No Easy Task

The Hospitalist. 2011 August;2011(08):

August 2, 2011 | The Hospitalist

Holland Hospital, a 213-bed facility, provides around-the-clock hospitalist coverage in its eight-bed ICU, according to VanDort. That change was precipitated by the nursing staff’s decision to pursue Magnet Status, which was awarded in 2007 by the American Nurses Credentialing Center (ANCC). For inpatient coverage, the hospital-owned HM group Lakeshore Health Partners, headed by Bart D. Sak, MD, MA, FHM, maintains six FTE hospitalists on a rotating block schedule. Each night, one physician works from 4 p.m. until midnight, overlapping with a nonphysician provider (NPP), a member of the hospitalist group, who works a 7 p.m. to 7 a.m. shift.

"We have two providers in-house when admissions from the ED are heating up, and then we have an NPP in-house to cover the one to three additional admissions that may come in after midnight and to field floor calls," Dr. Sak says.

The physician who worked until midnight is on call for backup support and might come back to the hospital if things get too intense in the pre-dawn hours. "This arrangement works quite well for a program of our size," Dr. Sak says. "It takes a team-oriented approach and experienced NPPs who can work independently."

The Holland approach simply wouldn’t work at Kaiser Permanente’s East Bay site in Oakland, Calif., where Tom Baudendistel, MD, FACP, is part of a 50-member hospitalist group and director of the internal-medicine residency program. "Between codes, cross-cover, ICU, and floor admissions, there is simply too much acuity and volume," he says.

Shifting from Nights to Days—and Back to Nights?

Are you a night owl or an early bird? Some people just naturally do better working at night. And some, says Dr. Humphrey, "avoid the night shifts like the plague."

According to Christopher P. Landrigan, MD, SFHM, MPH, associate professor of medicine and pediatrics at Harvard Medical School, and director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital in Boston, it’s possible to minimize many of the adverse effects of night shifts through scheduling practices and proper sleep hygiene.

One major challenge comes from shifting back and forth between nights and days. It’s hard to keep to a graveyard schedule (staying up at night and sleeping in the daytime) when you have days off. And, no matter how organized the scheduling for your HM group is, chances are there will be times when you have to pitch in and work some night shifts.

Before working a 7 p.m. to 7 a.m. shift, especially the first night in a string of consecutive nights, it is helpful if you can sleep for an hour and a half to two hours in the afternoon preceding your shift. "Even a 20-minute nap will provide some benefit and blunt the deterioration of performance that everybody experiences in the middle of the night," Dr. Landrigan says. -GH

The peak hours for East Bay admissions are mid-afternoon to midnight. Two overnight hospitalist shifts (one from 8 a.m. to 8 p.m., another from 7 a.m. to 7 p.m.) are supplemented with two swing shifts (one from 2 to 10 p.m., another from 4 p.m. to midnight). Four full-time nocturnists cover 10 of the 14 overnight shifts per week, which allows for vacation and some protected administrative time. The balance of the overnight shifts are covered by the rest of the hospitalist group, which has 50 members.

The contracted nocturnists are incentivized with additional compensation at the end of the year, when the chief of hospitalists allocates bonuses. They also work fewer shifts a month than the other members of the group. "One thing our group agrees on is that the night docs should get a little more," Dr. Baudendistel says. "It’s a very fair tradeoff for everyone."