Washington: In most teaching hospitals, after-hours patient responsibility is covered by resident physicians, who are always able to call a supervising senior physician for advice on handling situations that may come up. But which situations require immediate consultation and which can wait until the next day can sometimes be unclear.
A new study from the Massachusetts General Hospital for Children (MGHfC), published in the Journal of Paediatrics, finds significant discrepancies between paediatric residents and their supervising physicians regarding when supervisors should be called to help deal with specific after-hours situations. For some situations, even the supervisors disagreed among themselves regarding whether immediate consultation was required.
“Balancing the need for residents to develop autonomy with the level of supervision required to ensure safe and appropriate patient care is challenging,” says Dr Chadi El Saleeby, an MGHfC Hospital Medicine and Infectious Diseases physician and senior author of the report. “The variations we found between residents and attendings – and even more so among attendings – highlight the need for more structured, formal guidelines within programmes and institutions.” Dr El Saleeby is an assistant professor of Paediatrics at Harvard Medical School.
While the Institute of Medicine has recommended that improved supervision of trainee physicians through more frequent contact with supervisors could reduce errors and improve the quality of patient care, the authors note that appropriate levels of supervision and how they are to be established have not been defined. Other studies have examined attitudes and practices regarding resident/attending communications in Surgery and Medicine, but this is the first to do so in Paediatrics. Prior to this study the communications guidelines for MGHfC residents were quite general. Guidelines were included in the residency manual and available online, but since they were not specifically incorporated into resident training, individual trainees could have been unaware of their existence.
The current study, which was conducted from December 2012 through January 2013, surveyed all MGHfC residents in Paediatrics and in the joint Medicine/Paediatrics programme and their supervising physicians on the Paediatric Hospital Medicine service and in several other Paediatric specialties.
The surveys presented 34 scenarios related to clinical situations, laboratory/radiology or medication issues, and logistical/social situations, which ranged from the need to consult another service in the hospital to a parent or patient wanting to be transferred to another hospital or leave against medical advice. For each situation, participants were asked whether the resident should consult the supervisor “immediately” – a term that was not defined – or if consultation could wait until the next day. Residents were also asked whether they were aware of the existing communications guidelines.
The surveys were completed by 62 residents and 50 supervisors, and statistically significant differences between group preferences were observed in half of the scenarios. Overall, most residents indicated they would call immediately in 18 scenarios, while more supervisors would choose to be immediately contacted in 26. In each scenario with significant discrepancies, more supervisors than residents would choose immediate communication. There was strong agreement on the need for consultation in the most serious scenarios – such as a patient death, rapid deterioration or a medical error requiring intervention – as well as on many situations when communication could wait – such as routine lab and radiology orders or drug reactions that did not require intervention.
Some of the most striking differences were in logistical/social situations – such as an angry parent or family member, the need to put a patient in restraints, aggressive patient behaviour or the inability to carry out a procedure for any reason. In those and several other situations, residents preferred to wait until the next day, but supervisors preferred immediate consultation. The authors note that some of this discrepancy may result from residents’ not appreciating how the advice or intervention of a supervisor could defuse a challenging situation. More than 60 percent of residents were not aware of the existing communications guidelines, and most of those who were aware of their existence indicated not knowing their specifics.
While there were no significant differences in the responses of residents based on how far along they were in their training, the researchers were surprised to discover some significant differences among supervising physicians, with senior attendings being more likely than junior attendings – who could be fellows or attendings in practice less than five years – to prefer immediate notification for situations including patient falls, new or worsening pain, an angry parent or family member, or the need for restraints.
“We had theorized prior to this study that differences in communication would exist among members of the healthcare team, but the magnitude of the differences was surprising to us, along with the disagreements among attendings, many in the same division,” says lead author Dr Deepak Palakshappa, chief paediatric resident at the time of the study and now an instructor at the Children’s Hospital of Philadelphia. “This study provides a first step toward improving supervision of paediatric medical trainees by defining these significant differences in communication preferences.”
Based on the results of this study, the MGHfC developed new formal guidelines for resident/supervisor communications that were put in place for the current academic year. The ‘Guidelines for Requiring Supervisory Physician Involvement’ are available on the MGHfC website and will be reviewed on a biennial basis. Future studies should evaluate how these guidelines improve resident supervision and ultimately patient outcomes, the authors note. MGHfC physician Dr Lindsay Carter is also a co-author of the Journal of Paediatrics study.
The following guidelines have been developed to make explicit the conditions under which involvement of the supervisory physician should always be requested.
Guidelines for Requiring Supervisory Physician Involvement
Interns will, at all times, have an in-house supervisory resident, fellow or attending available to call for assistance and supervision. Junior and senior residents will have a fellow immediately available in the PICU (Paediatric Intensive Care Unit) and an attending immediately available in the NICUs (Neonatal Intensive Care Units). Elsewhere, they will have an attending available for phone consultation for assistance who is available to evaluate a patient in person as needed.
The following are explicit conditions when an attending should be contacted immediately. In addition, residents should always contact a supervising physician if they have a question or when they are uncomfortable or uncertain about patient care.
Specifically, the attending must be notified in the following cases:
1. Unexpected deterioration in a patient’s clinical status
b) Rapid response calls / Codes
c) Transfer to a higher level of care (e.g. ICU) or to another care facility
d) Haemodynamic instability or unexpected new/increased O2 requirement
e) New fever > 101 in an immunocompromised patient
f) New neurological or psychiatric development (e.g. change in mental status, CVA, new seizure)
g) Bleeding: haemoptysis, new GI bleed (Gastrointestinal bleed)
2. Abnormal/Critical lab with potential clinical significance (e.g. positive blood culture, rising creatinine)
3. Consulting another service
4. Drug reaction or medication error resulting in patient harm or requiring intervention or increased level of monitoring
5. Inability to deescalate a social situation (angry patient/family member, patient or family leaving AMA (against medical advice) or requesting transfer to another facility)
6. Nursing Concerns – if the nurse caring for the patient feels the supervisory attending or fellow should be contacted
7. Patient or family requests to speak to attending
8. Performance of a procedure/radiology
a) Need for invasive procedure (e.g. lumbar puncture)
b) Ordering an MRI or CT
9. Unexpected pain or inability to control pain
10. Unreasonable difficulty in obtaining a time-sensitive procedure or radiological intervention
A supervisory resident and chief resident must be notified in case of fatigue:
If a resident feels fatigue, patient volume, acuity or overwork compromises his/her capacity to give appropriate care to patients, the supervisory resident (in the case of interns) and chief resident on call (in all cases) should be called immediately to arrange for backup coverage.