Midnight Rounds: A Quality Improvement initiative to address patient safety at night

From the 2018 HVPAA National Conference

Benjamin Lawson (HonorHealth), Evan Holdsworth (HonorHealth), Sherry Razo (HonorHealth), Curt Bay (A.T. Still University), Melanie Brewer (HonorHealth), Allan Markus (HonorHealth), Rustan Sharer (HonorHealth), Kencee Graves (University of Utah School of Medicine)

Background

Hitcho et al, showed that a majority (58.5%) of falls occurred between 7pm and 7am. Hanane et al, found higher ICU readmission rates of nighttime transfers from ICU (12.2% vs 9.0% p=0.027) and longer hospital length of stay (8 vs 7 days, p=0.013), compared with daytime transfers from ICU group.

Objectives

We hypothesized that patient outcomes were attributable, in part, to a lack of formalized communication at night as opposed to day shift rounding.To address these concerns, we created a systematic process called “Midnight Rounds.” At midnight, providers met with inpatient ward nurses to discuss questions, concerns and foreseen issues with their patients. The goal of this quality improvement project was to determine if implementation of “Midnight Rounds” (MR) would improve patient outcomes (length of stay, falls, ICU transfers and communication ratings) and nurse engagement.

Methods

The intervention period was from July 1 2017-December 31 2017. Providers met with ward nurses as described above.  Outcome data collected during the pre-intervention period (July 1 2016-through-December 31 2016) were compared to analogous data collected during the intervention period (July 1 2017-through-December 31 2017). Outcome variables included: number of ICU transfers, length of stay, and falls between 7pm and 7am. Data were normalized for patient census. Patient satisfaction scores (HCAHPS) were compiled for physician communication and percent rating the hospital 9-to-10 out of 10. Night-shift nurse engagement was assessed using the Utrecht Work Engagement Scale (UWES). SPSS ver 24 (IBM Corp., Armonk NY) was used for the analyses. The nominal statistical significance level was 0.05, two-tailed.

Results

Our pre- and post- MR groups were not significantly different by demographic and illness severity data. MR found no difference in length of stay between the two time periods: 262 hours vs. 264 hours, respectively. There was no difference in rate of ICU transfers per 1000 patient-days (pre-mean 2.03 and post-mean 3.44). Patient satisfaction improved; physician communication scores increased from 76.2% to 79.1%, p=0.026. Nurse engagement was significantly higher following MR than prior to the intervention. The score on the Vigor scale increased from a mean (standard deviation) of 3.8 (0.8) pre-intervention to 4.7 (0.6) post-intervention, p=0.011; Dedication increased from 4.3 (0.7) to 5.1 (0.6), p=0.004; and Absorption increased from 3.5 (0.6) to 4.1 (0.5), p=0.004.

Conclusion

Midnight Rounds is an innovative quality improvement initiative to address patient safety at night. Although this project was not able to show a benefit in certain patient safety outcomes (length of stay or ICU transfers), we were able to demonstrate improvements in HCAHPS physician communication scores and overall nursing engagement scores. As a result of MR, there were additional outcomes that were not measurable statistically and included the discovery of locating a loaded gun in the hospital amongst a recently admitted patient’s private possessions. We believe further studies looking at use of night rounds including those with larger sample sizes are warranted.

Implications for the Patient

Midnight Rounds were able to increase satisfaction/ engagement scores, identify potential threats and allow for early recognition of disease complications. Overall, this process influences patient care at night and should be considered as a quality improvement initiative at other institutions.