Index score 24 vs. 22) between control and intervention periods. There was a significant decrease in intensive care unit length of stay (8.4 vs. 5.7 days, p = .04) with the shift model. Readmissions within 48 hrs were not different (3.6% vs. 4.9%, p = .39). Nurses preferred the intervention period (7% control vs. 73% intervention, n = 30, p = .00), and attending faculty preferred the intervention period and felt continuity of care was maintained (15% control vs. 54% intervention, n = 11, p = .15).

Conclusions: A shift-work schedule with structured sign-out curriculum is a viable alternative to traditional work schedules for the intensive care unit in training programs.

From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Laboratory (AA-K, DCA), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA; Multidisciplinary Critical Care Training Program (LLE, RV, PLR), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA; and Department of Biostatistics (YHK), Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.

*See also p. 3305.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (http://journals.lww.com/ccmjournal).

The work for this study was performed at the University of Pittsburgh Medical Center.

The authors have not disclosed any potential conflicts of interest.

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For further information regarding this article, E-mail: emlell@ccm.upmc.edu

© 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins