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'Waterfall' Shifts in ER Improve Flow of Patients

Analysis  |  By Christopher Cheney  
   October 15, 2018

Overlapping shifts for attending physicians in a busy pediatric emergency department have decreased patient handoffs and reduced opportunities for patient harm.

To boost patient safety and physician efficiency, Seattle Children's Hospital adopted overlapping emergency room shifts for physicians and achieved a dramatic reduction in patient handoffs, recent research shows.

"A total of 43,835 patient encounters were analyzed. Immediately after implementation of the new model, there was a 25% reduction in the proportion of encounters with patient handoffs, from 7.9% to 5.9%," the researchers wrote in the Annals of Emergency Medicine.

Patient handoffs bear high risk for compromised patient safety. An earlier study of ER shift-change handoffs showed that vital signs were not communicated for as many as 74% of patients, and another study showed errors or omissions occurred in 58% of handoffs.

At the Seattle Children's ER, the original physician shift model featured shifts ranging from 7 to 9 hours long. When there was a shift change, the outgoing and incoming physician would sign out the entire patient list.

The original model had several shortcomings:

  • Multiple patients were handed off to the incoming attending physician, creating multiple opportunities for communication errors and omissions.
  • As trainees and nurses waited to review patients with the incoming attending physician, patient care was delayed.
  • Attending physicians worked at full capacity through their shifts and often stayed late for charting.
  • Sign-out was stressful during peak arrival times, when patients would arrive during the handoff process.

The new "waterfall" ER physician shifts addressed pitfalls of the old model:

  • On arrival to the ER, an attending physician assumes a primary role. The next attending arrives 3-5 hours later, assumes the primary role, and immediately starts treating new patients.
  • The first attending transitions to a secondary role and completes work on existing patients while treating new, less complex patients with the intention of being able to treat and discharge them prior to the end of their 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," the researchers wrote.

Waterfall model implementation

Hiromi Yoshida, MD, MBA, the lead author of the research, told HealthLeaders that the waterfall shifts can be implemented at most ERs that have multiple attending physicians.

She said there are three primary implementation factors:

  • Getting buy-in from all parties involved in the change, including attending physicians and charge nurses. The waterfall schedule involves cultural changes such as the timing of shifts, so all attending physicians should review the new model individually and at ED division meetings.
  • Getting support from hospital leadership is crucial to help drive change. The leadership team can help encourage the implementation of the new model and provide support for staff as it is rolled out.
  • To maximize efficiency and enable patient evaluations, there must be enough patient care space to allow incoming physicians to see new patients.

Efficiency gains

Yoshida said the waterfall staffing model generates several efficiency gains:

  • Fewer handoffs ease the cognitive workload from interruptions and interactions in busy ERs. "It has been shown that excessive cognitive workload and increased stress negatively affect performance," she said.
  • With incoming physicians jumping into treating patients instead of spending time receiving handoffs, patient care is not delayed.
  • Decision-making is focused at the beginning of the shift, when physicians have better decision-making capacity. This also may lead to less decision-making fatigue throughout the shift.
  • The waterfall model ensures that a rested and refreshed physician is coming in at staggered times, which provides relief for the staff that has already been in the ED for several hours.
  • In the research, physicians reported an increased ability to leave on time and to complete charts prior to the end of their shift.
  • There are more opportunities to collaborate and interact with other physicians throughout the shifts instead of just the short period of time during end-of-shift handoffs.

Seattle Children's implemented waterfall shifts in the ER five years ago and the hospital is continuing to fine-tune the model, 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."

Christopher Cheney is the CMO editor at HealthLeaders.


At Seattle Children's Hospital, overlapping ER attending physician shifts have decreased patient handoffs 25%.

When handoffs occur under the new model, one goal is for patients to have less complex medical conditions.

The new model has generated several efficiency gains, including reduction of cognitive workloads and increased opportunities for physician collaboration.

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