The Case

A 64-year-old man was admitted to the hospital because of bilateral pleural effusions and pulmonary emboli in the setting of newly diagnosed metastatic cholangiocarcinoma. He remained short of breath and required anywhere from 6 to 10 liters of oxygen by nasal canula to maintain adequate oxygen saturation. Thoracentesis was performed on both sides to remove the pleural fluid. Ultimately, he required placement of bilateral pleural catheters to manage reaccumulation of the pleural fluid.

His overall clinical status remained tenuous, and he was followed closely by the hospital's rapid response team. One night, he developed acute worsening of shortness of breath and altered mental status. The bedside nurse paged the intern night float, who was cross-covering this patient, to come to the bedside to assess the patient's condition. The intern looked up the patient on her signout sheet and in the electronic medical record to check the patient's code status, clinical history, recent labs, and imaging. The signout did not provide a contingency plan explaining what course of action to take should the patient worsen. Moreover, although the patient was officially listed as a full code, the intern could not clearly determine the patient's overall goals of care from the signout. She ordered a stat chest radiograph, electrocardiogram, head CT, and laboratory tests. The patient continued to desaturate, and his blood pressure fell. The intern tried to call the rapid response team to switch the patient to high-flow oxygen by nasal canula, but she was unaware that she was using an incorrect paging number. When the intern asked the nurse to page them, the rapid response team finally arrived. The intern tried to page the senior resident responsible for assisting her overnight, but she also did not have the correct pager number for the resident. She could not leave the bedside to look for the resident because the patient was too unstable.

After an hour at the bedside, the intern saw a senior resident in the hallway and asked him to assess the patient and to assist in managing the patient's care. After reviewing the patient's laboratory test results (including a blood gas that revealed worsening oxygenation, hypercarbia, and an elevated lactate), the senior resident paged the ICU fellow and suggested to the intern that they call the patient's family to provide an update regarding the patient's worsening status and to determine if the family would want the patient intubated and placed on a ventilator if he continued to worsen. The family decided against intubation, changed the patient's code status to DNR/DNI, and, after talking in depth with the overnight intern and resident, transitioned the patient to comfort-focused care. The intern ordered a morphine drip for air hunger and symptom management. The patient died several hours later. The primary hospital medicine attending was not notified of the patient's change in clinical status overnight and did not learn of the patient's death until the following morning.

The senior resident who assisted the intern overnight debriefed the intern about the case. In the discussion, he learned that the intern had never before rotated at this particular hospital and had been pulled from the jeopardy pool to provide nighttime coverage over the holidays for another intern who was sick. When they reviewed the signout that had been provided by the primary team, they realized it had not been updated for several days and that the family had already decided the patient should be transitioned to comfort care should he worsen clinically. In addition, another senior resident who was supposed to oversee the intern overnight had become busy with emergency department admissions early in the evening and never formally introduced himself to the intern, so the intern never realized which resident was supposed to help her, nor did she know how to contact him. After this case, the internal medicine residency program reviewed its practices for signout and nighttime coverage. The orientation for interns and residents rotating at night was formalized, and detailed contact information for all essential teams and resources available overnight was widely distributed and clearly posted in the residents' workroom.

The Commentary

by Katie Raffel, MD

Caring for patients at night is considered the "crucible of clinical maturation" during residency training because of the high patient volume and the opportunity for autonomous practice. While these factors may promote clinical growth among trainees, they simultaneously increase risk for medical error and adverse patient outcomes. This case demonstrates a multitude of nighttime systems vulnerabilities, including inadequate handoffs, reduced night staffing, poorly calibrated trainee autonomy, and cultural hierarchy barriers that ultimately led to a delay in appropriate management of an acutely decompensating patient as well as delays in communication with the patient's family and between medical team members.

Autonomy vs. Supervision

This case demonstrates the safety implications of insufficient supervision of medical trainees. In a study of 240 closed malpractice claims involving trainees, lack of supervision contributed to more than half of cases and was the most prevalent teamwork problem.(1) Supervision may occur in three forms—direct supervision (a senior physician is physically present), indirect supervision (a senior physician is immediately available but not physically present), or oversight (a senior physician conducts a review of decisions made by trainees in a time-delayed fashion). Recommendations by the National Academy of Medicine and Accreditation Council for Graduate Medical Education have primarily focused on direct supervision. However, supervision expectations for nonprocedural specialties remain poorly defined.

Systems Change

Systematic analyses of the impact of enhanced supervision on patient safety are limited by lack of objective measurement of supervision, nonrandomized design, and small sample sizes. Studies of enhanced supervision trend toward positive impact on procedure-related outcomes for patients, whereas missed diagnoses or major changes to therapeutics are rare, making it difficult to prove benefit.(2) Two recent single-center randomized control trials evaluating enhanced attending supervision—one overnight in the medical ICU and the second on medicine work rounds—also failed to demonstrate clinical impact.(3,4)

Notwithstanding this paucity of evidence, certain changes designed to balance supervision and autonomy make sense. Systems should (i) focus on competency-based training and establish graduated levels of independence for trainees based on achievement of objective clinical milestones and (ii) communicate trainee progress to supervisors at regular intervals. It is not reasonable for an overnight supervising attending without an established trainee relationship to thoroughly assess the learner's capabilities, the task at hand, and the practice context to determine the appropriate degree of autonomy in real time.(5) There is a need for shorter-term studies that can be designed to assess variable models of autonomy and establish objective measures of supervision. Such studies could take into account intermediate safety outcomes, including whether or not guideline-concordant therapy was provided (e.g., time to appropriate antibiotics, appropriate vasopressor selection) or whether safety events occurred (e.g., rapid response, escalation to ICU).

In this case, the supervising senior resident and attending physician were both on-site overnight and able to provide direct supervision. However, neither of these parties were aware that this was the intern's first experience in the cross-coverage role or first time working at this particular hospital. Greater awareness of these factors may have changed their approach to overnight supervision.

Cultural Hierarchy

The way trainees access direct supervision may vary based on a program's cultural hierarchy. While in this case systems barriers limited access to the intern's more proximal superior (senior resident), failure to contact the on-site supervising attending likely reflects aspects of the academic hierarchy that may have subtly or overtly discouraged the intern from escalating concerns directly to the attending.

Cultural hierarchy is an authority gradient based on several factors including training, discipline, specialty, and demographics. This hierarchy has existed historically and may have benefits in terms of clarity of role definition and decision-making in acute situations. However, it can have a powerful, unintended influence on the way critical information is communicated—often limiting the propensity of subordinates to ask questions, express concerns, or otherwise challenge superiors. Communication failures remain a leading cause of sentinel events. From the trainee perspective, communication barriers are many—fear of retribution, concern for an ongoing relationship with their superiors, powerlessness—but perhaps the most pronounced is concern is the fear of being perceived as incompetent.(6,7)

Systems Change

It is vital to flatten hierarchy to promote direct communication, collaboration, and coordination among interdisciplinary teams and performance improvement through open feedback. To do this, systems must provide education and training on effective teamwork and communication; promote and monitor psychological safety; and create infrastructure that explicitly supports teamwork.

Current models of teamwork training assume consistent and predictable colleagues, which is rare on the inpatient wards of academic hospitals where trainee rotations and shift work create a continuously evolving team. In the case example, the intern had no prior experience with any of the nighttime team members. Because of this fluidity, clinicians need skill-building around "teaming"—on-the-fly collaborative and interdependent work among a shifting set of partners.(8) A foundation of teaming is the ability to quickly and effectively identify team members and to use structured models for communication and coordination in high-acuity situations. These communication structures may vary from those utilized to convey clinical information—the Situation, Background, Assessment, Recommendation (SBAR) framework (9)—or those designed to highlight an unaddressed concern—the two-challenge rule utilizing provocative CUS words—Concern, Uncomfortable/Unsafe, Scared/Stop.(10,11)

A second key element to successful teaming is the development of a psychologically safe culture. Psychological safety is established through inclusive leadership, a work environment focused on continuous improvement and by achieving a just culture that appropriately acknowledge individual- and system-level factors. Those who willfully contribute to an unsafe culture should be counseled and, importantly, if not responsive, should be dismissed. Finally, there must be structural changes that promote team engagement. For night rotations, this may include a team huddle. For example, in this case, if the intern, resident, attending, and rapid response team had huddled to discuss the patient's care when the intern was first contacted by the bedside nurse, the intern would likely have been better supported to manage the situation. Such huddles would ideally be structured to include introduction, role identification, assessment of intern autonomy, and explicit instruction on when and how to escalate concerns. Senior team members should provide concrete expectations for engagement (e.g., respiratory or hemodynamic compromise, rapid response, change in level of care, change in code status, etc.) to lower threshold for accessing supervision.

Systems Change for Night Supervision and Teaming

Night float coverage is uniquely complex and high risk because typically (i) trainee competency and the appropriate degree of autonomy remains unknown; (ii) explicit guidelines on supervisory models do not exist; (iii) cultural hierarchy (in particular failure to seek help due to trainee concern for perceived incompetence) curtails appropriate communication of trainee needs; and (iv) the critical step of teaming does not occur. Academic health systems can address these barriers by creating more transparency around trainee competency and appropriate autonomy, testing novel supervisory models, and training providers on effective communication strategies while building infrastructure to support teaming.

Take-Home Points

• Trainee responsibility should not be one-size-fits-all or time-based but instead reflect transparent competency assessment.
• Guidelines on supervision in nonprocedural specialties are needed for both practice and research should be defined locally.
• Effective teaming is dependent on structured communication, psychological safety, and engagement infrastructure.
• Enhanced collaboration and safety may be achieved through structured or simulated communication skills-based training.

Katie Raffel, MD

Assistant Clinical Professor of Medicine, Division of Hospital Medicine

Medical Director Unit-Based Leadership Team

Department of Medicine

University of California, San Francisco

References

1. Singh H, Thomas EJ, Petersen LA, Studdert DM. Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med. 2007;167:2030-2036. http://www.ncbi.nlm.nih.gov/pubmed/17954795

2. Farnan JM, Petty LA, Georgitis E, et al. A systematic review: the effect of clinical supervision on patient and residency education outcomes. Acad Med. 2012;87:428-442. https://www.ncbi.nlm.nih.gov/pubmed/22361801

3. Kerlin MP, Small DS, Cooney E, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;368:2201-2209. http://www.ncbi.nlm.nih.gov/pubmed/23688301

4. Finn KM, Metlay JP, Chang Y, et al. Effect of increased inpatient attending physician supervision on medical errors, patient safety, and resident education: a randomized clinical trial. JAMA Intern Med. 2018;178:952-959. https://www.ncbi.nlm.nih.gov/pubmed/29868877

5. Happel JP, Ritter JB, Neubauer BE. Optimizing the balance between supervision and autonomy in training. JAMA Intern Med. 2018;178:959-960. https://www.ncbi.nlm.nih.gov/pubmed/29868875

6. Bould MD, Sutherland S, Sydor DT, Naik V, Friedman Z. Residents' reluctance to challenge negative hierarchy in the operating room: a qualitative study. Can J Anesth. 2015;62:576-586. http://www.ncbi.nlm.nih.gov/pubmed/25792523

7. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79:186-194. http://www.ncbi.nlm.nih.gov/pubmed/14744724

8. Edmondson AC. The three pillars of a teaming culture. Harv Bus Rev. December 17, 2013. Available at https://hbr.org/2013/12/the-three-pillars-of-a-teaming-culture

9. Compton J, Copeland K, Flanders S, et al. Implementing SBAR across a large multihospital health system. Jt Comm J Qual Patient Saf. 2012;38:261-268. http://www.ncbi.nlm.nih.gov/pubmed/22737777

10. Green B, Oeppen RS, Smith DW, Brennan PA. Challenging hierarchy in healthcare teams—ways to flatten gradients to improve teamwork and patient care. Br J Oral Maxillofac Surg. 2017;55:449-453. http://www.ncbi.nlm.nih.gov/pubmed/28343734

11. Guttman OT, Lazzara EH, Keebler JR, Webster KLW, Gisick LM, Baker AL. Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety. J Patient Saf. 2018 Nov 9; [Epub ahead of print]. http://www.ncbi.nlm.nih.gov/pubmed/30418425