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Niche at Night


 

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.

The Challenges

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

ICUs and EDs are areas where night-shift hospitalists often work, treating patients who typically have symptoms of cardiac or respiratory distress, abdominal pain, and infectious diseases. They are often elderly.

As a result, night-shift hospitalists must work to build excellent relationships with the ED staff and doctors, other hospital staff, and the specialists who will pick up care of the admitted patients, says Robert Newborn, MD, medical director of the adult hospitalist program at Northern Westchester Hospital (NWH), a 175-bed community hospital in Mount Kisco, N.Y.

Dr. Newborn became director of NWH’s hospitalist program in 2004 when it was launched. He had served nearly 10 years as an attending physician in the ED and before that as associate director of the ED at NY Hospital-Cornell Medical Center in New York. NWH’s adult hospitalist program has five full-time physicians reporting to Dr. Newborn. Two pediatric hospitalists work during the day.

The adult-disease hospitalists work the nights in shifts, which Dr. Newborn believes is good for their professional development. “Rotating shifts are beneficial because you learn to work in all environments,” he says.

The NWH hospitalists work 12-hour shifts with face-to-face hand-offs with colleagues at the beginning and end. They review the census of patients (typically about 35) and get a thorough run-down on potential new admissions.

Robert Newborn, MD, director of the hospitalist program at Northern Westchester Hospital in Westchester County, N.Y., confers with Corina Sujic, MD, on a recent night shift.

Robert Newborn, MD, director of the hospitalist program at Northern Westchester Hospital in Westchester County, N.Y., confers with Corina Sujic, MD, on a recent night shift.

A Critical Shift

To Corina Suciu, MD, a hospitalist at NWH for 16 months, these sessions are obviously critical for patient care, but also for building a tight-knit group of physician colleagues.

Recently she began an 8 p.m. to 8 a.m. shift with a hand-off from the earlier shift. It looked like a pretty typical night.

Dr. Suciu began with the pending admission of a 26-year-old schizophrenic male who was acutely paranoid and needed a full medical exam.

After that, she needed to determine the medication status of a 90-year-old man who had suffered from diarrhea for days and had been falling at home—particularly dangerous because he was taking blood-thinning medication. The patient was taking five or six medications for heart rate, asthma, cholesterol, and more.

The man was not able to accurately report his full medication regimen. Neither was his wife. Dr. Suciu could not reach other family members by phone.

Dr. Suciu knew she needed precise dosages on the patient’s blood thinning (Coumadin) and heart rate (digoxin) medications, at least, in order to proceed with a treatment plan. “Medication reconciliation is an important part of a hospitalist’s job and it is hard, especially at night when there usually isn’t a pharmacist,” she says.

That night, everyone was lucky. The patient had his medications in-hand and the pharmacist was still on-site at 9:30 p.m. He determined the dosage and Dr. Suciu continued with the admission and treatment plan.

As she worked the phone and computer for the 90-year-old, Dr. Suciu got beeped by the emergency staff regarding a less typical case. A 21-year-old woman came to the ED unable to speak. A stroke was suspected. The patient had been in a year earlier, but tests at the time proved inconclusive. The emergency team admitted her for further testing.

Dr. Suciu talked by phone and face to face with nurses familiar with the patient. Then she headed to the ED to examine the young woman and talk to her family.

On the way, she ran into the patient’s neurologist. After discussion, they agreed the patient’s status was inconclusive, so testing was needed as soon as possible.

After gathering more information from the emergency team, Dr. Suciu spent 30 minutes examining the patient and talking to the patient’s family. Next she ordered testing, including a stroke work-up. She planned to monitor the woman through the night.

At 10:45 p.m., the patient was ready to be moved from the ED for a battery of tests to determine if she was suffering a stroke.

By her 8 a.m. hand-off, Dr. Suciu reported that the initial tests on the 21-year-old were fine. Her condition may have been related to a migraine headache. The 90-year-old man was stable.

Communication is Key

Facilitating admissions, moving treatment forward, and reconciling medications are typical duties for a night-shift hospitalist. A critical skill is communicating with the specialists and other outpatient doctors who will care for the patients longer-term.

“I always call the consulting specialists at night because 90% of the time they help a lot,” says Dr. Suciu. “We help them because we give immediate care, which improves the patient’s condition, even saves lives, and gets the patient ready for treatment the next day by the specialist.”

Dr. Laumeyer, who started working nights when it was impossible to juggle the needs of her children—then ages 1, 4, and 6—with her 2,400-patient clinic work, says hospitalists must work hard at night to determine the right time to call a specialist.

“I don’t call a specialist until a patient is stabilized,” she says. “Then I try to have clear questions, a sense of when the patient will be admitted, what I will have done, and what needs to come next. Even if they have to come in before morning, I try to make one call.”

An advantage to working nights often, Dr. Laumeyer says, is that hospitalists can learn what specific physicians like to know, how they want to work, and at what point they want to be involved. “Our chief cardiologist says she starts getting dressed as soon as she knows it’s me on the phone because she knows she’ll have to come in,” she says. “I take pride in that.”

While she feels strongly that hospitalists need to be prepared and clear when they call specialists at night, they should never hesitate to call. “If they’re sleepy or cranky, it doesn’t matter,” Dr. Laumeyer says. “What matters is advancing patient care.”

Her Kaiser colleague, Dr. Nagamine, teaches teamwork and communication skills. “This is critical for hospitalists,” she says. Especially at night, “they must be specific about what they need and its urgency.”

Dr. Nagamine believes structured communication systems, such as those used by the military and in aviation, would benefit medical professionals and patients. One example is the Navy’s situation, background, assessment, and recommendations system. “We’re pretty good at background, but we don’t always clearly state the situation and expectations,” she says. “We assume the person will take the information we’ve given them and come up with the same thinking we have. But just by being present in a situation, you know more.”

Dr. Nagamine believes the onus is on night-shift hospitalists to convey a clear picture of what is needed from a colleague because, obviously, “communication failures take patients down.”

She believes the healthcare industry needs to better understand these issues and notes that the Joint Commission on Accreditation of Hospitals urges a standardized structure for communicating that reduces variability in information. “A shy, inexperienced person will say less,” she says. “These systems help to take the person out of the conversation to be sure communications are effective.”

NWH’s Dr. Newborn believes his staff, and hospitalists in general, are “skilled at appropriately triaging the need for specialists to come in at night.”

In his experience, most specialists are happy to have hospitalists on board because they improve patient care and the specialists’ lives and practices. “They are glad that treatment for their patients doesn’t wait until 7 a.m., that they don’t have to come in at night as often, that they don’t have to do all their admissions and that they get patient referrals,” he says. “As a result, they’re generally happy to take hospitalists’ calls in the middle of the night.”

Lab and ancillary services have increased, too. In the ED, advanced imaging, blood drawing, and electrocardiograms are available all night, says Dr. Newborn. There is a computerized system of patient and medication information that can warn doctors and other staff about potential medication problems.

Nevertheless, night-shift hospitalists are on their own more than their day-time colleagues.

At Beth Israel in Manhattan, the day-shift hospitalists are part of a teaching service. “The hospitalist communicates with the resident who is the in-house physician, or the ICU intensivist, or the fellows who are post-residents training in a specialty,” says Dr. Rizk.

The Beth Israel hospitalists are on a team or are assigned patients based on floors or wards rather than shifts. “The advantage is that one hospitalist cares for a given patient for a longer term, working with all the acquired knowledge,” says Dr. Rizk. “We minimize the number of providers working with a patient and the physician knows the goals for care and the treatment plan well.”

At night, the Beth Israel hospitalists are on-call, but because of the hospital’s growth, Dr. Rizk is working to establish a 24-hour, seven-day hospitalist program that will not be a teaching service. She is recruiting for two night-shift hospitalists who will staff the units.

She knows from her efforts to expand her staff in general that recruitment of night hospitalists will be a challenge. Dr. Rizk agrees with many who think night-shift hospitalists must be given incentives such as higher salaries, more time off, or hybrid schedules (such as one month of night shifts per year).

Yet there are benefits to working at night, she and others agree. “Since it’s shift work, when your beeper is off, you are off,” she says. “You can have more time off, and it can suit personal needs and lifestyles.”

It can be quieter at night with few meetings and little committee work. It can be a good fit for a physician who is between residency and working toward further specialization.

Most importantly, she says, it makes it possible to really focus on patients.

“It’s medicine without the committee,” says Dr. Laumeyer at Kaiser. “At night, there are fewer people to run decisions by, but you can learn and make a big difference.”

She cautions, however, “You have to be comfortable with what you can do on your own and get help with what you can’t.”

Dr. Nagamine agrees. “The most important thing is to recognize the limits of your experience and the scope of your practice. You also must be very aware that what you’re doing at night may be different than it would at 2 p.m. As long as you recognize a discrepancy, you can decide if you need to take another step to ensure the best patient care.” TH

Karla Feuer is a journalist based in New York.

References

  1. Silbergleit R, Kronick SL, Philpott S, Lowell MJ, Wagner C. Quality of emergency care on the night shift. Acad Emerg Med. 2006 Mar;13(3):325-330.
  2. Tobin AE, Santamaria JD. After-hours discharges from intensive care are associated with increased mortality. Med J Aust. 2006;184(7):334-337.
  3. Priestap FA, Martin CM. Impact of intensive care unit discharge time on patient outcome. Crit Care Med. 2006 Dec;34(12):2946-2951.

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