Background:

Hospitalized patients frequently show signs of clinical instability several hours before experiencing cardiac arrest or being transferred to the intensive care unit (ICU); earlier intervention and assessment might prevent adverse outcomes. This study examined whether communication barriers between nurses and physicians contribute to delays in care of clinically unstable patients on general inpatient wards at an academic medical center.

Method:

We administered a 30 question survey to nursing staff on 8 adult general medical and surgical wards at UCSF Medical Center. Our survey used a clinical scenario to solicit nurses' impressions of factors influencing the care of unstable patients: identification of unstable patients, ability to communicate with physicians, and the ability of nurses and physicians to accurately assess and provide care for unstable patients. The survey also evaluated nurse's general perception of patient safety and their nursing environment. All responses were on a 5‐point Likert scale (ranging from 1 = “never” to 5 = “all the time”.)

Summary of Results:

78 of 350 surveys were returned (response rate 22.2%.) Nurses felt comfortable in their ability to identify deteriorating patients (4.1 on 5.0 scale, standard deviation (SD) 0.64) and felt encouraged to call physicians when concerned (3.5, SD 1.0). Nurses did not experience difficulty locating the appropriate physician, and felt very comfortable (4.3, SD 0.89) contacting the housestaff, but were significantly less likely to contact the attending physician even when they could not contact the housestaff (3.1, SD 1.47, p < 0.01 for comparison). Once contacted, nurses reported that physicians assessed the patient within 30 minutes less than half of the time (2.7 +/−0.99), but nurses felt this was more often because the resident was too busy (2.6 +/−0.86) than because the resident was not concerned about the patient (2.3 +/−0.86; p < 0.01 for comparison). After the assessment, nurses felt that physicians only communicated their plan about half of the time (3.0 +/−0.96). While nurses were generally satisfied with the quality of care on their unit, they did feel that nearly half of the unstable patients experience delays in care that could lead to adverse events.

Statement of Conclusions:

Medical and surgical nurses feel comfortable identifying unstable patients and contacting housestaff, but are reluctant to contact the attending physician. Nurses frequently wait over 30 minutes before a physician evaluates clinically worsening patients, are often not informed of the treatment plan and feel that resulting delays put patients at risk. Delays in intervening on clinically unstable inpatients may be related to suboptimal communication of treatment plans from physicians to nursing staff, as well as a culture that discourages nurses from directly contacting attending physicians.

Author Disclosure Block:

C.J. Olson, None; S.R. Ranji, None.