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The SafeTy And Resource (STAR) Clinician: Improving care and hospitalist satisfaction with a novel support role

2024; Wiley; Linguagem: Inglês

10.1002/jhm.13563

1553-5606

Amy W. Baughman, William C. Hillmann, Emily Hughes, Zachary Ranta, Cindy Yu, Denisa Gace, Meghan Meehan, Camille Couture, Holly Jackson, Kelly W. Maloney, Melissa L. P. Mattison,

Patient Safety and Medication Errors

Hospitalized patients often experience unpredictable clinical events that can consume 100% of a hospitalist's attention, such as rapid responses, codes, goals of care conversations, and psychiatric emergencies. During these events, hospitalists are unable to advance the care of other patients or respond in a timely fashion to other tasks. Hospital medicine staffing models do not typically account for unpredictable events, thereby resulting in high stress, possible burnout, and potentially suboptimal care when hospitalists are forced to triage their limited bandwidth.1, 2 In other clinical domains, such as nursing, however, staffing models do account for unpredictable clinical needs. For example, the Charge Registered Nurse (RN) is a front-line, unit-based leader who has a reduced or no patient census and is available to help manage a wide variety of time-sensitive challenges. Studies have shown that Charge RNs can improve employee satisfaction by providing close and continuous support to staff3, 4 and enhance care by providing "another set of eyes," preventing errors and monitoring quality.5 Our Hospital Medicine Unit (HMU) created a new role called the STAR Clinician to proactively support overextended physicians and advanced practice providers (APPs) with clinical care, educational, or administrative needs, and to help ensure timely and optimal care for all HMU patients. We implemented a 6-week pilot of the STAR Clinician in March 2021 at our large academic medical center. HMU cares for up to 200 medically complex medicine patients, including those requiring short-term invasive ventilation, high-flow oxygen, or coordination of multiple subspecialty consultations. HMU day staff includes up to 18 physicians and 16 APPs, who cover regionalized medicine, nonregionalized medicine, procedures, and Emergency Department (ED) Boarder services. This operational initiative did not meet the criteria for human subject research and was not subject to Institutional Review Board review per our institutional policies. The STAR Clinician was designed as a flexible and supportive role, available from 8 a.m. to 6 p.m., 7 days a week. Experienced hospitalist physicians with 3 or more years of experience were selected for this role. The role was created in a budget neutral process by repurposing an admitter physician from our large ED Boarder service, which employed a flexible staffing model to accommodate variable ED volume. STAR Clinicians were oriented through an email describing responsibilities. These were also posted on the Unit's intranet. Workflow included sending a daily email to staff including examples of how they could help (Appendix A), reviewing unstable patients on the STAR list in the electronic medical record, and walking on hospitalist units to engage with teams and directly offer help. The STAR attended all rapid responses and codes for Hospital Medicine patients. When not busy, STAR Clinicians were in close communication with the nurse who distributed admissions and could help admit patients. Pager coverage [n = 63]. Round on stable patients [n = 42]. Assist with rapid response or unstable patients [n = 35]. Documentation (e.g., event notes, transfer summaries) [n = 33]. Communication assistance with clinical team or families [n = 33]. Assist with ED Boarder patients [n = 30]. Admissions and discharges [n = 20]. Administrative tasks [n = 17]. Teach learners [n = 13]. Procedures [n = 5]. In the optional surveys to primary clinicians who were the physicians and APPs assisted by the STAR Clinician (n = 59/78, 77% response rate), staff overwhelmingly reported that working with the STAR Clinician was helpful (92%), decreased stress (90%), and helped them leave their shifts on time (78%) (Figure 1). They reported minimal barriers to contacting the STAR for help. These optional surveys remained available after the pilot phase, revealing similar trends. Both STAR Clinicians and primary clinicians reported improved quality of care—most frequently more efficient and appropriate care (Figure 1). Narrative responses were strongly favorable, giving important context on what was most helpful. Two respondents requested STAR support overnight. Only one respondent raised a criticism, expressing worry that involvement might fragment care by adding another clinician. The Operations team and STAR Clinicians from the prior week met weekly to review survey feedback and iterate on STAR responsibilities through plan-do-study-act cycles. We broadened pager coverage to include important personal (e.g., lactation needs), clinical, or professional meetings. We identified helpful specific behaviors like being highly visible (e.g., sitting at an assigned STAR computer in our main workroom and proactively offering help on walk rounds) and being well prepared to assist (e.g., doing advance chart review). We found that admitting patients interfered with time-sensitive STAR tasks, and the STAR role was modified to only supervise admissions. To our knowledge, this is the first flexible physician support role developed for hospitalists. Physicians and APPs who worked with STAR as well as STAR Clinicians perceived improvements in the quality of care as reflected in surveys. We found that the STAR role may improve staff well-being by providing support, decreasing clinician stress, and helping staff leave on time. Weekly meetings and surveys enabled rapid improvements and provided examples of how the STAR could best assist front-line clinicians. Numerous responses described the benefit of cognitive assistance for challenging cases and having a dedicated colleague to assist without burdening those already on service. Informal feedback from nursing leadership spoke to the improved care provided by having an additional physician resource at the patient bedside. Our daily surveys showed reductions in stress and quality concerns. Following the pilot, informal feedback gathered in person, through continued optional surveys, in-person, and via email was overwhelmingly positive, highlighted by statements such as, "The STAR saved me multiple times." Based on this, the STAR Clinician was maintained and expanded to night shifts as well as a second STAR Clinician who is an APP. We did not objectively assess quality and efficiency metrics such as length of stay or mortality. However, a 6-week pilot is likely not long enough to have a measurable effect, and a single physician can only assist a limited number of staff on such a large service. Another limitation is the potential for selection bias in the optional surveys. Finally, other institutions may be relative value unit based and not able to fund or rearrange existing staff as we did to support the role. We appreciate our leadership's dedication to fostering a sustainable and fulfilling hospitalist career by promoting a supportive role that enhances resilience and can reduce stress and attrition over time. By instituting a novel, flexible support role to assist front-line hospital medicine clinicians with unanticipated and overwhelming work, we reduced daily levels of stress and improved perceptions of quality care. Future work should evaluate objective measures of quality improvement. All authors listed have read and approved this manuscript for submission. All authors have contributed sufficiently to the project to be included as authors, and all those who are qualified to be authors are listed in the author byline. The authors have no funding to report. The authors declare no conflicts of interest. Discharging straightforward patients. Carrying a pager and/or signing in as the covering clinician. Rounding on stable patients and writing a progress notes. Assisting with rapid responses and emergency situations. Assisting with documentation such as an event note, transfer summary or against medical advice discharge paperwork. Helping with paperwork related to a death. Communicating with consultants. Accompanying a patient for transport to STAT imaging or to the intensive care unit. Helping with chart review. Performing medication reconciliations. Obtaining outside hospital records and providing a summary of the pertinent information. Acting as a sounding board for case discussion. Assisting with procedures (e.g., removal of a central line, applying Dermabond to a leaking paracentesis site, removing staples or sutures, paracenteses, nasogastric tube insertion). Teaching students. Submitting a safety report. Helping to resolve an issue by speaking with the nursing director, administrator, and others. Providing pager coverage so colleagues can tend to important personal and/or medical issues (e.g., pumping, doctor appointments, meetings).