Published in the June 2012 issue of Today’s Hospitalist
WHEN YOU WORK NIGHTS, should you have a place to put up your feet, check your personal e-mail or even grab a quick nap?
For hospitalists working nights, particularly those who rotate between day and night shifts, the idea of a call room seems reasonable enough. If you’re going to disrupt your circadian rhythms to pull all-nighters every few weeks, you need a place to sit down and get some rest. It’s a small step to help ensure patient safety “and prevent physician burnout.
But while that exact logic is used to justify call rooms for anesthesiologists, surgeons and nurse midwives who spend upwards of 24 hours in the hospital, not everyone agrees that it applies to hospitalists.
In Glenwood Springs, Colo., the issue of a night room of one’s own for in-house hospitalists came up several months ago when a surgical specialist asked why the hospitalists should have a call room when his colleagues didn’t. The hospital’s 4.5 FTE hospitalists provide 24/7 in-house care for Valley View’s 82 beds, rotating night shifts on a flexible schedule.
“The surgeon argued that the hospitalists are ‘shift workers’ and therefore don’t need one,” recalls hospitalist Al Saliman, MD, chief medical officer of Valley View Hospital. The issue was especially touchy because the hospital was undergoing renovations. Everyone felt pinched by space shortages, and there weren’t enough call rooms for all the specialties that wanted one.
To resolve that turf fight, Dr. Saliman brokered an arrangement whereby the surgery subspecialty can share the hospitalists’ call room. While he says the room is nothing fancy, it does have a bed, TV and shower.
According to Dr. Saliman, he’s heard no complaints, so he assumes the dispute is over. He also suspects the surgeons have never used the call room.
And he is sure that the idea of a call room for hospitalists is good medicine. “If I have a hospitalist who works 12 hours,” says Dr. Saliman, “do I want that hospitalist to be sleep deprived at 2 a.m.? No. When you are in a cognitive specialty, fatigue is a potential patient-safety compromise. For patient safety, I feel it is perfectly appropriate that if you can have a break, you take it.”
Being paid to sleep?
When the hospitalist group at Baystate Medical Center in Springfield, Mass., requested a call room or a break space with a futon for its three nocturnists, the administration was not really receptive. That’s according to Roy I. Sittig, MD, medical director of the center’s hospital medicine programs. The issue boiled down to the premise that the full-time nocturnists were working their scheduled shifts “and were not expected to have down time to sleep.
Because Baystate’s nocturnists don’t work day shifts, the thinking went, they could make do with the existing break space that doubles as the hospitalists’ office. The nocturnists admit between seven and 12 patients a night and provide cross coverage for between 120 and 140 patients. They rarely, if ever, get 15 minutes without their pager going off, Dr. Sittig says, let alone an hour to sleep.
But over the last year or so, his program’s views on call rooms for hospitalists and the amenities those rooms should contain have changed. He now realizes that even full-time, dedicated nocturnists rarely fully switch their sleep-awake cycle. He also figured out that “even little power naps “15 or 20 minutes throughout the night ” can make a big impact on your thought processes and your stamina.”
Moreover, he says, to stay competitive and to recruit and retain nocturnists, a comfortable call room is now a must-have. “It is a small price to pay to provide people with a space to close their eyes for a few minutes,” Dr. Sittig says, “rather than view them as shift workers and have them burn out and quit, or go somewhere else.
When the group made that argument to the hospital recently, Baystate’s administration agreed. Renovations on the new office space and break room are due to start later this year, and the group’s 43 hospitalists should end up with a suite-like lounge with a common break area and a private bathroom, which will include a shower. The plan is to also have a separate, private call room for the nocturnists that has a bed, computer and a phone, if space is available.
Real and symbolic value
Any discussion of hospitalist break rooms raises the question of just how many amenities hospitalists need. Bed or recliner? Mini-fridge or fully stocked kitchen? Washroom or shower “or neither?
While some features may seem like overkill in a room that won’t be used most of the time, some hospitalists say what a call room looks like and what it contains are good indicators of how the hospital values the hospitalist program.
“It’s symbolic of the relationship,” explains Laurie Bankston, MD, co-chief of Sound Physicians at Springfield Regional Medical Center in Central Ohio. The existence of a comfortable call room is “not so much about whether there is a bed or not, but about how the hospital administration and the leadership of the group communicate with each other.”
Dr. Bankston points out that she works seven nights in a row every two or three months. During those 12-hour shifts, she says, it’s nice to be able “to go back, wash your face and brush your teeth, and start over again.”
Her hospital now provides both an office and a separate call room with a desk, a computer and printer with access to the hospital’s EMR, a bed and a TV. On most nights, she can “decompress for a little bit” during the typical lull between 2 a.m. and 4 a.m., after admissions are done and before morning labs start coming back.
During that quiet time, she tries to finish dictations, “flip the TV on for some background noise” and occasionally catch a cat nap. (She says she’s never used the shower.)
At the same time, Dr. Bankston is quick to point out that luxury isn’t a necessity. A hospital where she worked previously had no separate call room, but the group’s office had a fold-out couch, like the kind newer patient rooms have to allow families to stay over. “That worked out pretty well,” she says.
A spartan arrangement
At Southern Maine Medical Center in Biddeford, the anesthesiologists have a call room in a hotel across the street from the hospital, and the ED physicians have a new call room in the renovated emergency department. The hospitalists, on the other hand, have a windowless storeroom tucked away in the hospital’s storage and maintenance area that has been converted into a call room.
The arrangement may be spartan, but Frank Green, DO, medical director of the hospitalist service, says it is more than adequate. He explains that the hospital carved out the space when the hospitalist group began providing 24/7 in-house care.
“It is probably more of an afterthought than a planned space, but in our hospital, like in many others, space is the final frontier,” Dr. Green says. His group has six physicians and five midlevels, and each physician works one week of nights every eight weeks. On any given night, hospitalists may process between three and 10 admissions and cover a patient census of about 50 patients, including those in the ICU.
The call room currently includes a bed, bedside table, lamp, computer, cable TV, telephone, small refrigerator and microwave. In an ideal world, Dr. Green says, the computer would be able to break through the hospital-IT firewalls so he could take care of things other people do during the day “like online banking “during any down time in the middle of the night.
He’d also like to have a shower for days he has early morning meetings. “It would be nice to have a place to shower and change,” he says.
But one item close to the top of his wish list is re-labeling the call room in the hospital’s phone and caller ID system. Right now, it’s identified as the “sleep room,” which contributes to an “underlying current of resentment” among some physicians and nurses that hospitalists are being paid to sleep.
Dr. Green says he also can’t help but think that nicer facilities and more amenities in the call room would make it easier to recruit. “If you are going to attract people to work an undesirable shift, you have to pay them significantly more money, or you are going to have to add some amenities to make it a little bit more attractive,” he notes. “You are going to pay for it one way or another.”
Dr. Bankston agrees. In her view, hospitalists working 12-hour night shifts probably have less need for a sleeping room than someone in-house for a 24-hour shift, like an anesthesiologist or obstetrician. But she adds that hospitalists have more of a need than emergency physicians, whose overnight shift lasts only eight hours.
At the same time, she adds, night coverage is so essential that hospitalist group members are willing to donate money to provide some amenities that a hospital might not decide to spring for.
“Whatever you have to do to get people to work nights, that’s OK,” Dr. Bankston says. “If we need to buy a TV, we’ll chip in and buy a TV. Better coffee? We can do that. Within reasonable bounds, we will do whatever we can to get you to stay here all night.”
The Ritz-Carlton treatment
While better amenities may make a night shift more appealing, they are not the entire picture. At BryanLGH Hospital in Lincoln, Neb., the hospitalist call room may be the Ritz-Carlton, at least compared to Dr. Green’s Motel 6. The room has a kitchen, a refrigerator stocked with sandwiches, snacks, and drinks, a separate office space, sleeping space, lounging space “and a 55-inch flat-screen TV.
The set-up is wonderful, says Tamer Mahrous, MD, a partner in the privately-owned hospitalist group there, but it’s fantastic only because he gets a chance to use it. And that happens only because the group has worked to improve workflow at night so that doctors get a chance to lie down briefly during their ever-busier shifts. (See “Beyond amenities.”) The group’s 20 hospitalists rotate through the 7 p.m.-7 a.m. shifts, admitting between five and 12 patients and cross-covering about 120 patients.
“On most nights, I have time to lie down for at least one or two hours at a time,” he says. “If we are going to have stable hospitalists long-term, we have to make sure that they are satisfied.” That’s true, Dr. Mahrous adds, whether the doctors rotate on and off the graveyard shift or are dedicated nocturnists.
The lack of both a call room and amenities contributed to the decision by Phoenix-based physician Maria Hoertz to leave a nocturnist position and work emergency medicine shifts instead. In her last job as a nocturnist, she not only didn’t have a private call room, but she didn’t have access to a locker, desk or even a drawer to lock her purse.
Eventually, the emergency department made a space for her in the ED that had a computer and a phone. Having that space and the camaraderie of her ED colleagues, Dr. Hoertz says, helped make up for the lack of amenities. But she still had to leave her purse and personal belongings in her car.
Part of the reason why it’s so easy to shortchange amenities for doctors who work nights, she notes, is that they’re invisible most of the time. “How many people see the nocturnist be unhappy? They don’t even see the nocturnist. The only time they see nocturnists is when people are complaining about them,” she says.
In cities where there may be a glut of hospitalists, complaints about needing a place to decompress may fall on deaf administrator ears. But when you are on your feet for 12 hours, says Dr. Hoertz, “even 10 minutes to lie down will allow you to refresh and go back.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
HOW LUXURIOUS should a hospitalist call room be? The fact is that amenities don’t mean much if night shifts are so chaotic that hospitalists can’t use them.
With that in mind, Tamer Mahrous, MD, a partner in the privately-owned hospitalist group at BryanLGH Medical Center in Lincoln, Neb., has championed several initiatives to make sure the hospitalists working nights are not run ragged. In his view, doctors who are overworked and overwhelmed not only are inefficient, but more likely to make mistakes. “The ability to sit down or lie down at some point is a patient safety issue,” Dr. Mahrous says.
One recent initiative, for example, took aim at being “bombarded” between 4 a.m. and 6 a.m. with calls reporting critical lab values.
“If you have 3.1 reported as your potassium and the lab says the critical value is 3.2, patient safety standards require that the lab call the nurse and the nurse call the physician,” Dr. Mahrous explains. “We found that a lot of these lab values at my hospital were set at very conservative levels.”
After the hospitalist group studied the levels used by many other hospitals, they reset their critical value standards. As a result, Dr. Mahrous says, “80% of our early morning critical lab value calls went away.”
Another project enlisted nursing leadership to educate floor nurses to call the right physician by verifying who ordered a lab or service. (The default had been automatically calling the night hospitalist because he or she was onsite and easy to reach.)
Other efforts have streamlined the process for direct admissions from primary care physicians so those can be done earlier in the day, instead of spilling over into the night shift’s workload. A similar initiative led to diverting nonurgent calls to a voicemail and/or fax system that the day and night hospitalists can review during the 7 a.m. checkout rounds.
The result has been “a tremendous difference in our nighttime calls,” Dr. Mahrous says. “In fact, I bring my own pillow because I know that on most nights I am going to have the opportunity to lie down and close my eyes.” While he remains at the whim of what happens in the ER, “I’m not at the whim anymore of unnecessary calls about critical lab values that we shouldn’t have been getting in the first place.”