Background: Effective after-hours communication is critical to patient safety, yet consensus on best practices among hospital staff remains poorly defined. This study sought to establish evidence-based standards for cross-cover communication and escalation in acute care settings.
Methods: A cross-sectional survey of 105 nurses, physicians, and clinical staff at an academic community hospital assessed perceptions of workflows and cross-cover practices using 35+ Likert-scale items. Agreement proportions were tested with one-sided binomial analyses and Clopper-Pearson confidence intervals. Items meeting ≥80% agreement with p < 0.05 were classified as best practices. Comparative analyses examined demographic influences across roles, shifts, units, and experience.
Results: Respondents were mainly nurses (57.7%) and physicians (30.8%), with most female (71.2%), white (69.2%), and aged 35–50 (52.9%). Nearly half worked overnight shifts (48.1%) in medical-surgical units, and 41.3% had over 10 years of experience. Five thematic domains emerged:Theme 1: Escalation consensus – Items like Rapidly worsening condition (96.2%, p < 0.001), Significant patient change (95.2%, p< 0.001), Care plan change (91.4%, p < 0.001), Issue cannot wait until daytime (90.2%, p< 0.001), Physician judgment (95.1%, p< 0.001), and Unsafe/confusing orders (98.0%, p< 0.001) all met best practice thresholds. Results underscore physician bedside evaluation and documentation as critical safeguards.Theme 2: Communication Protocols - Items such as Maintain professional tone (99.1%, p< 0.001), Separate patient threads (93.1%, p< 0.001), Contacting assigned residents (93.1, p< 0.001), and Verify on-call assignment (82.2%, p< 0.001) all met best practice thresholds, reflecting broad endorsement of structured communication protocols.Theme 3: Decision Authority - Low agreement on nurse-led decisions such as Medication adjustment requests (17.4%, p>0.99) and Code status updates (38.4%, p>0.99). This revealed variability in perceived scope of practice, with physicians less supportive of nurse-initiated actions.Theme 4: Communication Formats – Items like SBAR requirements (67.3%, p< 0.01) and preference for free text (56.4%, p< 0.01) were statistically significant but below best practice thresholds, highlighting tension between structured formats and ease of use among younger nurses. Theme 5: Escalation Hesitancy - Moderate to low agreement on hesitancy to call RRT (51.5%, p< 0.01) and group consensus before calling RRT (15.9%, p>0.99) highlights uncertainty in escalation protocols, pointing to gaps in education and policy clarity.
Conclusions: This study establishes consensus-driven best practices for after-hours cross-cover communication and escalation, while highlighting variability in nurse-initiated actions, documentation, and escalation hesitancy. To enhance patient safety, streamline workflows, and strengthen collaboration among overnight acute care teams, the adoption of standardized after-hours protocols— reinforced through targeted training and refined institutional policies – is essential.