No Easy Task

The Hospitalist. 2011 August;2011(08):

August 2, 2011 | The Hospitalist

But here’s the problem with studies such as this, says Dr. Cram: "Patients admitted on evenings and weekends are not the same as those admitted 9 to 5 on weekdays."

During weekdays, admissions combine patients with emergent issues and those scheduled for elective procedures. On weekends, "you get only emergencies—you don’t have low-risk patients," he points out. "So, even with optimal 24/7 staffing, you would still expect those patients coming in at night, and on holidays, to have worse outcomes because they are coming in with more acute problems. It remains an open question whether 24/7 staffing will improve off-hours outcomes." More research, Dr. Cram adds, is needed to establish whether full in-house staffing is the best solution.

Dr. Epstein has compared on-call versus in-house night staffing. In a 2007 study, he found no difference when using indicators such as length of stay, readmission rates, and patient satisfaction.⁴ However, he noticed positives from in-house coverage. "Although there are no data supporting the value of hospitalists on these parameters, having a nocturnist in-house increases nursing satisfaction, because they are responsive to pages when there is a question about a patient," he says. "It’s also a service to hospital medical staff, because they can handle rapid responses and codes."

There is some evidence that working nights can be deleterious to physicians’ and nurses’ health. One study found that interns were more likely to be involved in collisions after leaving extended night shifts; another found an increased risk of needle-stick injury at the end of a long night shift; and data from the long-running Nurses’ Health Study indicate that long-term night work can result in increased risk of colorectal and breast cancers.^5,6,7,8 The increased risks of cancer could be related to lack of exposure to light at night and the body’s decreased production of melatonin, although this remains a topic of ongoing research.

Nocturnists Are Key to a 24/7 Hospitalist Presence

Unless your hospital is admitting eight to 10 patients per night, a nocturnist program is not financially justifiable and is an added expense, Dr. Epstein says. However, nocturnists provide valuable backup for ED physicians and nursing staff, and for those reasons alone might justify the added expense. Having contracted nocturnists also can function as retention tool for hiring and keeping daytime hospitalists.

Dedicated nocturnists are hard to find: Just 6% of hospitalists self-identified as nocturnists in SHM’s 2007-2008 compensation and productivity survey. Programs can incentivize other staff hospitalists with additional pay for working nights or defining full-time status as fewer shifts per month.

"There is a niche group of people who really enjoy nights," Dr. Humphrey says. The hours might fit physicians’ diurnal rhythms or allow them to structure their private lifestyles to allow more daytime activities.

At St. Rita’s Medical Center in Lima, Ohio, where Dr. Humphrey is chief clinical officer of emergency and ambulatory services, one of their "powerhouse nocturnists" is an energetic internist who prefers to work alone. But, Dr. Humphrey advises, "you’ve got to be cautious about references when hiring nocturnists. It is important to make sure nights have not been selected for the wrong reasons. In 20 years of hospital-based practice and physician management, I have seen my share of failures. In these cases, there often is an issue with competence, accountability, or some behavioral or personality issues that preclude the [provider] of being successful during the day."—GH

"No Easy Answers"

VanDort, the nursing director, is "passionate" about having 24/7 coverage and reports that her nursing staff is happy with the hybrid model currently used at Holland Hospital. "I do envision a day when we’ll have physicians here around the clock," she says. "Patients are sick during the middle of the night, so you can’t staff your system one way during the daytime hours and your nighttime differently. It’s not fair to those patients."