Nighttime cross-coverage is associated with decreased intensive care unit mortality. A single-center study.
BACKGROUND
Cross-coverage is associated with medical errors caused by miscommunication during handoffs. However, no direct evidence links handoffs to outcomes, or explains the mechanisms leading to outcomes. Furthermore, the previous literature may overestimate the impact of handoffs because of hindsight bias.


OBJECTIVE
To explore the effects of nighttime cross-coverage on mortality and decision making in critically ill patients.


METHODS
Observational cohort of 629 consecutive critically ill admissions, admitted for at least 48 hours, and critical care fellows in an academic hospital.


RESULTS
Intensive care unit (ICU) mortality and nighttime decisions. Our exposure variable was cross-covering status of fellows. We observed a decrease in ICU mortality (odds ratio, 0.77 per 1 d; 0.60-0.99; P = 0.04), a higher number of nighttime decisions (19.3 vs. 10.4%; odds ratio, 2.02; 95% confidence interval [CI], 1.03-3.95; P = 0.04), an increase in fentanyl equivalents administered to patients at night (difference, +10.2 μg/h; 95% CI, +1.4 to +19.0; P = 0.02), and an increase in transfusions at night (difference, +465 ml; 95% CI, +98 to +832; P = 0.01) when fellows were cross-covering.


CONCLUSIONS
In this single-center study exposure to cross-covering fellows was associated with a decrease in ICU mortality and with more nighttime decisions. Our findings contradict the dominant hypothesis that cross-coverage is associated with worse outcomes, and suggest that a "second look" by cross-covering fellows may mitigate cognitive errors. Future interventions to improve patient safety in ICUs should focus both on the quality of handoffs and on strategies to decrease cognitive errors.
1 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.
Andre Carlos
AC
Kajdacsy-Balla Amaral
Bernardo S
BS
Barros
Camilla C P P
CC
Barros
Cameron
C
Innes
Ruxandra
R
Pinto
Gordon D
GD
Rubenfeld
D000328:Adult; D039602:After-Hours Care / Q000706:statistics & numerical data*; D000368:Aged; D000369:Aged, 80 and over; D002170:Canada / Q000453:epidemiology; D015331:Cohort Studies; D016638:Critical Illness / Q000401:mortality*; D005257:Fellowships and Scholarships / Q000706:statistics & numerical data; D005260:Female; D017052:Hospital Mortality; D006785:Hospitals, University; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D007396:Internship and Residency / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008505:Medical Staff, Hospital / Q000706:statistics & numerical data*; D008875:Middle Aged; D009551:Night Care / Q000706:statistics & numerical data; D010561:Personnel Staffing and Scheduling; D012121:Respiration, Artificial / Q000401:mortality