The middle-age man came to Kaiser Foundation Hospital’s emergency department (ED) in the middle of the night in the late stages of a heart attack.
No catheterization lab operates at night at the Santa Clara, Calif., teaching hospital. The emergency team called a cardiologist for advice and gave the man clot-busting medication.
Still, he did not respond well to treatment.
Jean Laumeyer, MD, of the hospitalist staff, was called in. She had seen many similar cases in her 11 years of working the night shift. Within an hour, Dr. Laumeyer stabilized the man’s condition with “a combination of blood thinners, beta-blockers, pain medications … i.e., general medical management.”
The next day, a woman walked up to Dr. Laumeyer’s husband at a car wash and told him his wife had saved her husband’s life.
“Cases like that are what makes me feel good about working at night,” says Dr. Laumeyer. “I’d seen many cases like it and when you do something a lot, you get good at it. And at night you really have to work well as a team, and we did.”
Dr. Laumeyer is one of the growing number of hospitalists working at night. They are filling critical roles in patient care as hospital medicine becomes more complex and oriented to acute care.
Focus on Quality
Whether they work other shifts or are dedicated nocturnalists like Dr. Laumeyer, a mother of three, night-shift hospitalists are increasingly playing key roles in admissions, medication reconciliation, co-management of surgical patients, and more. They are becoming increasingly important to patient care, to outpatient colleagues’ practices, and the effectiveness of today’s hospitals (see The Hospitalist, May 2006, p. 22).
“These days, a patient typically has to be very sick to be in a hospital,” says Janet Nagamine, MD, who has also been a hospitalist at Kaiser, and, years ago, an intensive care nurse. “Many patients who would have been in intensive care units 20 years ago are in step-down units today.” Now, she is primarily involved in risk management and consulting on quality and safety. She chairs SHM’s Hospital Quality and Patient Safety Committee.
Dr. Nagamine believes typical night-staffing patterns established decades ago may not always be what is needed for optimal patient care, especially lab and ancillary services (see The Hospitalist, April 2007, p 39). “The hospitalists working at night are on the front lines of dealing with this,” she says.
Dahlia Rizk, MD, director of the hospitalist program at Beth Israel Medical Center in New York’s Union Square facility, agrees hospitalists are grappling with some vexing issues in hospital medicine. “We’re involved in every medical issue within quality improvement and patient satisfaction,” says Dr. Rizk. “We are the go-to people for administrators dealing with these issues, on the training of new doctors, and in promoting good communication with other professionals and the community.”
Dr. Rizk is building a 24-hour, seven-day hospitalist program at Beth Israel, where the hospitalist staff has grown from two to 12 full-time physicians in 6 1/2 years. That staff handles nights with an on-call system.
Recent research does not indicate a statistically significant difference in patient outcomes when comparing day and night shifts. But some studies find challenges at night, including in EDs and with discharges.
A 2006 study in Academic Emergency Medicine found that while there are no marked deficits in ED patient care at night, there is a small but measurable increase in early mortality.1
Another 2006 study, published by the Medical Journal of Australia, found that over an 11-year period, more patients were discharged from the ICU in the afternoon and night and that they had an increased risk of death.2 Similar results were reported in a study published in December 2006 by Critical Care Medicine.3