The effect of shift changes on cesarean complications

AORN Journal, May, 2008 by George Allen

American Journal of Obstetrics & Gynecology

February 2008

Work-hour reform for physicians has been proposed as a way to improve the safety of patients by decreasing their exposure to sleep-deprived physicians. One consequence of such changes in physician work patterns, however, is an increase in the number of shift changes, with subsequent multiple hand offs of patients between different responsible caregivers. Several studies have shown that a shift change can be a dangerous time for patients, with one study reporting that an adverse event is more than three times more likely to occur during cross coverage. Currently, there is no evidence that obstetric outcomes are affected by shift changes. The objective of this prospective study was to determine whether maternal or perinatal outcomes associated with unscheduled cesarean deliveries are affected by physician and/or nursing staff shift changes.

Women in 13 tertiary care teaching hospitals undergoing unscheduled, term cesarean deliveries in 1999 and 2000 were included in the study. Information on the timing of physician and nurse shift changes Monday through Friday was identified from the participating centers; data from only 10 centers were available for physician shift changes. The period around the shift change was defined as one hour before and one hour after caregiver turnover. Nurse shift changes were defined as 6 AM to 8 AM, 2 PM to 4 PM, and 10 PM to midnight. Physician shift changes were defined as 6 AM to 8 AM and 5 PM to 7 PM. Patients were considered to be delivered at change of shift if the time of delivery was during any one of these periods, and their outcomes were compared with those of patients delivered at all other times of the day.

Maternal and infant complications were considered individually and as a composite morbidity. Maternal complications included

* blood transfusion,

* cystotomy,

* bowel injury,

* urethral injury,

* postpartum endometritis,

* wound infection,

* wound hematoma,

* ileus,

* cesarean hysterectomy,

* maternal readmission,

* anesthesia complications,

* deep venous thrombosis,

* pelvic or abdominal abscess,

* septic pelvic thrombosis,

* pneumonia,

* pulmonary embolus,

* uterine rupture,

* uterine dehiscence,

* postoperative need for ventilation,

* postoperative seizure,

* need for central venous access,

* necrotizing fasciitis,

* sepsis,

* wound evisceration,

* wound dehiscence,

* coagulopathy,

* pulmonary edema,

* intensive care unit admission, and

* maternal death. Neonatal morbidities included

* cord pH less than 7,

* base excess less than -12/mmol/L,

* brachial plexus injury,

* skull fracture,

* facial nerve palsy,

* clavicle fracture,

* fetal lacerations incurred during cesarean delivery,

* neonatal intensive care unit admission,

* neonatal seizure, and

* neonatal death.

Common statistical techniques including the Wilcoxon rank sum test, Fisher exact test, chi-square tests, and multivariate analysis were used to analyze the data.

FINDINGS. Of the 17,996 women who met the inclusion criteria, 4,358 (24%) delivered during a nurse shift change. Seventeen percent (n = 1,842) of the 10,845 who delivered on a weekday (ie, Monday through Friday) delivered during a physician shift change. Physician shift changes were found to have no measurable effect on maternal and neonatal outcomes. Neonatal facial nerve palsies significantly increased at nurse shift changes (five versus zero) as did maternal hysterectomies (33 [0.24%] versus 23 [0.53%], P < .007). Nurse shift changes had no effect on composite maternal morbidity after controlling for age, race, insurance, medical problems, prior incision type, weekend day, and prenatal care (odds ratio = 0.98, 95% confidence interval = 0.98-1.08).

CLINICAL IMPLICATIONS. The results of this study revealed that physician shift changes had no measurable effect on maternal and neonatal outcomes and that nurse shift changes were associated with increased risk for neonatal facial nerve palsies and maternal hysterectomies. The researchers concluded that further investigation is needed to determine the cause of this association. Perioperative nurses and managers should assess their shift change procedures to minimize the risk for negative outcomes to patients.

Bailit JL, Landon MB, Lai Y, et al. Maternal-Fetal Medicine Unit Network Cesarean Registry: impact of shift change on cesarean complications. Am J Obstet Gynecol. 2008;198(2):173.e1-173.e5.

GEORGE ALLEN

PHD, RN, CNOR, CIC

DIRECTOR OF INFECTION CONTROL

DOWNSTATE MEDICAL CENTER

BROOKLYN, NY