Hospital Care — who’s in charge?

mtsfig1

Diagram of the Multi-Team System (MTS) for patient care is from the AHRQ web site.  This is an idealized concept of what should happen that often does not happen.

A recent article in the New England Journal of Medicine (NEJM) described an unfortunate but all too common situation in hospitals.  In this article a patient was very sick in the intensive care unit with respiratory failure (on a ventilator) and with an unusual skin rash.  40 doctors and far more nurses were involved in the patient’s care.  So many people, in fact, that nobody knew who was in charge and except for ordering more and more tests nobody did anything.  The NEJM article sites the “Bystander Effect” which is the tendency for everyone in a big group to assume someone else will act.  Finally, the patient was saved by an acute problem which forced a doctor on the spot to actually do something.

Quality care is doing the right thing at the right time.  On both counts the NEJM case represents low quality.  Other factors beside the “Bystander Effect” may have been at work.  Perhaps the “Silo Effect” where all the care givers were in their own silo without regard to the big picture.  Perhaps it was the “Swiss Cheese Effect” where  errors on several levels lined up and the patient fell through.  But, most likely, the low quality was due to poor communication — the usual suspect.  If the care team does not talk the sense of urgency and the sense of danger are lost.  The patient was in grave danger!

So, you think this would never happen to you or happen at your local hospital? Think again.  It happens all the time when more than one doctor is involved (including on-call doctors).   Are there solutions?  Yes.  The most desperate need is always to designate who is in charge for every minute and every hour and every shift — including doctors and nurses.  In-charge is not a title, it means willing and able to act.  There should be a sign in each patient’s room with the name of the in-charge doctor and in-charge nurse.  Also, there should be a sign on the intensive care door: “All consultants who enter must talk to the doctor  in-charge before leaving”.

On a more hopeful note, research has some useful  ideas  for the teamwork-challenged hospital.   Here are some pre- and post-shift check lists from the STEPPS program:

Briefing  Checklist

During the brief, the team should address the following questions:
___ Who is on the team?
___ All members understand and agree upon goals?
___ Roles and responsibilities are understood?
___ What is our plan of care?
___ Staff and provider’s availability throughout the shift?
___ Workload among team members?
___  Availability of resources?

Debriefing  Checklist

The team should address the following questions during a debrief:
___ Communication clear?
___ Roles and responsibilities understood?
___  Situation awareness maintained?
___  Workload distribution equitable?
___ Task assistance requested or offered?
___  Were errors made or avoided? Availability of resources?
___ What went well, what should change, what should improve?

The question of  “who is in charge” is critical for hospital care.  Trauma surgeons seem to have this issue mastered (they are in charge) but other doctors are in a quandry when more than one is involved.  Patient safety demands US hospitals do better!

Finally, a comment about cost.  The lack of someone in-charge leads to high cost.  The NEJM article itself failed to mention the cost of 40 doctors working on the case.  In this time of rising health care cost the nation can not afford such lavish use of resources.

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