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.
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.