“Waterfall” Shifts Improve Hospital Efficiencies

Could “waterfall” shifts improve hospital medicine operations, including reducing cognitive workloads and increase collaboration?

A recent study of a busy pediatric emergency department may provide some clues.

The Seattle Children’s Hospital analyzed 43,835 patient encounters using a new model where the ER department implemented overlapping physician shifts.

According to the study, the shift change resulted in a 25% decrease in handoffs.

This was significant since an earlier study of the hospital’s typical ER shift change handoffs showed that vital signs were not communicated for as many as 74% of the patients, and another study showed errors and omissions occurring in 58% of handoffs.

The research authors suggested that the waterfall staffing model generated several efficiency gains:

  • Fewer handoffs ease the cognitive workload from interruptions and interactions in busy ERs.
  • With incoming physicians jumping into treating patients instead of spending time receiving handoffs, patient care is not delayed.
  • The waterfall model ensures that a rested and refreshed physician is coming in staggered times, which provides relief for the staff that has already been in the ED for several hours.
  • Physicians reported an increased ability to leave on time and to complete charts prior to the end of their shift.
  • More opportunities to collaborate and interact with other physicians occurred throughout the shifts.

The lead author, Hiromi Yoshida, MD, MBA, says that waterfall shifts can be implemented a most ERs that have multiple attending physicians. She says there are three primary implementation factors:

  1. Getting buy-in form all parties involved in the change, including attending physicians and charge nurses.
  2. Getting support from hospital leadership is crucial to help drive change.
  3. To maximize efficiency and enable patient evaluations, there must be enough patient care space to allow incoming physicians to see new patients.