Editors’ note: We originally conceived this article with the authors just before Hurricanes Katrina and Rita devastated the Gulf Coast last year. Once the hurricanes hit, we decided to “bump” this article in favor of running coverage of the hurricanes and their effects on hospitals in the Gulf Coast area.
The Ochsner Clinic Foundation rests on the eastern bank of an acute flexure in the Mississippi river similar to its twin just downstream, which lurches around a crescent forming the historic and infamous French Vieux Carré, or Old Quarter. From a perch on the hospital’s 11th floor I often start my evening by taking in the full scope of the river’s powerful swirling eddies and copious flotsam churning past in the westerly sun. The view has become a familiar sight to me over the past several years as our hospital’s primary night shift internist.
Though my comrades jokingly refer to me as Ochsner’s “nocturnist,” an assignment surprisingly relished by few, the position has proven mutually beneficial in serving a vital role for the hospital and our group, while accommodating my own crepuscular nature and lifestyle.
Our night position—officially known as IHC (or in-house call)—was conceived from several requisites desired by both administration and physicians. Ochsner Clinic Foundation is steeped in academic history, and the nights have traditionally been dominated by semi-autonomously operating residents. During the past five years, practice changes in the local area afforded Ochsner unprecedented growth, requiring constant accommodation and development of our hospitalist group. Many of these changes were accelerated by the devastation wrought by Hurricane Katrina. With a nod to quality over quantity, we decided against expanding the teaching program in favor of developing several non-resident-based hospital services.
These unique and burgeoning parallel systems of care quickly presented many challenges for those staff clinicians stationed at home when problems arose during the evening. The original expectation was that the residents would have no direct involvement in the care of this subset of patients to avoid overburdening a system already operating near capacity. Subsequent intradepartmental disputation ensued over how to provide our patients with personal on-site care through the wee hours while arresting the surge of hectoring beeps that inevitably start after midnight. The exigency of solving this problem grew as our physicians’ slumber waned and patient admissions soared over the following months.
Our group’s consensus that a full-time night staff physician was needed soon emerged as the best potential remedy for our predicament. As no person wanted to be commandeered for the job, volunteers were sought for a trial run with the very reasonable hours of 4 p.m. to midnight, Monday through Friday. Hardly ever retiring to bed before the witching hour, I accepted the first week of our nascent, early evening shift.
The Rise of the Nocturnist
The expectations were simple. I was to independently admit “bounce-backs:” observation level patients, hip fracture service patients, and overflow admissions from a frequently dropsical emergency department. This specious solution proved very successful but ultimately served to highlight the overall need for a hospitalist to remain in-house for the duration of the evening and early morning hours.
The subsequent creation of a newly expanded, more permanent role for our IHC was proffered for consideration. This vision of moving to 24-hour staff coverage on site met with universal acceptance from the physicians, nursing staff, residents, and administration. The lone problem remained of finding physicians willing to dedicate themselves to working primarily at night.
Rather than rotating doctors weekly, we hoped to maintain some consistency by having certain physicians dedicated to staffing nights. From this graveyard shift arose true nocturnists, as in my case, working evenings nearly 75% of the time. Implementation of a weekend nocturnist to cover Saturday and Sunday is being developed as the need for coverage increases and the success of the current system continues.
These expanded changes to the system soon proved fortuitous. Within one year after the inception of IHC, admissions to the medicine services had consistently swollen to between 20 and 30 patients each night—a record for even the busiest periods in the history of the institution. The surge of patients being admitted through our emergency department to medicine proved to be an enduring change, which progressed unabated until Katrina struck. By necessity, the number of “unresidented” services quickly grew to accommodate our patients’ needs and concerns.
In addition, residency-review guidelines governing capitation of resident admissions were also carefully maintained to provide a consistent teaching environment for the house staff. Though stalling momentarily after Katrina struck, medical admissions have continued to climb seemingly without limit. The capacity of our six inpatient medical services with residents is now matched by an equal number of services managed privately by attending physicians alone.
Post-Katrina, the responsibilities of our three primary “nocturnists” have grown in tandem with the increasing number of patients on the wards to now cover the sub-acute nursing facility patients, geriatric nursing home patients, and acute preoperative clearances throughout the night. The lion’s share of time is still spent assisting and facilitating the admissions process for our patients through the emergency department.
In the past several years the role of the night hospitalist has become an integral part of our emergency department. In effect, most of the night is now spent in the emergency department providing consults, triage help, and early assistance with the care of patients ultimately bound for medicine admission. Besides the pragmatic benefits of expedited care, new interpersonal bonds of understanding and empathy have been forged between the two departments. I now count most of the emergency department staff, from physicians to nurses and secretaries, as personal friends and colleagues. The beleaguered admitting process has gradually transformed into a more cooperative, harmonious transfer of patient care between trusting teams.
With so many patients now spilling over the next day to various teams, one of the most vital functions of the IHC staff is to provide complete and accurate information about each patient assigned to the accepting teams the following day. This has required cooperation from both emergency staff in writing temporary floor orders, proper information flow between the on-call resident, night float resident and IHC staff, and proper notification of direct admissions arriving on the floor of patients accepted from the on call medicine staff during the day.
Currently each patient is simultaneously tracked by name, clinic number, and diagnosis by both the IHC staff and the overnight resident. The lists are frequently compared for accuracy, and in the morning an individual e-mail notification is sent to every physician on service for the day of every admission, distribution, and diagnosis by the IHC staff. As a second line of defense against error, the resident places an individual phone call to each physician receiving an overnight admission to reiterate any clinical problems.
As a department we have crafted fixed schedules of admission for the following morning so each day a physician knows whether to expect patients on the service or not. These numbers are forwarded to admissions for that day in order to keep each of the services as numerically equitable as possible. These careful tracking mechanisms, expectations of good communication between our physicians, and months of trial and error have proven invaluable during the months of highest volume when essentially every patient admitted overnight must be redistributed to various teams in the morning.
In addition to securing safe transition of the patient between teams and ensuring proper medical care, each patient is greeted in his or her room in the emergency department by the IHC staff, who take a moment to explain the admission process, the future plan of care, and who will assume the patient’s case in the morning. This has continuously provided an early opportunity to establish bonds of trust with each patient and assuage any lingering questions the patient may have after evaluation by the resident physician. Many of our patients are now displaced, frightened, and homeless. The value of providing face-to-face, 24-hour attending level care for our patients cannot be overstated.
Auguring the future of medical practice in New Orleans since hurricanes Katrina and Rita ravaged the city has proved difficult if not impossible. The degree of change during the past six months has shown that flexibility and adaptability are mainstays of the ability to practice good medicine. Without doubt, New Orleans will return more lively, more resilient, and wiser for all of our losses over the past year. TH
Dr. Blalock is based at the Department of Hospital-Based Internal Medicine, Ochsner Clinic Foundation, New Orleans. Special thanks to Steven B. Deitelzweig, MD, Doris Lin, MD, and Srinivas Vuppala, MD, for their assistance with this article.