Supplementing cross-cover communication with the patient acuity rating

Abstract

Background: Patient hand-offs at physician shift changes have limited ability to convey the primary team's longitudinal insight. The Patient Acuity Rating (PAR) is a previously validated, 7-point scale that quantifies physician judgment of patient stability, where a higher score indicates a greater risk of clinical deterioration. Its impact on cross-covering physician understanding of patients is not known.

Objective: To determine PAR contribution to sign-outs.

Design: Cross-sectional survey.

Subjects: Intern physicians at a university teaching hospital.

Interventions: Subjects were surveyed using randomly chosen, de-identified patient sign-outs, previously assigned PAR scores by their primary teams. For each sign-out, subjects assigned a PAR score, then responded to hypothetical cross-cover scenarios before and after being informed of the primary team's PAR.

Main measure: Changes in intern assessment of the scenario before and after being informed of the primary team's PAR were measured. In addition, responses between novice and experienced interns were compared.

Key results: Between May and July 2008, 23 of 39 (59 %) experienced interns and 25 of 42 (60 %) novice interns responded to 480 patient scenarios from ten distinct sign-outs. The mean PAR score assigned by subjects was 4.2 ± 1.6 vs. 3.8 ± 1.8 by the primary teams (p < 0.001). After viewing the primary team's PAR score, interns changed their level of concern in 47.9 % of cases, their assessment of the importance of immediate bedside evaluation in 48.7 % of cases, and confidence in their assessment in 43.2 % of cases. For all three assessments, novice interns changed their responses more frequently than experienced interns (p = 0.03, 0.009, and <0.001, respectively). Overall interns reported the PAR score to be theoretically helpful in 70.8 % of the cases, but this was more pronounced in novice interns (81.2 % vs 59.6 %, p < 0.001).

Conclusions: The PAR adds valuable information to sign-outs that could impact cross-cover decision-making and potentially benefit patients. However, correct training in its use may be required to avoid unintended consequences.

Trial registration: ClinicalTrials.gov NCT01082991.

Figure 1.

Survey tool. PAR, Patient Acuity Rating. *X represents the PAR score given by the primary team.

Figure 2.

Change in level of concern for patient by discrepancy in PAR score. PAR, Patient Acuity Rating. The x-axis represents the difference between the subject assigned PAR score and the primary team assigned PAR score for a given sign-out. A positive number indicates that the primary team assigned a higher PAR score, and a negative number indicates that the subject assigned a higher PAR score. The y-axis represents the difference in the subject’s level of concern before and after revealing of the primary team assigned PAR score. A positive number indicates the subject increased their level of concern after revealing the primary team PAR score, while a negative number indicates a decrease in level of concern. The size of the circle represents the frequency weighted distribution, and the straight line is the linear best fit regression. R² = 0.547.

Figure 3.

Subjective evaluation of the Patient Acuity Rating by experience level.