After-hours Physician Care 2013

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Palliative Medicine

2014, Vol. 28(3) 281287

The Author(s) 2013

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DOI: 10.1177/0269216313497227

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After-hours physician care for patientswith do-not-resuscitate orders: An

observational cohort study

Nin-Chieh Hsu1,2,3, Ray-E Chang3, Hung-Bin Tsai1,2, Yu-Feng Lin1,2,

Chin-Chung Shu1,2, Wen-Je Ko1 and Chong-Jen Yu2

Abstract

Background:Medical care at night for patients with do-not-resuscitate orders and the practice patterns of the on-call residents have

rarely been reported.

Aim:To evaluate the after-hours physician care for patients with do-not-resuscitate orders in the general medicine ward.

Design: Observational study.Setting/participants:This study was conducted at an urban, university-affiliated academic medical center in Taiwan. The night shift

nurses consecutively recorded every event that required calling the duty residents. Patients with and without a do-not-resuscitate

order were compared in demographics, reasons for calling, residents response, and nurses satisfaction. A standard report form was

established for the nurses to record events.

Results: From October 2009 to September 2010, 1379 inpatients contributed to 456 after-hours calls. do-not-resuscitate

patients accounted for 256 (18.7%) of all inpatients, and 160 (35.1%) of all after-hours calls. The leading reason for calls was

abnormal vital signs, which was significantly higher for patients with do-not-resuscitate orders compared to patients without a

do-not-resuscitate order (64.4% vs 36.1%, p< 0.001). The pattern of residents responses showed a significant difference with

more bedside visits for patients with do-not-resuscitate orders (p< 0.001). The nurses were usually satisfied with the residents

management of both groups.

Conclusion:Abnormal vital sign, rather than symptom, was the leading reason for after-hours calls. The existence of do-not-

resuscitate order produced different medical needs and physician workload. Patients with do-not-resuscitate orders accounted for

one-third of night calls and nearly half of bedside visits by on-call residents and may require a different care approach.

Keywords

After-hours care, do not resuscitate, palliative care

1Division of Hospital Medicine, Department of Traumatology, National

Taiwan University Hospital, Taipei, Taiwan2Department of Internal Medicine, National Taiwan University Hospital,

Taipei, Taiwan3Institute of Health Policy and Management, College of Public Health,

National Taiwan University, Taipei, Taiwan

Corresponding author:

Wen-Je Ko, Division of Hospital Medicine, Department of

Traumatology, National Taiwan University Hospital, No. 7, Chung-Shan

South Road, Taipei 100, Taiwan.

Email: [email protected]

7PMJ28310.1177/0269216313497227PalliativeMedicineHsu et al.

Original Article

Introduction

The night shift is a time when on-site faculty supervision

and nurse staffing ratios are reduced resulting in a different

system of care at night compared to the day.1,2There is someevidence that the medical events which occur at night are

associated with poor clinical outcomes.3 Studying nursing

and beeper calls at night allows for researchers to under-

stand the demand and need of inpatients at night.

Unfortunately, such studies are rare in the literature. Studies

focusing on paging patterns4,5 showed that interns were

interrupted frequently during both sleep and patient encoun-

ter and that nurses perception was not in agreement with

residents responses.6 Another study investigating paging

times showed that on-call days generate nearly five times of

workload to physicians.7 However, these studies focusing

on the occurrence of paging provide incomplete information

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282 Palliative Medicine28(3)

regarding physician workload. The unanswered questions

regarding on-call residents workload are the sources of pag-

ing as well as workload produced after paging. To answer

these questions, the demand of paging and behavior of on-

call residents should be observed.

Palliative care (PC) is a continuous process, which typi-

cally begins with discussing advance care planning andend-of-life (EOL) care.8Patients who have do-not-resusci-

tate (DNR) orders are a particular population in a hospital,

and their physical, social, and mental needs may be very

different.9,10 With the progress in palliative medicine,

patients are well cared for by specialist PC teams during the

daytime. However, the treatment for inpatients may be sub-

optimal at night and outside the PC unit. In the general

medicine setting, the medical needs of inpatients with DNR

orders may be different from other inpatients and are less

satisfactorily met at night with the current off-hours care

system. Our study aims to investigate the physician care for

inpatient at night and allows to compare between patients

with and without a DNR order. It is hypothesized that

patients with DNR order would generate different work-

load for after-hours physicians.

Methods

Study setting

This study was conducted at the National Taiwan University

Hospital (NTUH), a 2000-bed, university-affiliated tertiary

referral medical center in Taiwan. A hospitalist acute gen-

eral medicine service was established in October 2009, and

general medicine patients are admitted to this hospitalistward from the emergency department (ED). The perfor-

mance in caring for general medicine patients in this ward

was demonstrated in our previous study.11

Three working shifts, day, bridge, and night, were designed

for the hospitalist ward and remained unchanged during the

study period. Patients newly admitted from the ED were

assigned to both day and bridge hospitalists. In general, all

beds were fully occupied in the evening. The night shift was

from 11 p.m. to 8 a.m. the following day, with the staff taking

handoffs from the bridge shift (from 1 p.m. to 11 p.m.) and

covering the whole ward overnight. Nurse practitioners were

assigned to the day and bridge shift hospitalists, and residents

were assigned to the night shift hospitalist. Residents were thefirst to whom night shift nurses reported inpatient problems

and data. Each hospitalist, resident, and nurse practitioner had

a mobile phone to communicate with each other.

Night shift call recording

A standard night shift call record form was designed by

our study group. The night shift nurses (working from 11

p.m. to 8 a.m.) were responsible for recording every

event that required calling the duty residents. In order to

minimize the bias of underreporting or overreporting,

night shift nurses who participated in the study were

informed that the record forms aimed to monitor the resi-

dents management and notify the day staff of important

events. The on-call residents were blinded to the study

design. To minimize the observation effect, the

Institutional Review Board (IRB) of our institutionagreed that only the night shift nurses required the

informed consent.

Population and data collection

The IRB of NTUH approved the study (201006028R).

This study was performed by prospective data collection

with retrospective analysis. A standard night shift call

record form was used for quality control purpose, and it

consisted of time of call, classified call reasons, vital signs

at calling, subsequent management of the physician,

and the nurses satisfaction on the whole management

process.

Advance care plans are scarcely noted in hospitalized

patients in Taiwan. DNR is typically discussed after admis-

sion and is usually initiated by physicians when the

patients clinical status becomes life-threatening or irre-

versible. If a patient has a DNR order that has been signed

by himself/herself (or families) and by in-charge physi-

cians, it is legal for physicians to withhold cardiopulmo-

nary resuscitation in our country since 2000. Patients who

had DNR codes during hospitalization in the hospitalist

ward were included as the population of interest. Patients

with DNR orders were labeled as DNR in green in the

health information system of our hospital, whereas theremaining patients were not labeled in green. We were thus

able to easily identify DNR patients when the calls were

placed.

In order to analyze the night shift events and patterns,

the management of the residents was classified as telephone

order, immediate bed visit, or delayed bedside visit. Drug

prescriptions could be made by the residents via the elec-

tronic prescription system anywhere in the hospital. The

residents did not have to go to the nurse station for simple

medication requests such as sleeping pills or drug refills.

On-call residents, who were blinded to the study, decided

by themselves whether an immediate (within 15 min) bed-side visit was required. A bedside visit more than 15 min

after a call was defined as a delayed bedside visit, as used

in a previous study.6The actual time lag between the call

and visit was recorded by the nurses.

For analysis, the reasons for the night call were classi-

fied into six categories by the night shift nurses(1) abnor-

mal vital signs; (2) original symptom/problem; (3)

new-onset symptom/problem; (4) need for physicians

evaluation, prescription, or procedure; (5) need for expla-

nation/communication; and (6) othersin descending

order of priority with the category of highest priority being

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Hsu et al. 283

recorded. The classifications, definitions, and examples areshown in Table 1.

The night shift nurses who participated in our study

were requested to complete informed consent process by

the IRB of NTUH. The nurses satisfaction was measured

using a Likert scale including five levels of satisfaction:

very satisfied, satisfied, unsure, dissatisfied, and very dis-

satisfied. The night shift nurses completed the satisfaction

scale within their shift.

Statistical analysis

The data were analyzed using SPSS software (version 16;SPSS Inc., Chicago, IL, USA). We compared the basic demo-

graphic data, reasons for the night call, residents response,

time to bedside visit, and nurses satisfaction score between

patients with and without a DNR order. Subgroup analysis

was done for all DNR night calls to compare characteristics

between cancer patients and noncancer patients. Intergroup

differences were compared using Pearsons chi-square test or

Fishers exact test for dichotomous variables and using the

MannWhitney Utest for continuous variables.

Results

Demographic data

From October 2009 to September 2010, a total of 1379

patients were admitted to the hospitalist ward. Among

them, 258 patients (18.7%) had DNR orders during hospi-

talization. Table 2 depicts the demographic data and out-

comes of all patients with DNR orders.

Reasons for night shift calls

Within the 1-year study period, a total of 456 night calls to

physicians were recorded. Table 3 shows the characteristics

of the night calls with comparisons between patients with

and without a DNR order.

Patients with and without a DNR order accounted for

160 (35.1%) and 296 (64.9%) of all calls, respectively. For

both groups, the leading reason for the night calls was

abnormal vital signs, which was significantly higher for the

DNR group (64.4% vs 36.1%, p < 0.001). Compared to

patients without a DNR order, patients with DNR orders

Table 1. Classification of call reasons with definitions and examples.

Call reason category Definition Example

Abnormal vital signs Abnormal blood pressure, heart rate,respiratory rate, body temperature, oxygensaturation, or consciousness

Hypotension, arrhythmia, fever, orhypothermia

Original symptom/problem An existing symptom or problem which hasbeen handed over from the previous shift Cancer pain breakthrough and ileuswith refractory vomiting

New-onset symptom/problem A new symptom or problem which was notnoticed in the previous shift

Chest pain, shortness of breath,and oliguria

Need for physicians evaluation,prescription, or procedure

Events that nurses think the physician shouldevaluate, prescribe orders, or perform medicalprocedures

Hyperglycemia, difficulty in sleeping,and Foley obstruction

Need for explanation orcommunication

Situations on which the nurses think thephysician should answer questions or saysomething to the patients or relatives

Refuse protective constraints,refuse treatment advice, and angrypatient or relative

Others The physician should be informed but noneed for direct evaluation

Falling without obvious injury

Table 2. Demographics of the patients with DNR orders in thewhole study cohort.

DNR patients (N= 258)

Age (years) 77.7 (36105)

Male 137 (53.1)

BMI (kg/m2) 20.8 (12.133.8)

CCI on admission 3.0 (011)

Barthel Index on admission 10 (0100)

Cancer history 140 (54.3)

Organ failure 162 (62.8)

From hospitalization toDNR (h)

69.5 (01791)

Hospital LOS (days) 9 (088)

ICU admission 12 (4.7)

Hospital mortality 117 (45.4)

Outcome and disposition

Death 99 (38.4)

GHTD 18 (7.0)

Home 85 (33.1)

Nursing home 26 (10.1)

Other department/institution

29 (11.3)

BMI: body mass index; CCI: Charlson comorbidity index; DNR: do-not-resuscitate; GHTD: go home to die; ICU: intensive care unit; LOS:

length of stay.Data are expressed as median (minimummaximum) or number ofcases (%).

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had significantly fewer calls for symptoms or problems,

regardless of whether they were original or new.

Among 158 calls from patients with DNR orders, 70

(44.3%) were from patients with history of cancer. When

comparing cancer and noncancer patients, there was no sig-

nificant difference between call reasons (Table 4).

On-call residents response and nursessatisfaction

The percentages of bedside visits were 50.6% and 30.7%,

and the percentages of immediate visits within 15 minwere 23.8% and 18.9% for patients with and without a

DNR order, respectively. Telephone orders without visits

occurred in 49.4% of night calls for patients with DNR

orders but 69.3% for patients without a DNR order.

Overall, the pattern of the residents responses showed a

significant difference between patients with and without a

DNR order (p< 0.001), with more bedside visits for the

former.

Of all 172 bedside visits, patients with and without a

DNR order accounted for 81 (47.1%) and 91 (52.9%),

respectively. Regarding direct patient care workload, it was

similar between the DNR and non-DNR groups although

the former was a minor subpopulation.

A total of 449 nurse satisfaction reports were used for anal-

ysis (7 were excluded due to missing data). The nurses scored

very satisfied in 36.5% and 44.1% for patients with and

without a DNR order, respectively. In general, the nurses

were satisfied with the residents management, and there was

no significant difference between the two groups (Table 3).

Time distribution of night shift calls

Figure 1 depicts the distribution of the 456 calls on an

hourly basis throughout the night shift. Two peaks of the

night calls, at 13 a.m. and 68 a.m., were noted. The vari-

ation seemed to be more prominent for patients without a

DNR order than patients with DNR orders, although there

was no significant difference.

Discussion

Abnormal vital sign was the leading reason for after-hours

calls whether patients had DNR or not. To the best of our

Table 3. Comparison of demographics, call reasons, and residents responses for night calls between patients with and withoutDNR orders.

Calls from patients withDNR (n= 160)

Calls from patients withoutDNR (n= 296)

pvalue

Demographics

Age (years) 77.5 13.3 69.8 14.3


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Hsu et al. 285

knowledge, this is the first report on after-hours calls to

physicians comparing patients with and without DNR. The

most valuable finding is that the reasons for the calls to the

residents at night were significantly different between

patients with and without a DNR order, with more urgent

calls for abnormal vital signs for the former. The behavior

patterns and workloads of the on-call residents were also

different, and these findings may be valuable in improving

resident care at night.

Patients with DNR orders were a minority of the patients

in the general medicine ward; however, they accounted for

one-third of night calls and half of direct patient care work-

load. This finding is important for researchers because we

usually assume that patients with DNR orders require fewer

medical interventions. After discussing DNR and EOL

issues, we also assume that patients and relatives have an

insight into terminal or near-terminal conditions and

demand conservative, noninvasive, and symptom-oriented

treatments after signing DNR consent. However, we may

be neglecting the need for mental support and bedside visitsjust for the comfort and reassurance of continuing care.

When vital signs worsen, which accounted for 64.4% of

night calls in our study, the patients and relatives may still

need supportive visits. These psychological needs are simi-

lar to the patients without a DNR order. There were fewer

symptoms requiring night calls for patients with DNR

orders compared to those without a DNR order, which indi-

cates fair pain and symptom management for the former

group in the study ward. However, if unexpected pain,

dyspnea, or delirium occurs, evaluation and prescriptions

by the residents are still mandatory. Finally, death can occur

Table 4. Comparison of call reason and residents response for DNR patients with and without a diagnosis of cancer.

Cancer (n= 70) Noncancer (n= 88) pvalue

Demographics

Age (year) 70.1 13.7 83.4 9.5


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at any time. All the aforementioned needs contributed to the

reasons for the night calls for patients with DNR orders in

this study, and they were a significant source of night shift

workload for both nurses and residents.

The attitude toward the patients with DNR orders did

not appear to change because of DNR consent itself. In

addition, it is natural for nurses to call duty physicianswhen the idea of calling is necessary for unstable condi-

tions is so firmly rooted in their minds. The fact that two-

thirds of the calls for patients with DNR orders were due to

abnormal vital signs has important clinical implications

and suggests a way to decrease avoidable calls at night. It

appeared as though pain and symptom management were

performed well. However, our results may suggest that we

can discuss the issue of managing abnormal vital signs

more with the nursing staff. First, we should have a consen-

sus on the use of fluid resuscitation, blood transfusions, and

vasopressors. We should even discuss whether bedside

monitoring is appropriate or what to do when a monitor

sounds an alarm. Is a fast heartbeat harmful or just a mirror

of stress and anxiety to which we should pay attention? Is a

slow heartbeat dangerous or a reflection of being comfort-

able? Should we do routine workup for fever or just give

antipyretics and relieve the associated symptoms? All these

points may be helpful when the nursing staff face changing

conditions. In addition, fewer routine checkups may allevi-

ate the anxiety of the patients and relatives. In our study, the

two peaks of night call distribution shown in Figure 1

reflected the nursing round pattern at night.12While routine

checkups are mandatory for general patients, is it necessary

to closely monitor patients with DNR orders during sleep?

If we communicate more and reach a consensus, the nurseswill be more likely to feel at ease without doing routine

round and checkups at night.

Second, we should facilitate communication between

nurses and physicians, especially during off-hours.13Nurses

could be included in the PC and EOL discussions or, at

least, the nurses could be made aware of how we plan to

handle abnormal events. Without these steps, the patients

and relatives may become confused with the inconsistent

attitudes of the nurses and physicians. Such internal com-

munication takes time but is always worthwhile.

With regard to the residents responses, 50% of after-

hours calls for patients with DNR orders required immedi-ate or delayed bedside visits by on-call residents. Again, the

workload for the residents appeared to be much higher than

for patients without a DNR order who needed only 30%

bedside visits. When nurses called the residents for a patient

with DNR order, it could only be handled by telephone

order or electronic prescription system half of the time.

When analyzing all bedside visits made by the residents,

half were for patients with DNR orders and half for patients

without DNR, although the former group accounted for

18.7% of the ward. From this point of view, it is reasonable

to assume that the workload for night staff will rise substan-

tially if the number of patients with DNR orders increases.

In a previous survey in Japan, Morita et al.14pointed out

that the number of nurses and the number physicians were

significant determinants of family satisfaction. A question

that researchers should study is how to predict the neces-

sary level of manpower required to care for patients withDNR orders.

This study has several limitations. First, the reasons why

the patients called the night shift nurses were not studied. In

a previous study, the reasons were different from those caus-

ing nurses to call doctors.15The nursing need for patients

with DNR orders is also an important issue. However, we

only focused on the need to call an on-call resident, so the

response patterns could be studied. Second, we only sur-

veyed the need for resident care at night for patients with

DNR orders, which cannot be generalized to the daytime.

Care at night aims to provide the best possible sleeping

environment for the patients.16 Night call studies are thus

valuable because they reflect the real needs for the patients

at night, without being confounded by daytime activities. To

improve nighttime problems and design effective care in a

hospital, it is critical to gather frontline information at night.2

Third, patients with DNR orders in a general medicine set-

ting may be different from those in a specialist PC unit.

However, the subgroup analysis showed that cancer and

noncancer patients had similar reasons for night calls.

Therefore, we believe that the results are representative.

The medical need for the patients with DNR orders was

different at night, but we have not yet designed a patient-

centered, after-hours PC system in the hospital. Therefore,

we can hardly say that PC at night is as good as that in theday. In order to minimize the inequity of day-and-night PC,

potential solutions are to facilitate handoff communication,

to improve doctornurse communication, and to introduce

mandated 24-h coverage by specialist PC teams or hospital-

ists with PC training.17

Conclusion

Our study unveils the picture of medical care delivery at

night in the general medicine setting. The DNR status

increased medical need at night and on-call residents

workload. Patients with DNR orders were a minority of thepatients in the general medicine ward but accounted for

one-third of after-hours calls and nearly half of direct

patient care workload by on-call residents. The medical

need at night for patients with DNR orders may require a

different care model. Therefore, further studies into after-

hours PC are warranted.

Declaration of conflicting interests

None.

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Hsu et al. 287

Funding

This research received no specific grant from any funding agency

in the public, commercial, or not-for-profit sectors.

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