Docs Around the Clock
Our hospitalist group presently takes out-of-house call at night, but our hospital is pressuring us to move into the hospital 24/7. What should we do?
Afraid of the Dark,
Dr. Hospitalist responds: It can be a real challenge to find sufficient providers to staff the hospital nightly. But I encourage you to take this step. I believe there is a quality advantage to having hospitalists in house 24/7 versus having physicians on call at night from outside the hospital.
Hospitalized patients are no less likely to become acutely ill at night as during the day. From a quality perspective, it has never made sense to me why hospitals do not routinely have a physician in house 24/7. Many hospitals say they cannot afford to pay a physician to work in house at night because there are few opportunities to generate revenue. But in today’s environment, can you afford not to have a hospitalist in at night?
Hospitals without hospitalists in at night often encounter issues with patient throughput each morning. Nurses are waiting for physician orders, and physicians are scrambling to write admission notes on patients admitted overnight. This delays morning discharges and admissions, leading to other problems including overcrowding in the emergency department.
Hospitalized patients are now sicker than ever. Delays in evaluations can mean adverse outcomes. Just because the doctor is not in the hospital does not relieve them of any responsibility if a patient suffers an adverse outcome as a result of delay in care. Patients and payers are not only scrutinizing the care patients receive in the hospital but also paying based on performance. Can you and your hospital afford to not provide the timeliest care possible?
Right Night Solution?
Do you think it is better to have dedicated nocturnist(s) or have hospitalist staff members take turns working nights?
Sleepless in San Diego
Dr. Hospitalist responds: There are advantages and disadvantages of having a dedicated nocturnist versus having a rotation model with regular hospitalist staff members taking turns working nights in the hospital. If your hospital has different groups of nurses for days and nights, there may be an advantage to having nocturnists.
This model allows the doctors and nurses to work closely and develop a cohesive team. This would be more difficult if the doctor at night changes frequently. Using nocturnists to staff nights can also make daytime staffing easier or more difficult.
Consider this analogy. At the end of this baseball season, the New York Yankees faced the decision of whether or not to re-sign arguably the best player on the planet, Alex Rodriguez. With A-Rod’s high price tag ($30 million-plus annually), would the Yankees be better served taking this money and signing several players (because we assume no single player could match his talent)? What would happen if they signed A-Rod and he got hurt? Wouldn’t that leave a hole in the lineup the size of the Milky Way?
How different are nocturnists in today’s hospitalist workplace? Most hospitalist programs covet them. They can do things others can’t—work a large number of nights on the schedule. This means fewer or no nights for colleagues, which makes them happier. Nocturnists command a high salary, and if one leaves for your program for any reason, they leave a gaping hole in the schedule.
My advice is to hire a nocturnist but don’t rely solely on nocturnists to cover nights. Covering your night schedule with a mix of nocturnists and staff hospitalists will allow everyone to appreciate the nocturnist but won’t put you in the uncomfortable position of relying solely on nocturnists to keep your program running effectively.