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Nocturnists: Soaring volumes mean trouble at night

December 2011

Published in the December 2011 issue of Today’s Hospitalist

When Terance Millan, MD, launched his career as a nocturnist in 1997, he would start his shift by signing in with hospital operator, who would give him the number of the sleep room for the night. But in the 14 years since, that ability to nap at night has completely disappeared.

“Gosh,” says Dr. Millan, trying to think of the last time he slept during a night shift, “it has been more than 10 years.”

It’s just one more way that life for nocturnists has changed. Dr. Millan recalls that when he first began working nights at North Florida Regional Medical Center, a 326-bed regional referral center in Gainesville, a busy night meant seven or eight admissions.

Just a few years ago, that number had jumped to 14 or 15 admissions. But on an average night now, Dr. Millan and his partner “who together rotate a 4 p.m.-midnight swing shift and a 7 p.m.-7 a.m. night shift “may have 22 admissions. That’s on top of cross coverage, which includes ICU patients, as well as codes and rapid responses.

That reality is in stark contrast to the party line on nocturnists, which for years has said that nocturnists hold down the fort at night, answering an occasional code and taking an occasional admission. But many hospitalist groups are starting to wake up to the fact that that picture is no longer accurate. Night-time volumes of everything “admissions, pages, cross coverage “are surging to the point that many hospitalist groups are considering ways to beef up resources for beleaguered nocturnists. The goal is not only to head off burnout for these physicians, but to ensure adequate safety for patients at night.

“Night work is the soft underbelly of the entire medical system,” says Sandeep Sachdeva, MD, a 12-year veteran hospitalist who’s worked for the past three years as a nocturnist for Seattle’s Swedish Medical Center.

“You have all these robust resource available during the day time, but then you go down to the bare bones at night.”

An emerging specialty
In the 2011 Today’s Hospitalist Compensation & Career Survey, 40.5% of responding nocturnists claimed they admitted between six and 10 patients per night “while almost 25% of them reported admitting more.
Among nocturnists who provided cross coverage, almost half (42.9%) were responsible for 50 or more patients. And close to one in five nocturnists (23.8%) reported having more than 21 patient encounters per shift.

Nocturnists insist that the level of service and coverage they provide goes way beyond that of hospitalists who occasionally rotate nights or work on a per diem basis.

“Per diem night-time hospitalists just plug holes,” says David R. Tomlinson, MD, who’s worked as a nocturnist for seven years at South County Hospital in Wakefield, R.I. “As a professional nocturnist, my care at night can add to the care that’s continued during the day.” And nocturnists ” just like everyone else in hospital medicine “are now a victim of their own success.

Because he’s a known entity in his community hospital at night, for instance, Dr. Tomlinson says, “nurses call us because they trust us, even when it’s not one of our patients.”

In Arizona, Maria Hoertz, DO, MPH, has worked as a nocturnist for a year “and completely agrees that the coverage nocturnists provide goes well beyond that of what on-call or rotating physicians deliver. Being a nocturnist, she points out, means that hospitalists also need to serve in part as ED physicians, intensivists, proceduralists, subspecialists and counselors.

“Our challenge,” Dr. Hoertz says, “is to define ourselves as specialists in night-time care and to start defining our specialty.”

Rising volumes
What kind of volume are nocturnists handling? An unpublished study tracked nocturnist volumes at two hospitals within Seattle’s Swedish health care system for two weeks in 2010, which authors say makes it the first such study of its kind.

According to Dr. Sachdeva, who was one of the study authors, he and his team found that two nocturnists admitted close to 300 patients over the course of those two weeks, and evaluated more than 50 patients as part of cross cover calls.

They also entered nearly 15,000 electronic orders ” more than 1,000 per night “all the while fielding more than 1,500 pages from nurses. Except for the admissions and some consults, the nocturnists weren’t able to bill much of that workload.

“When I’m on a phone with a nurse, that’s not billable,” says Dr. Sachdeva, “but it’s certainly not without value.”

What’s behind rising night-time volumes? According to Dr. Millan in Gainesville, escalating volumes reflect the success of hospital medicine. As hospitalists care for a much wider swath of patients from primary care physicians, subspecialists and surgeons, his private nocturnist group is seeing its volume spike up.

But the latest hike in night-time volumes at his hospital was also related to the economy. One of three community hospitals in the Gainesville area closed within the past couple of years. “We had a real uptick,” Dr. Millan says.

Subspecialists piling on
Dr. Tomlinson in Rhode Island chalks up surging volumes to the ongoing array of comanagement and admitting arrangements the hospitalist group has agreed to at night. “Specialists, surgeons, GIs, anesthesiologists “you name it,” Dr. Tomlinson says. On any given night, out of the hospital’s total of 100 beds, he estimates that he’s covering probably 70.

Jalila Cunningham, MD, who’s now in her fourth year as a nocturnist, has worked for the past two years at Hamilton Medical Center in Dalton, Ga. She says that her burgeoning volumes likewise come from her group’s willingness to admit just about any type of patient at night.

“There was a time I was getting six to eight admissions a night,” Dr. Cunningham notes. “Now, it’s double digits every night, and even nephrologists are jumping on the bandwagon. In addition to GI bleeds and head bleeds, we’re even admitting dialysis patients.”

At Taylor Hospital, a community hospital in Ridley Park, Pa., contractual coverage and comanagement arrangements have meant a big bump in patients that nocturnists have to admit and follow in the open ICU. But the Taylor nocturnists are also struggling to keep up with the growing number of observation patients, says hospitalist medical director Stanley Josue, MD. “We have seen a surge in our total census capacity of about 20% within the past year,” Dr. Josue says.

Spillover relief
As for solutions, busy nocturnists say those need to be two-pronged: One, hospitals and hospitalist programs need to look at adding resources (or cutting back on service calls) that come in during the night. But just as importantly, nocturnists say, hospitals have to address spillover from the day shifts being passed onto them.

If you come in at 7 p.m. and find five admissions waiting for you that the day shift hasn’t processed, says Dr. Cunningham, that pretty much consumes you for hours “while you continue to be slammed with new admissions and floor calls. For Dr. Tomlinson in Rhode Island, daytime spillover became so onerous that he issued an ultimatum a few years ago.

“I basically said, ‘Either we get a daytime admitter who consistently admits patients during the day, or I quit,'” he recalls. “We got a daytime admitter.”

Help also comes in the form of various swing shift clinicians and staggered shift times for daytime hospitalists. At a previous hospital where she worked as a nocturnist, Dr. Cunningham says that a hospitalist working a 1 p.m.-1 a.m. shift was a big help. “This helped cover the ‘rush hours’ for admissions, which are 1 p.m. to 8 p.m.”

At her current job, spillover relief came last month in the form of filling a third hospitalist daytime slot. In addition to increasing the number of daytime admitting hospitalists, “Our hospital is now staggering daytime admitting schedules so that each hospitalist admits for only four hours,” says Dr. Cunningham. That gives the daytime admitting physicians enough time to finish admissions and round on their established patients, avoiding spillover for the night shift.

At Taylor Hospital, the hospitalist program hasn’t yet decided to add a third hospitalist during the day. But Dr. Josue says that the group has moved to stagger daytime schedules to help out.

“Instead of having two doctors come in at 7 in the morning, we have one doctor work 8 a.m. to 8 p.m.,” Dr. Josue says. “We also have a physician extender working 8 a.m. to 8 p.m. to overlap with the nocturnist’s schedule.” And starting in October, Dr. Josue began auditing the number of observation patients and rapid response calls that both day- and night-time physicians have to deal with to try to get a better handle on figures relating to volume.

That will help him decide, he adds, whether or not a third hospitalist needs to be hired during the day. If and when that third doctor comes on board, Dr. Josue notes, he’d want that physician to provide even more evening overlap, working perhaps 9 a.m. to 9 p.m.

Solutions at night
While these approaches should help lighten the nighttime load, most nocturnists have their own wish list of resources to make them more productive.

In Rhode Island, Dr. Tomlinson notes that orthopedic patients take up a lot of his time and energy.
“I think orthopedics needs to contribute,” he points out. “They need to either hire their own hospitalist or somehow share with us so we end up increasing manpower to help meet that need.”

In Arizona, Dr. Hoertz says she’d love an in-house intensivist during the night to help with the ICU load. Right now, she points out, an intensivist remains on call “but she is the one who handles all the questions from the ICU nurses. And in Georgia, Dr. Cunningham would appreciate it if her hospital kept some version of the daytime PICC team in-house at night as well. That would alleviate the need for her to do too many time-consuming procedures.

“We can put a line in when we need to,” Dr. Cunningham says. “But that basically means losing time to see other patients and admissions.” She now routinely asks ED personnel to put in lines while patients are still in the ED before they even reach the floor. She also doesn’t hesitate to call on surgeons and anesthesiologists for help with procedures when she’s swamped.

In Seattle, however, Dr. Sachdeva is able to access the only night-time resource he thinks is appropriate: a backup hospitalist, one who is already awake and working. Swedish now has four nocturnists working on any given night covering four campuses, but the nocturnist who covers one of the system’s community hospitals has the lightest load, Dr. Sachdeva explains. That hospitalist often spends the evening at Swedish’s main campus helping a swing-shift physician and the scheduled nocturnist, at least during the evening.

“It’s so very important to have that back-up system in place, a valve that you can let steam out of if things implode,” says Dr. Sachdeva. “You need to be able to call a physician in and not feel guilty about it, and that’s a huge patient safety and quality issue.” Having that evening back-up, he adds, makes the difference “between having an unbearable shift and feeling nervous about missing things and having a busy but satisfying shift.”

That’s also the only way, he adds, his program has been able to handle what he calls “the bottleneck”: going from eight daytime physicians down to one at night, while covering the same number of patients.

Opting for another nocturnist
Dr. Sachdeva considers himself fortunate to have hospitalist back-up, at least during the evening. But other hospitalist groups are realizing that night-time volumes have reached such a dangerous level that they need more than back-up. Instead, they need to schedule a second full-time night-shift position.

That’s the situation for John Muir Medical Group, a primary care group whose 40 hospitalists staff programs in two Bay Area hospitals. To handle the growing number of admissions and transfers over the past several years, the hospitalists have experimented with different iterations of a swing shift to help out the nocturnist, explains Niki Jones, DO, the associate director of the John Muir hospitalist program at the Walnut Creek campus.

“The swing shift evolved from 2 p.m. to 10 p.m., then 3 to 11, then 4 to midnight,” Dr. Jones says. “Then we decided that day rounders had to stay later to clean out the ER, so we made the swing shift 6 p.m. to midnight.”

The group also briefly piloted having a hospitalist embedded in the ED from 4 p.m. to 2 a.m. to handle admissions. But the hospitalists realized, Dr. Jones explains, that on top of it being “totally crazy in the ER” many nights, the nocturnist was also cross covering as many as 100 patients at the Walnut Creek campus.

“We piloted changes in workflow, and we realized that we need two night docs,” Dr. Jones says. “The volume of work is just too much, and the cross coverage isn’t safe for one person to handle.”
This summer, the hospitalist group got a commitment from the hospital system to hire an additional nocturnist at each of the two campuses from 6 p.m.-6 a.m. (the other nocturnist works 7 p.m.-7 a.m.), as well as an additional daytime rounder at each hospital.

According to Dr. Jones, the group hopes the two new nocturnists will be hired and working by Jan. 1. In the meantime, she notes, as of Nov. 1, the group has mandated extending the swing shift from 6 p.m.-midnight to 6 p.m.-2 a.m.

And until Jan. 1, when that swing shift will become a permanent second night shift, “people who want to change their assigned swing to a 6 p.m.-6 a.m. night shift,” says Dr. Jones, “are welcome to do so.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Midlevels at night: big help, or more work?

AMONG THE ARRAY OF SOLUTIONS being discussed to restore some sanity to night-time volumes, hiring midlevels often tops the list. But talk to nocturnists, and you’ll hear a different story.

“A lot of people like to think that midlevels help,” says Jalila Cunningham, MD, a nocturnist at Hamilton Medical Center in Dalton, Ga. “But a lot of the people who feel like that aren’t physicians.”

Having a midlevel on board at night might allow her to offload an occasional “easy” patient, one with a UTI, for instance, and some chart review. But “in terms of patient care, it really doesn’t change anything,” Dr. Cunningham explains. “It doesn’t change the amount of time you spend evaluating things, making decisions and talking to patients.”

That was the experience at Taylor Hospital in Ridley Park, Pa. “The initial idea was to use an extender to help the nocturnist, so we scheduled a midlevel from2p.m.to10p.m.,”says program director Stanley Josue, MD. “But instead of helping the nocturnist, it created more work.”
The solution was to instead bring the midlevel in during the day to work 8 a.m.-8 p.m. That helped avoid spillover for the nocturnist coming on at 7 p.m. “and allowed for more hospitalists on-site to supervise the extender.

Part of the problem with assigning midlevels is that patient acuity at night is so high, says Sandeep Sachdeva, MD, who’s now in his third year as a nocturnist at Seattle’s Swedish Medical Center. Another issue is that ancillary resources are pared back throughout the hospital at night, making supervision more onerous.

In fact, Dr. Sachdeva points out, not only do nocturnists not want to hire midlevels, but the specialists who rely so heavily at night on internal medicine nocturnists are now reluctant to hire their own specialty-specific extenders.

On-call cardiologists, for instance, have figured out that they would still be directly responsible for any work done by a midlevel at night on his or her service.

“Instead of hiring midlevels, specialists feel more confident in having a fully-licensed physician who can do their work up to a certain level,” says Dr. Sachdeva. “I also think that physicians have a better recognition of when to call in the specialist, and when not to call.”

How many pages need personal attention?

In an unpublished study that tracked nocturnist volumes at two hospitals within Seattle’s Swedish health care system for two weeks in 2010, nocturnist Sandeep Sachdeva, MD, and his research colleagues racked up an astonishing array of statistics. The study found that in addition to admitting almost 300 patients over the course of those two weeks, two nocturnists entered nearly 15,000 electronic orders and fielded 1,542 pages from nurses. That averaged out to more than 50 pages per doctor per night.

But the study also found, Dr. Sachdeva explains, that nocturnists had to respond in person to only 15% of those pages. In an effort to figure out how to help nocturnists handle escalating patient volumes, Dr. Sachdeva says those data bode well for an e-nocturnist model or at least e-nocturnist back-up.

“For the 85% of pages that can be handled by a provider without physically checking on a patient, that provider could be off-site “as long as there was someone on-site to check as needed,” he points out. He has made an internal presentation to physician leaders at Swedish Medical Center based on a care innovation described in an October 2008 Journal of General Internal Medicine article from Toronto researchers.

That initiative, which relied upon an electronic medical record (which Swedish has), shunted non-urgent pages from nurses to a Web-based slate. Urgent pages that might need personal attention were still sent to a physician through a pager.

For nocturnists, such a system would mean that an off-site provider could fill the seemingly endless requests at night from nurses for heartburn medications. “I would not be distracted,” Dr. Sachdeva says. “When I’m talking to a patient or family member, I wouldn’t have to stop five times in 10 minutes to look at non-urgent pages.”