Workflow barriers out of hours: optimising critical care outreach to support clinical decision making in medical and surgical care settings

摘要

Introduction : The out-of-hours period is associated with less favourable patient health outcomes as well as unpredictable workloads and reduced support structures for clinical activity. In particular, appropriate skill mix, staff numbers, resources, communication structures and access to diagnostic services can influence patient safety and risk. As part of continued efforts to improve patient care and hospital management, one major academic hospital is in Ireland has been engaged in work re-design during the out-of-hours service period to improve supports for clinical decision-making in medical and surgical care wards. Aim : To gain understanding of facilitators and challenges and barriers to effective work flow and clinical decision-making out-of-hours To undertake work redesign as needed to enable critical care outreach to medical and surgical out of hours Methods : An exploratory mixed methods design included surveys and semi-structured interviews and focus groups with various stakeholders involved in out-of-hours service delivery and management as well as nursing staff and non-consultant hospital doctors. Ethical approval was granted by the Trinity School of Nursing and Midwifery Ethics Committee. Results : Overall, these findings provide an overview of the typical patient activity patterns within the medical/surgical wards and highlight the potential impact of changing hospital environment on out-of-hours clinical workflow and gives some insight into potential flashpoints that may arise. The on call task activities indicate recurring patterns in relation the nature of routine activity and prescribing patterns out-of-hours. Findings from inductive analysis of qualitative interviews identify the nuances of the experience of working out-of-hours for staff and the barriers to workflow, the centrality of communication to effective performance, and the latent effects of call arrangements and work design. There was consensus across all grades of clinical staff around the positive benefits of the Emergency Response Team/ Early Warning Score (ERT/EWS) systems. Discussion : This study has identified areas of service delivery out-of-hours that are working well such as the EWS system but has also revealed areas that might benefit from improvement for example communication strategies, medical workflow design, logistical access to equipment, services and clinical support at bedside. Conclusions : (comprising key findings) The task of delivering health care effectively and safely out-of-hours should be considered against a backdrop of a changed health care environment with increased survival rates, greater levels of chronic illness and considerable innovation in technology, diagnostics and medical interventions. A critical care outreach senior nursing role for the out of hours period was found to be needed and has been recently implemented to support nurses caring for high dependency patients on the wards and to provide advice and support to NCHDs out of hours. Suggestions for future research : Following implementation of new clinical support role conduct a longer term evaluation of the impact on workflow, task allocation and staff/patient experience out-of-hours. Conduct larger studies in partnership with other hospitals that employ innovative solutions to out-of-hours support to contribute to the wider body of knowledge nationally and internationally.