Jackson Memorial Hospital is an accredited, nonprofit, tertiary care hospital and the major teaching facility for the University of Miami School of Medicine. Jackson Memorial Hospital is one of the busiest centers in the country, with approximately 1500 licensed beds, 225,000 emergency and urgent care visits, and nearly 60,000 admissions to the hospital each year. Furthermore, JMH is the only full-service provider for the uninsured and medically indigent in Miami-Dade County, Florida.
Jackson Memorial Hospital has a broad range of tertiary services and clinical programs designed to serve the entire community. Its medical staff is recognized nationally for the quality of its patient care, teaching, and research. The hospital has over 11,000 full-time employees, approximately 1000 house staff, and nearly 700 clinical attending physicians from the University of Miami School of Medicine alone.
Our medicine department is composed of the following inpatient services: eight general medical teaching teams, three HIV/AIDS teams, one cardiology team, an acute care for the elderly (ACE) unit, one oncology team, and a hospitalist run (non-teaching) service.
Over the last several years a combination of the pressures from outside regulatory agencies and an increasing number of patient admissions brought the admitting process to a breaking point. Teaching services were being held to the admission cap guidelines by the Residency Review Committee (RRC). Furthermore, the Accreditation Council for Graduate Medical Education (ACGME) began to enforce strict work-hour rules for all training programs. With these restrictions a fixed number of admissions were admitted to a fixed number of services within a shorter period of the day. In fact, many patients were being held in the emergency department (ED) for as long as 15 hours before an internal medicine service saw the patient or wrote admission orders. We had concerns about safety and the provision of high quality of care for these patients. One of the concerns was that ED physicians were caring for patients who were essentially inpatients while continuing to treat new ED cases.
In an attempt to provide excellent care to our patients, we developed the Emergency Medical Hospitalist Service (EMHS), a nocturnist service. The goals of this service are to: (1) provide attendinglevel care to patients requiring admission, (2) allow the hospital to operate within the admission cap guideline set forth by the RRC, (3) function during the time in which the ACGME work hour limits were affecting the hospital, and (4) operate in a manner that would be at least cost neutral for the institution. We hired two internists (myself and Dr. Roshan K. Rao) to admit patients overnight and begin their inpatient work-up. During this shift, we admit and initiate the inpatient care of all medical admissions for the inpatient services, including the housestaff covered teams. During a typical 12-hour shift, we will admit an average of 10–12 new patients from the ED. In addition to this, there is one resident on each night (termed “night relief”), who provides cross-coverage of existing medical inpatients. We also work in close concert with the newly developed “Patient Placement Coordinator,” who facilitates prompt bed assignments and movement of these patients to in-house beds.
Currently there are two of us, so we make our own schedule depending on each others’ needs. We currently work one week on/one week off, from 8 p.m. To 8 a.m. Towards the end of the shift, we sign out the newly admitted patients to the appropriate services. Typically, the resident will come into the ED and take their sign-out from one of us. The geriatrics fellows and non-teaching hospitalists usually take sign-out over the phone. The entire sign-out process occurs anytime from 6:00 a.m. to 8:00 a.m. We also reserve this part of the shift to follow up laboratory studies and other diagnostic procedures. Occasionally, we are able to discharge some patients by the end of the shift as well.
On occasion, we will call in the other nocturnist to help out when admissions are too numerous for one physician to handle. This typically occurs towards the end of the work week. We usually require “double coverage” approximately 6–8 nights per month.
Since we instituted the nocturnist program 2 years ago, we have seen great improvements in ED throughput, inpatient bed utilization, patient satisfaction, average length of stay (both in the ED and inpatient), and quality of care. As soon as the emergency physician makes their decision to admit the patient, one of us is already interviewing, examining, and writing admission orders on the patient. This speeds up the process of the patient’s evaluation and allows the patient to be immediately transferred to a quiet room. Furthermore, this allows us to develop a rapport with the patient in the middle of the night, instead of feeling rushed in the morning to round on as many as 20 new patients. This also ensures a good night’s rest for the patient and improves the bed utilization. Moving patients to the floor in a timely fashion also allows for the ED to treat more patients.
Having a nocturnist in the hospital throughout the night allows for a more precise and accurate physical exam, formulation of an impression, and execution of a treatment plan. Physicians who are on-call at home often do not get the complete or correct story from the ED, which can lead to incomplete admission orders and delayed treatment plans. This can lead to unnecessary increases in length of stay. For example, I often admit “chest pain” patients, who by morning have already “ruled out” for an acute coronary event, had a stress test, and are ready for discharge before the “daytime” physician has seen the patient. Another example is diabetic ketoacidosis. I am able to be very aggressive with the treatment plan throughout the night, again decreasing length of stay and hospital costs.
Nocturnism is not only advantageous to the hospital and patients, but also to the nocturnist himself/herself. Dedicated nocturnists have less fatigue and stress. I work only nights, so I do not become excessively tired. My sleep schedule is completely reversed from the norm. This also has many advantages to my personal life. One of these is that I never miss a package delivered to my home!
Indeed, developing this program was a challenge. Initially we sold the idea through a combination of patient safety and revenue. The hospital cannot bill for holding patients in the ED. If we admit patients and move them to an inpatient bed, the hospital can generate this otherwise lost revenue. As with any new idea, we did meet resistance and opposition along the way. However, we were able to overcome these obstacles and build upon them. Once the administration saw the improvements and our productivity, they were immensely pleased. In fact, the administration is already looking at expanding our staffing and our services. Our billing and collections have shown we pay for our cost and generate additional funds for the hospital, despite a poor payer mix. I am excited to see what the future holds for nocturnists, not only in our institution, but across the country. Groups that employ nocturnists probably wonder how they ever survived without them in the past.
Dr. Sabharwal can be contacted at ASabharwal@med.miami.edu.