Kevin Kathrotia, MD

NICUs transitioning away from shift work to improve patient health, worker health and hospital costs

January 31, 2020
By Kevin Kathrotia, MD

While admitted to the hospital it’s unlikely that you’ll see the same doctor or nurse two days in a row, a direct result of the traditional scheduling model of assigning hospital-based physicians to work intermittent shifts. While doctors and nurses typically work intermittent shifts at most hospitals nationwide, it’s time we take a step back and re-evaluate if this model is what’s best, in terms of quality of care and efficacy, for patients, physicians and overall hospital operations—especially in regard to NICUs.

The case for consecutive work days
A recent study by Medscape found that when hospitalists work several consecutive days, as opposed to working intermittent shifts, patient outcomes improve and costs decrease.

For example, among the more than 114,000 patients studied, major outcomes, such as 30-day mortality risk after discharge, readmission risk, and discharge to home, all improved with hospitalist continuity of care.

The benefits of transitioning away from shift work are compelling, and can be attributed to three key areas:

Continuous, personalized care
When a hospitalist works several days in a row, they get to know the patients and their families on a much deeper level. This not only is good to minimize errors in patient care, but it helps develop a bond between the patient/patient's families and their physician. This potentially leads to improved compliance with discharge instructions/discharge care plans/ seeking medical advice in the future.

Adapting this to the NICU, where the health of newborn babies lies in the hands of the attending physician, working several days in a row allows nurses and doctors to see a patient's condition improve or worsen. Instead of a point in time, it allows the patient to develop their story with the neonatologist, which could help with diagnosis. This also helps the nurses know how to predict certain treatments or plans of care, since they are working together with the same physician over several days.

Additionally, having a consistent presence at the hospital allows the physician to get to know the parents of the baby and establish a trusting relationship instead of being seen as a rotating doctor.

Healthier staff, better outcomes
There is also the issue of staff burnout. If you work a long shift one day, have a day off and then work long shifts two days in a row, it seems like you never really catch up on your sleep or other things going on in your life. In fact, nearly one-third of healthcare workers report they do not get enough sleep, which increases the risk of fatigue related injuries and errors. When monitoring the working hours of nurses and their errors/near-errors during work hours, one study found they had over three times the odds of making an error when working 12 or more hours, compared with 8.5-hour shifts.

Working a few days in a row and then having a few days off in a row is often better for neonatologists because it puts them into a routine and gives them mental health relief from work, along with many other benefits. If the entire hospital staff is relaxed and healthy, there is more time and energy to focus towards patients, thus resulting in better outcomes for preemies in NICUs.

Better business model
From the hospital business perspective, there are a number of reasons to transition away from shift work. First is the opportunity to improve patient satisfaction ratings due to parents/family members of the patients feeling more at ease with a physician or nurse that they’re familiar with. It comes as no surprise that shifts greater than 13 hours have been linked to patient dissatisfaction with physician communication and level of care, which resulted in the patient not recommending the hospital.

Another aspect of implementing continuous care is the associated cost savings. The standardization of care by one doctor will improve outcomes by decreasing errors associated with multiple handoffs, which in turn shortens the length of patient stays and ultimately saves both hospitals and patients money. The Medscape study found that 30-day post discharge costs were $223 lower per patient when hospitalists work several consecutive days.

Make the scheduling change
In order for a hospital to introduce this new scheduling format, it’s important to evaluate the current scheduling system and get in weigh in from the medical staff. Present the idea to doctors and mid-level employees and explain the implications of implementing this new scheduling model--improved patient outcomes, healthier staff and a better business model. With their support and the proper management structure, transitioning neonatologists away from shift work will be attainable and the positive impact on all parties will be apparent almost immediately.

About the author: Dr. Kathrotia is dual-boarded in General Pediatrics and Neonatal-Perinatal Medicine, and serves as Managing Partner and Chief Operating Officer of Millennium Neonatology, a practice management firm for Neonatal Intensive Care and Newborn Services.