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One hospital’s solution to being overwhelmed at night
A night-nurse collaborative makes a nightmare shift more manageable
by Paula S. Katz



Published in the October 2008 issue of Today's Hospitalist

IMAGINE THAT AS THE ONLY HOSPITALIST working the night shift, you have to admit 15 patients, answer 40 cross-coverage pages and handle assorted other phone calls. While that might be the stuff of your worst nightmare, it was becoming a regular feature of night work for the hospitalists at Banner Gateway Medical Center.

When the 176-bed hospital in Gilbert, Ariz., opened in September of 2007, administrators never dreamed that the nights would be so busy. As a result, they assigned only one hospitalist to the cross-coverage shift.

Within six months, the hospitalist group
“This allows the physician to put a plan together without being interrupted.”

–Marjorie Bessel, MD
Banner Gateway Medical Center


realized that it had to do something different to cover nights. But with no time to hire or license new physicians or locum tenens, the service had to find a different kind of solution—and it had to act quickly.

Banner decided to pair a nurse with the overnight hospitalist to free the physician to focus more on patient care. A “high-functioning” RN is “joined at the hip” with a hospitalist for a 12-hour shift. The nurse carries the pager, organizes the cross coverage, and literally sits next to the hospitalist during dictation, looking at the order screen to make sure errors aren’t made or details overlooked.

That arrangement means a major shift from the typical “Lone Ranger” hospitalist identity, acknowledges Marjorie Bessel, MD, Banner Gateway’s chief medical officer. But she says the hospitalists have quickly seen the benefits.

“This allows the physician to put a plan together without being interrupted,” Dr. Bessel explains, noting that nurses also take care of the minor phone calls that can throw hospitalists off track. “It also reduces the probability of errors.”

A 48-hour solution
Last winter, Banner was not only struggling with growing pains and a backed-up ED, but with a burgeoning patient population common in the Southwest during the winter. (That phenomenon, says Dr. Bessel, has continued at the same pace through the summer.) That’s when staff began discussing possible solutions.

“Crisis makes you think outside the box: What are our resources, our needs?” says Dr. Bessel. “The nursing collaborative was a resource we felt could be immediately mobilized.” Within 48 hours, in fact, the hospital created and implemented the plan.

A key to the initiative’s success was the quick response from nursing staff. The hospital had no problem finding six nurse volunteers to give the collaboration a try. Some were clinical nurse managers, others charge nurses from the floor, house supervisors or nurses from the ICU. What they all had in common was an ability to work well collaboratively and a desire to try something new.

Not all of them had worked nights—7 p.m. to 7 a.m.—but they all saw a benefit. “If physicians are having issues in care delivery, it spills over to the nurses,” Dr. Bessel says. “If the doctor can’t function well, the nurse can’t either.”

And while night nurses receive an approximate 20% night-shift differential plus overtime during the busy winter months, pay was not the motivating factor for many. Some, for example, saw it as an opportunity to expand their careers. “For one nurse, it was an ‘a-ha’ moment,” Dr. Bessel points out. “She’s decided to pursue a nurse practitioner career.”

Step by step
On a typical evening, the nurse comes on at 7 p.m. and gathers sign-out information from the day physicians. She makes a list of anything on crossover that needs to be done, such as following up on a pending CT scan.

The nurse carries the crossover pages and batches them so the hospitalist can respond when there’s a break. The physician takes calls in real time only on new admissions to facilitate physician-physician discussion.

The nurse accompanies the physician to see new patients, accessing the EMR. If the physician wants to know about a test result, the nurse pulls that up so the physician can continue the exam.

Occasionally, the nurse works independently to get something from a fax machine or to answer pages. The program’s 12 hospitalists rotate through the night shift equally throughout the month and work with the nurse who’s scheduled for that night.

Overcoming obstacles
The nurses received additional training on the hospital’s cutting-edge EMR. That system is central to Banner Gateway’s “next-generation hospital” billing, but it’s also been time-consuming. The nurses working nights meet once a month to discuss the operational process, and one nurse has been appointed the leader of the group. Ongoing classes are planned to discuss clinical issues such as DVT prophylaxis.

Coming up with a schedule was initially challenging and required shifting around people to fill vacancies left by the night nurses. Now, the program has settled into a regular schedule.

And given the nursing shortage, finding well-qualified nurses was an issue. The goal is to make sure everyone’s skills are being used to the maximum, Dr. Bessel says.

A new attitude
Physicians used to working alone also need to adjust to no longer flying solo. As part of the program, they meet every other week.

But Banner has found that physicians working the night shift show increased satisfaction. Not only do they have a “second set of eyes and ears” to handle time-consuming order entry and to return phone calls, but they also have someone to work with. “It can be a very lonely shift,” Dr. Bessel says. “Now they’re not heading into the night shift with the dread they had before.”

The initiative is now viewed as a “smashing success” because nurses help prioritize the flood of requests for the hospitalist.

“When there are multiple calls from the floor, it’s not always easy to know which rises to the top and which to see,” Dr. Bessel explains. “The nurse helps field those calls and triage those patients along with the physician.”

While the hospital has just begun crunching numbers, she anticipates seeing improved wait times for emergency physicians to get callbacks from the hospitalist, as well as better wait times for patients to be admitted and response times for nurses on the floor.

Meanwhile, the hospital’s newfound efficiency is already allowing staff to accept night admissions from rural areas. “Before we had to say ‘no,’ so this is going to impact our revenue,” Dr. Bessel says.

Perhaps the most telling measure of the program’s success is that Dr. Bessel is now fielding requests to extend the initiative to the day-time physicians. The hospital continues to recruit both hospitalists and nurses.

“Retention is better for hospitalists,” she says. “The only thing that’s going to happen to this program is that it’s going to expand.”

Paula S. Katz is a freelance health care writer based in Vernon Hill, Ill.
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