More hospitals are hiring experienced "nocturnalists" to improve patient safety and prevent calls to tired on-call physicians, Liz Kowalczyk writes for the Boston Globe.
Traditionally, residents and nurses manage patients overnight while more experienced physicians remain on-call from home. If the night staff need guidance, attending physicians—who had already worked a full day's shift—are called at home.
"It always feels wrong when a nurse calls me at 2 a.m. and I want to be asleep and we need to talk about this patient," said John Nelson, a physician at Overlake Medical Center and co-founder of the Society of Hospital Medicine. "It makes sense to have somebody in the building."
Enter the "nocturnalists." They're experienced physicians, able to counsel residents about patient care. And they work only at night, taking the responsibility away from tired on-call physicians.
"There is a simplicity and clarity," said Sarah Henry, chief nocturnalist at Boston Children's Hospital. Night shifts are more casual, she added, without the worries of workplace politics or administrative meetings that can dominate the day.
The field is growing: In 2012, 55 percent of adult hospitalist groups maintained a physician in the hospital for the night shift. By 2014, that number had jumped to 81 percent.
Benefits of nocturnalists
Under the traditional arrangement, residents may be forced to perform procedures during the night shift that they don't feel ready for, or to make the tricky decision to contact the on-call physician. Nocturnalists can take those tough calls out of residents' hands. They also can ease ED congestion, as nocturnalists can admit patients at all hours.
Still, residents do see some benefits from the demands imposed by overnight shifts. The night shift "is a nice environment for trainees to practice with a little bit of autonomy and make decisions," said Elyse Portillo, a third-year resident at Boston Medical Center and Boston Children's.
But Portillo added that she's been grateful to have a nocturnalist on hand for trickier, complicated procedures.
Henry, the Boston Children's nocturnalist, said, "When you have a big complicated issue, it's better to have someone who can navigate it and think about whether there is a better option." At Children's, attending physicians typically work overnight in the ICU and ED, but the hospital still has doctors on-call for its oncology and pulmonology services.
Ebrahim Barkoudah, medical director of Brigham and Women's Hospital's nocturnist service, said he does not know of research that compares the safety of having attending physicians in the hospital overnight versus on-call.
Vincent Chiang, who leads the hospitalist program at Children's, said that for many hospitals "the issue is cost," adding, "Physicians are more expensive than trainees. And you need higher incentives to get people to sign up" for night shifts (Kowalczyk, Boston Globe, 7/4).
Hospitalist program improvement toolkit
In most hospitals, hospitalists--like nocturnalists--care for over 50 percent of patients and are an inflection point for many of the metrics used in pay-for-performance programs. A high-performing hospitalist program is a key strategic asset, yet few hospital leaders feel they have fully leveraged their hospitalist program to advance outcomes.
With the right support and expectations, hospitalists can have a profound impact on quality and culture across the organization. However, there are many barriers hospitalist programs must overcome to optimize performance.
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