In college, while most of her fellow students were staying up late and sleeping in, Alice Marshbanks, MD, FHM, was an early riser. Now she regularly works from 4 p.m. to 2 a.m., and she sleeps in most mornings. “I’m sleeping later and living more of a teenage lifestyle,” she jokes. “I’m actually getting younger.”
Dr. Marshbanks might be an anomaly among established hospitalists. A physician since 1989 and a hospitalist since 1995, she actually prefers working the swing shift, and she says she’s the only one in her group at WakeMed Hospital in Raleigh, N.C., who does. Although Dr. Marshbanks is not a true nocturnist—she doesn’t work the typical 7 p.m. to 7 a.m. graveyard shift—her contracted position provides valuable transition coverage for night admissions, which have increased as the HM program at WakeMed has grown.
Surveys indicate that HM groups continue to move toward in-house coverage models to provide 24/7 hospitalist responsiveness. In the 2011 SHM-MGMA State of Hospital Medicine report, which will be released next month, 81% of responding nonteaching hospitalist practices reported providing on-site care at night. That’s up from 68% of responding HM practices that reported furnishing that service in the 2010 report. Only 53% of HM groups reported providing on-site night hospitalists in the 2007-2008 State of Hospital Medicine survey, which was produced solely by SHM.
Kenneth R. Epstein, MD, MBA, FACP, FHM, chief medical officer for Hospitalist Consultants Inc., headquartered in Traverse City, Mich., has observed this trend first-hand. In academic hospitals, due to new Accreditation Council for Graduate Medical Education (ACGME) and Resident Review Committee (RRC) regulations, “the only safety valve to handle admissions after the house staff numbers are capped is the hospitalist.”
The need for such a safety valve will increase again this summer, as new ACGME duty-hour regulations on resident hours and supervision kick in.
Nonteaching hospitals are not exempt from these pressures. To deal with increasing demands for night coverage, HM groups across the country are using a variety of practice models, such as hiring dedicated nocturnists or moonlighters to cover nights, rotating shifts among team members, or using midlevel providers (physician assistants or nurse practitioners) as night staffers. On-call or in-house coverage models are determined by a variety of factors, including the size of the HM group, patient volume and acuity, and staff availability. Sustainability continues to be a challenge for most groups; however, the in-house coverage model seems to increase nursing and ED satisfaction, most experts say, and is an added value for hospital administration, although financial returns vary.
Continuity of care is at the heart of the night-coverage issue. Some experts worry that patient outcomes will suffer if there isn’t an in-house presence, but studies looking at this issue have been inconclusive, asserts Patti VanDort, RN, MSN, NEA-BC, vice president of nursing and chief nursing officer at Holland Hospital in southwestern Michigan.
“You’ve got to have the same level and quality of care during nights and weekends that you have during the weekdays,” she says. “It’s got to be the same for all.”
That said, some hospitals don’t have the volume to justify in-house night staffing. Hospitalists and program directors have described the ways in which they handle night staffing, balancing demand, program size, and physician satisfaction.
Tailored to Fit
“Hospitalist programs have different scale and scope depending on the needs of the institution,” says Michael R. Humphrey, MD, vice president and chief clinical officer for Emergency and Ambulatory Services at St. Rita’s Medical Center in Lima, Ohio. A 365-bed community hospital, St. Rita’s employs nocturnists as part of its 24-hour hospitalist program. Dr. Humphrey still works as an ED physician and reports that the hospitalists are invaluable for admitting, providing cross-cover, covering the ICU, and handling code blue and rapid responses. “As a Level II trauma center, we can’t have ED physicians leave the department to run upstairs and do codes,” he says. “They typically don’t get back within five minutes.”