Shift change can be a dangerous time for emergency department (ED) patients. This is especially true for pediatric patients in busy EDs. Now, there is evidence that a new approach using “waterfall” shifts can improve the flow of patients through a pediatric ED.

Officials at Seattle Children’s Hospital created overlapping shifts for ED physicians five years ago, and it dramatically reduced patient handoffs.

Researchers analyzed 43,835 patient encounters. They discovered a 25 percent reduction in the proportion of patient encounters ending in patient handoffs immediately after implementation of the new shifts. The researchers published their findings in the Annals of Emergency Medicine.

Problems with Standard Shifts and Handoffs

Research presented by the American Academy of Pediatrics shows that transitions of care during shift change, also known as handoff, handover or report, could cause communication failures and other problems that can increase the risk for patient harm.

Another study showed a failure to communicate vital signs in as many as 74 percent of patients. Other research showed that errors or omissions occurred in 58 handoffs.

Before the creation of the new model, ED physicians at Seattle Children’s Hospital worked shifts that were anywhere from 7 to 9 hours long. During shift change, the outgoing physician would hand over his or her entire patient list to the incoming physician.

There were several problems associated with this approach, but perhaps the largest shortcoming is that handing off several patients to the incoming physician created multiple opportunities for communication errors and omissions.

Handoff created other problems as well. Patient care was often delayed as nurses and others had to wait to review patients with the incoming physician.

Doctors frequently worked at full capacity until the end of their shift, and then stayed late for charting. Handing off was also stressful during peak ED times, especially when patients would arrive during shift change.

The new “waterfall” approach addressed many of these shortcomings. In this approach, a physician assumes a primary role upon arriving at the ED. The next physician arrives in the emergency department 3 to 5 hours later; he or she assumes the primary role by immediately taking care of any new patients that arrive.

The first physician assumes a secondary role by completing care for existing patients; this physician can also take ones complex patients that he or she can treat and discharge prior to the end of his or her shift.

“With overlapping shifts and change in patient care prioritization, the goal was to decrease the number of patients who require handoff at the end of the first attending physician’s shift, and if handoffs had to occur, they would be for patients with less complex disease,” said the researchers in a release.

Implementing Waterfall Shifts in the Emergency Department

Lead author of the research, Hiromi Yoshida, MD, MBA, suggests that most emergency departments with multiple attending physicians can implement waterfall shifts. To implement such shifts, there must be agreement about the shift change from doctors and nurses, support from hospital leaders and sufficient care space to accommodate new patients seen by the incoming physician.

Implementing waterfall shifts can reduce handoffs, shorten patient delays, ease interruptions and decrease interactions in busy EDs.

These shifts can focus a physician’s decision-making at the beginning of the shift and at the onset of patient care, when doctors have better decision-making capacity. Waterfall shifts may result in fewer mistakes associated with decision-making fatigue later in the shift. Physicians could also complete their charts prior to the end of their shifts and leave on time.

Seattle Children’s Hospital implemented this model five years ago and the ED continues to fine-tune the approach. Yoshida said, “We are continuing to monitor feedback from the division and improvements are made to the model as the environment changes. This is a QI project and we aim to continuously improve.”