Starting on Night-Float Intern Year

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Found out my very first block is night-float.

(1) Since every intern will also be new to sign-outs, what are the most important pieces of information I should request about every patient?

(2) Also, do night-float interns run codes or is there usually a supervising resident that comes too (this is a large university center)?

Thank you for the advice.

Originally Posted by BucketMan

Found out my very first block is night-float.

(1) Since every intern will also be new to sign-outs, what are the most important pieces of information I should request about every patient?

(2) Also, do night-float interns run codes or is there usually a supervising resident that comes too (this is a large university center)?

Thank you for the advice.

Don't the new work hour rules require that Interns always have direct supervision? I'm pretty sure you should have a senior resident on night float with you.

Originally Posted by Perrotfish

Don't the new work hour rules require that Interns always have direct supervision? I'm pretty sure you should have a senior resident on night float with you.

Lame, so I have to wait until PGY2 for the training wheels to come off?

Originally Posted by BucketMan

Lame, so I have to wait until PGY2 for the training wheels to come off?

We have very different confidence levels.

Originally Posted by BucketMan

Lame, so I have to wait until PGY2 for the training wheels to come off?

After about one week in, when you realize how totally clueless you are about the actual practice of medicine, you tune will change dramatically.

Originally Posted by BucketMan

Found out my very first block is night-float.

(1) Since every intern will also be new to sign-outs, what are the most important pieces of information I should request about every patient?

(2) Also, do night-float interns run codes or is there usually a supervising resident that comes too (this is a large university center)?

Thank you for the advice.

I'm still hoping someone will answer the first question.

Originally Posted by koennen

After about one week in, when you realize how totally clueless you are about the actual practice of medicine, you tune will change dramatically.

Don't you just pan-CT, start on beta blocker/ ACEI, stress test, and d/c to PT?

Originally Posted by Elixir86

I'm still hoping someone will answer the first question.

me too

really the most important things for signout are

Code status
Room number
medical record number /name

signout in order of importance:
Code Status
Allergies
Changes over the last 24 hours (i.e. increasing pain, SoB, not responding to Lasix).
Things that need to be ACTIVELY follow up on overnight.
Everything else is pretty much TMI.

Originally Posted by BucketMan

Found out my very first block is night-float.

(1) Since every intern will also be new to sign-outs, what are the most important pieces of information I should request about every patient?

(2) Also, do night-float interns run codes or is there usually a supervising resident that comes too (this is a large university center)?

Thank you for the advice.

I wonder, do patients experience worse outcomes in July when residents turnover?

Originally Posted by RestoreSight

I wonder, do patients experience worse outcomes in July when residents turnover?

yep

http://www.ama-assn.org/amednews/201...1/prse0715.htm
http://www.springerlink.com/content/n502614282p9266t/

Originally Posted by BucketMan

yep

http://www.ama-assn.org/amednews/201...1/prse0715.htm
http://www.springerlink.com/content/n502614282p9266t/

Amazing. Reminds me of a story I heard on M&M (probably fairly common). 85 y/o guy p/w fever, productive cough. poor resident on nightfloat pancultures him, but forgets to check his orders for broad spectrum abx were actually performed for presumed pneumonia/sepsis after getting slammed with admissions at 2 am. The guy dies that night. It must be awful to have something like that hang over you, even if its not "technically" your fault.

S: Sick or not sick
I: Identify - name, diagnosis, code status
G: general (BRIEF) hospital course
N: new (relevant) events of the day
O: Overall health/clinical condition
U: Upcoming possibilities/changes WITH rationale
T: Tasks to complete
?: Questions


I started as a night float and LOVED it. It's a great time to just be a doctor and not worry about the BS discharge stuff. Remember, as the night float you are covering many lists with many patients you don't know very well. You should NOT have to think too much into things unless something unexpected happens. ALWAYS demand code status and identification. When sign-ed out a task, always know exactly why you're doing it. Always make sure you have parameters if you are checking up a lab. E.x. if you get signed out to check a midnight I's and O's, what is their goal? What do you do if you are not within goal? If they want someone to be net neg 1L, and the patient isn't, you shouldn't have to be rummaging through past medication orders to figure out what would be a good dose.

They should have a list of contingencies. Common problems that may occur: known sundowning, anxious patients, patients who malinger, pt's who will complain about pain etc. What should follow is what you should do about it. e.x. sundowning and combative --> 1mg IV haldol. This list does not and should not be talked about everytime on signout but instead acts as a quick reference for you as a night float should something come up.

If a contingency would become an emergency then it should be mentioned at signout. E.x. I had a patient who would go into VT spontaneously. Contingency plan = EKG, bolus lido 100mg, start gtt at 1mg/hr, stat page EP, consider CXR and troponins if indicated.

My hospital's signout system also lets us include a list of meds and most recent labs which is SUPER helpful because then I wouldn't have to log into the computer and wait for it to load before loading the website/program to look that stuff up.

You as the intern should NOT be running codes.

Originally Posted by SuperHiro

S: Sick or not sick
I: Identify - name, diagnosis, code status
G: general (BRIEF) hospital course
N: new (relevant) events of the day
O: Overall health/clinical condition
U: Upcoming possibilities/changes WITH rationale
T: Tasks to complete
?: Questions


I started as a night float and LOVED it. It's a great time to just be a doctor and not worry about the BS discharge stuff. Remember, as the night float you are covering many lists with many patients you don't know very well. You should NOT have to think too much into things unless something unexpected happens. ALWAYS demand code status and identification. When sign-ed out a task, always know exactly why you're doing it. Always make sure you have parameters if you are checking up a lab. E.x. if you get signed out to check a midnight I's and O's, what is their goal? What do you do if you are not within goal? If they want someone to be net neg 1L, and the patient isn't, you shouldn't have to be rummaging through past medication orders to figure out what would be a good dose.

They should have a list of contingencies. Common problems that may occur: known sundowning, anxious patients, patients who malinger, pt's who will complain about pain etc. What should follow is what you should do about it. e.x. sundowning and combative --> 1mg IV haldol. This list does not and should not be talked about everytime on signout but instead acts as a quick reference for you as a night float should something come up.

If a contingency would become an emergency then it should be mentioned at signout. E.x. I had a patient who would go into VT spontaneously. Contingency plan = EKG, bolus lido 100mg, start gtt at 1mg/hr, stat page EP, consider CXR and troponins if indicated.

My hospital's signout system also lets us include a list of meds and most recent labs which is SUPER helpful because then I wouldn't have to log into the computer and wait for it to load before loading the website/program to look that stuff up.

You as the intern should NOT be running codes.

That's a nice acronym! We use a similar one.

I like to know any issues that are likely overnight - pain, who is likely to crash and why, labs/tests due and why, code status. Mostly all the stuff you mentioned.

Also keep in mind, night float is not the time to start new medications unless you really have to. I would prescribe as a one time dosage if I really needed to give them something. Your job is to maintain patients for the day team to handle. Good luck I got my start in night float.

Thanks for the tips! Really appreciate it.

Sign outs tend to get long and full of non-essential stuff. I usually keep my sign outs to:
1. Why is the patient here? (chief complaint and eventual diagnosis)
2. How is that condition doing? (eg., volume status now if CHF exacerbation, sats / RR / O2 requirement if pneumonia, last chest pain episode if CP r/o, etc.)
3. (If presenting condition is completely resolved) - what's keeping him here then?
4. Anything to check on?
5. Has the previous floats been called before?
6. If patient is really sick or has 100 comorbids, I ask more about code status - ie., if they have talked to the family about code status and what the situation is (eg. full code no matter what vs. full code for now but 'thinking about it' and leaning towards changing but not yet, no escalation, etc.)

Code status, room number, MRN should be on the patient sheet. Other stuff like comorbids, etc. should be on the daily note if you get called on someone. It takes awhile to get good at sign outs. More information doesn't always mean a better one as you'll tend to forget a lot of it if it's too long.

Also, if anyone signs out an H/H or CBC, always make sure they have a consent for transfusion. ALWAYS. Don't accept, "oh, we don't anticipate he'll need one". Because if they don't anticipate it, why check an H/H in the first place.

Originally Posted by flipmd

Also, if anyone signs out an H/H or CBC, always make sure they have a consent for transfusion. ALWAYS. Don't accept, "oh, we don't anticipate he'll need one". Because if they don't anticipate it, why check an H/H in the first place.

Good tip -- any more subtle tips like this?

Generally I always want to know what baseline neuro deficits exist (if any) for a patient with head trauma or stroke so I can identify changes that may require intervention. Also important if one of the night float tasks is something like, "if the abdominal exam worsens, call surgery"... important to know what the baseline abdominal exam is. Common sense stuff.

I echo the above regarding parameters for transfusion, goal BPs or HR, net negative fluid (or minimal urine outputs). And I would set an alarm or something on my phone to remind me to check up on something, especially if it was later in the night... if it gets busy at night it's easy to forget.

A consent takes <5 minutes. Honestly, no intern in July is going to be able to anticipate every little thing before sign out. That takes time. Just the basics first.

Originally Posted by TheLesPaul

Good tip -- any more subtle tips like this?

There are a million things like this you only learn with time--did you do the MRI consent and questionairre for an overnight MRI, did you remember to order the BHCG before that procedure tomorrow.

Originally Posted by sprinkibrio

A consent takes <5 minutes. Honestly, no intern in July is going to be able to anticipate every little thing before sign out. That takes time. Just the basics first.

Not in a VA.

Name, hospital #, Room #

Allergies, Code status

Brief one-liner (should be similar to what you're writing at the beginning of your A/P on your note)

Remember that a lot of fevers overnight will get tylenol and low BPs will get fluids so anything that would preclude that like CHF or CKD, you can actually make a template for this to check yes or no or if patient should be cultured if spikes.

IV access needed, GCS if altered or if disoriented (dementia, DTs, etc) how oriented, and neuro deficits that would make a nurse think the patient was having a stroke

I put stuff to do at the bottom for each patient, including any specific if -> thens that have been issues before especially if they are unusual or mimic emergencies (chest pain that resolves with antacids etc)

Seriously make a template and just print it and you can save yourself 15 or more mins if you have a busy and sick service

Oh and give signout how you would like to get signout, if you're asking someone to check a patient's HGB because they may/may not be bleeding you should consent them because yes at the VA it takes about 15 mins once you find a computer..take it there...log in... load windows......open cprs......open the consent thing.....give you schpiel....teach the patient how to use the signature pad.....click through 7 screens etc
if you're getting consent over the phone it's worse because you have to do a 3 way call with a witness. Don't be a douche to your coworkers.