Nav: Home

The unintended consequences of a hospital's attempt to improve

May 31, 2016

Philadelphia, PA, May 31, 2016 - As hospitals try to maintain effective and efficient operations, physician call systems can be a critical element in maintaining quality medical care and financial stability. In a new report published in The American Journal of Medicine, a decade-long study from a large teaching hospital in Toronto, Canada, shows that a change in staff scheduling resulted in 26% higher readmissions, an unintended and negative result.

"Medical practice is a paradox of sustainability and continuity. Sustainability means that one physician cannot be available at all times because of their own personal needs and finite stamina. Continuity means that one patient prefers to have the same physician every time for building understanding and avoiding handover errors. This paradox is pervasive in acute care medicine and particularly important following recent changes to house-staff physician schedules in the United States and Canada. The situation has no simple solution and a better understanding of trade-offs is necessary for thoughtful decision-making," according to lead investigator Donald A. Redelmeier, MD, of the Department of Medicine, University of Toronto.

The Sunnybrook Health Sciences Centre is a large teaching hospital with about 10,000 medical inpatient discharges annually. Admissions and patient care are conducted by teams comprised of attending physicians, senior residents, junior residents, and medical students; each team is responsible for 15-25 inpatients. In 2009, the hospital's Division of General Internal Medicine changed how it organized physician teams. Previously, teams had been deployed using a concentrated or bolus system, which meant that teams remained together throughout a single shift, with four teams covering 24-hour periods. The new arrangement distributed the senior and junior residents across the four shifts.

This distributed system meant that patients could have a team member present every day, theoretically improving continuity of care and decreasing patient readmissions.

The study covered the period from January 2004 through December 2013 and determined readmission rates for 89,697 consecutive discharges, with 37,982 before the call system change and 51,715 afterwards. After correcting for each patient's likelihood of readmission using an established method (the LACE score), the call system change increased the readmission rate by 30%, and this increase persisted across diverse patients (age, readmission risks, medical diagnoses). The net effect was equal to 7240 additional patient days in the hospital following call system change. There was no significant change in mortality.

As a check on the results, the researchers also examined the readmission risk at a nearby control hospital and found no similar increase during the period.

"Together, the findings show that well-intentioned and well-received changes aimed at improving physician call systems can have unintended, undesirable, and unrecognized consequences," noted Dr. Redelmeier, who analyzed the data at the Institute for Clinical Evaluative Sciences where he is a core scientist.

Investigators caution that the observed increase in readmission rates does not prove that the distributed physician call system is a failure and needs to be reversed to the concentrated model. The increase in readmission rates was not associated with worsened patient mortality, increased workload imposed on surrounding hospitals, or decreased healthcare worker satisfaction. Dr. Redelmeier emphasized that "Our data suggest that the distributed call system creates a different balance of sustainability with continuity and merits more reconsideration for improvement."

Elsevier Health Sciences

Related Sustainability Articles:

Cities provide paths from poverty to sustainability
Understanding how cities develop at the neighborhood level is key to promoting equitable, sustainable urbanization.
Improving the sustainability of US cities - new report
A new report from the National Academies of Sciences, Engineering, and Medicine offers a road map and recommendations to help US cities work toward sustainability, measurably improving their residents' economic, social, and environmental well-being.
Two tales of a city to understand sustainability
Just as there are two sides to every story, sustainability challenges have at least two stories to reach every solution.
Global sustainability projects offer hope for the future
Global examples of sustainability projects, which offer a positive future for the environment, have been identified by an international group of researchers including Professor Martin Solan from the University of Southampton.
Sustainability projects offer potential seeds for a more just future
It is rare to hear environmental scientists sounding positive about the future.
Sustainability criteria for transport biofuels need improvements
In its Renewable Energy Directive, the European Union has set a 10 percent goal for the use of renewable energy in transport by 2020.
Like to get more bang for your sustainability-boosting buck? Here's how
Researchers at the University of Minnesota and University of Michigan have developed a method for assessing and comparing the various costs and benefits of green products -- making it possible for purchasers to get the most environmental bang for their sustainability-investment buck.
Economic concerns drive sustainability in American cities and towns
While environmental issues are often cited as a major factor in cities and towns in pursuing sustainability, a new study shows that economic concerns can be just as important to local governments in adopting concrete sustainability plans.
Sustainability management: Legitimacy is more important than profit for large companies
The driving force behind sustainability management activities of large companies is mainly the pursuit of social acceptance.
One Ecosystem Journal: Innovation in ecology and sustainability research publishing
Focused on the fields of ecology and sustainability, One Ecosystem is an innovative open access scholarly journal that goes beyond the conventional research article publication.

Related Sustainability Reading:

Best Science Podcasts 2019

We have hand picked the best science podcasts for 2019. Sit back and enjoy new science podcasts updated daily from your favorite science news services and scientists.
Now Playing: TED Radio Hour

Digital Manipulation
Technology has reshaped our lives in amazing ways. But at what cost? This hour, TED speakers reveal how what we see, read, believe — even how we vote — can be manipulated by the technology we use. Guests include journalist Carole Cadwalladr, consumer advocate Finn Myrstad, writer and marketing professor Scott Galloway, behavioral designer Nir Eyal, and computer graphics researcher Doug Roble.
Now Playing: Science for the People

#530 Why Aren't We Dead Yet?
We only notice our immune systems when they aren't working properly, or when they're under attack. How does our immune system understand what bits of us are us, and what bits are invading germs and viruses? How different are human immune systems from the immune systems of other creatures? And is the immune system so often the target of sketchy medical advice? Those questions and more, this week in our conversation with author Idan Ben-Barak about his book "Why Aren't We Dead Yet?: The Survivor’s Guide to the Immune System".