Published in the August 2013 issue of Today’s Hospitalist
WHEN HE JOINED Brandywine Hospital in Coatesville, Pa., a year ago as hospitalist director, Edward Ma, MD, faced some tough staffing and recruiting dilemmas.
Those problems were compounded by the fact that the hospitalists in the group had to spend one out of every three shifts covering nights “a huge dissatisfier, particularly when doctors in neighboring programs worked many fewer nights or none at all.
Dr. Ma knew he could try to hire nocturnists. But compensation for nocturnists in his region can run 50% higher than median hospitalist income.
He could eliminate 24/7 staffing and switch to pager call, but that was not really viable at his facility. He could use a small pool of moonlighters “but finding committed moonlighters could be as tough as finding full-time
Or he could make night coverage more sustainable by letting hospitalists spend at least part of the night shift sleeping on the job. After several months of deliberations, that was the solution put into place six months ago. Now, all routine admissions after midnight are deferred to the morning team, while the physician working the night shift goes to bed in the call room.
It’s not, Dr. Ma admits, an earth-shattering idea; many groups, after all, take pager call from home and routinely give orders to ED nurses for patients admitted in the evening.
But the concept flies in the face of what’s considered normal in hospital medicine when doctors are physically inhouse. However, “given the realities of the hospitalist shortage,” Dr. Ma says, “we have to be more creative in providing quality care without burning out our most valuable resource, which is physicians.”
How it works
Common sense played a big part in devising the new coverage strategy, Dr. Ma says, with hospitalists no longer processing admissions after midnight.
“I chose midnight mainly because I wanted our group to maximize billing, but also because it seemed like a reasonable cut off,” says Dr. Ma. “We have very few admissions coming in after midnight, and most nights we have none.”
For most night admissions, the hospitalists are notified before midnight. “By being proactive and doing a little reconnaissance in the ED, we can tackle nearly all late-night admissions,” he says. That way, the nighttime hospitalist preempts any 3 a.m. phone call on a patient who has been in the ED since 8 p.m.
After midnight, the hospitalist admits routine, non-ICU admissions via phone. “We keep the orders simple for the ED nurses,” Dr. Ma explains. “It may be only three lines such as, ‘bed status, IV fluids and pain meds.’ ” Orders for additional tests and antibiotics or diet instructions are left for the morning hospitalist coming on at 7 a.m., as is medication reconciliation.
“The ED doc makes sure patients receive their evening meds,” says Dr. Ma, “and the morning hospitalist takes care of the rest.”
Making the case
When he pulls the night shift, Dr. Ma is usually in bed by 1 a.m. and will sleep until 8 a.m., even though his shift ends at 7 a.m. If he is up at night with an ICU admission or calls from floor nurses, he may sleep in later.
“Before turning in, I leave a written signout for the morning doc,” he notes. “Then I check in with him or her before I leave in the morning.” As for unseen night admissions, “there’s always enough information in our EMR for the morning doc to figure out what is going on.”
According to Dr. Ma, ED nurses balked initially at taking verbal orders from hospitalists who were inhouse. While Dr. Ma pointed out that this was what they were already doing for other admitting physicians, “my main pitch was that this would allow us to retain our good docs and recruit more.”
While the new coverage strategy has attracted more candidates, Dr. Ma points to the program’s acceptance among existing staff.
“Doctors who didn’t like doing nights before,” he says, “are excited to work this shift, because they can function the next day and take care of personal things at home.” Patients likewise seem to appreciate not having to give their history again at 3 a.m. when they just want to sleep.
Better continuity, fewer handoffs
The new system offers additional upsides. To maximize continuity, for instance, the night hospitalist sometimes also works the next day shift. Doctors may wake up at 9 a.m. and start rounding on patients, including those they admitted the previous evening. Another hospitalist with a nurse practitioner begins at 7 a.m. to handle admissions that came in after midnight.
That arrangement benefits those patients, Dr. Ma notes. Under the old system, the night doctor would have completed a 3 a.m. admission and handed that patient off to the daytime hospitalist, who sometimes may not have seen that patient until the next afternoon.
“The new system,” he says, “has overall reduced the number of handoffs.”
The potential downside of test delays hasn’t materialized, Dr. Ma adds. Instead, the doctor at 7 a.m. orders tests immediately, which wouldn’t have been processed before then if ordered a few hours earlier anyway.
And because “night” doctors also work days, they are fully part of the team. That eliminates the problems nocturnists have of not feeling like they’re an integral part of the hospital or practice.
The plan’s success hinges on being able to trust the ED physicians, Dr. Ma points out.
“If I don’t lay eyes on the patient and I can’t 100% rely on the ER physician, I can’t use this system,” he says. He worked with the ED from the beginning to standardize diagnostic protocols. “We want to make sure we’re not missing some serious conditions like aortic dissection when they tell me it’s a simple chest pain admission, or a pulmonary embolism when they tell me it’s a pneumonia.”
Perception is another potential challenge; it can look bad for doctors to be sleeping, especially when nurses aren’t. “They feel care is being compromised if the doctor is sleeping,” he says, but that’s not true. While Dr. Ma has only anecdotal evidence so far, he says seeing a patient at 7 a.m. vs. 3 a.m. has had no impact on patient outcomes or length of stay.
As for patient throughput, the ED loves the new system because patients can be moved to floor beds more quickly instead of waiting for a hospitalist to complete an admission in the ED. “Patients usually don’t need to be seen in the ED,” Dr. Ma says, noting that as many as 80% of their patients are first seen by the hospitalists on the floor anyway.
“We don’t have enough hospitalists to go around,” he says. “This is an attempt to fix this mess with nighttime coverage.” He is convinced that the system not only ensures the highest quality of care but arguably improves care. And “it certainly improves the quality of life for physicians
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.