Night Float???

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Omiganlode

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Can someone please explain how night float works? What are the benefits in applying to a program that has night float in place, etc...:confused:
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Omiganlode said:
Can someone please explain how night float works? What are the benefits in applying to a program that has night float in place, etc...:confused:
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Think of it like shift work. Those not on night float work only regular "daylight" hours, maybe with some form of "call" to around 8pm every few days. The nightfloat resident (or team) comes in some time around 6pm, and generally leaves around 6am. The person on nightfloat may keep this up for 1-4 weeks at a time (I thusfar have not heard of anyone doing consecutive months of nightfloat), with the requisite days off. The advantages that this has over a traditional call system include the fact that the daytime residents do not have to work overnight, thus avoiding the 24+ hour work days, and there is some continuity, as the same person/team cares for the patients every night (so you know how Mrs Smith behaves when the sun goes down, and what works for her). However, it can really suck to be the nightfloat person, as your clock just doesn't quite get used to the time inversion, and the inevitable flip back to daylight hours at the end (not nearly as bad as what the EM guys do, but still not pleasant).
 
Omiganlode said:
Can someone please explain how night float works? What are the benefits in applying to a program that has night float in place, etc...:confused:
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There are two possible systems for overnight coverage, the call system, where residents from the day stay on overnight a couple of times a week, or night float, where a different group of residents is on during the day and on the night. Basically when you are on night float, you work from the evening to the morning six days a week for up to a month. You often don't get access to a call room because it is presumed you are sleeping in the daytime, like a vampire. Your job is to finish up the stuff that didn't get done during the day, make sure everyone slated for morning procedures is NPO or gets their bowel prep etc, and generally just try to keep everyone alive and in more or less the same condition as they were handed off to you. Many patients decide to crash or code late at night, so it can be very busy, but since things only happen on an emergent basis overnight, there's a lot of routine phone calls you don't have to deal with in the wee hours.
 
Law2Doc said:
There are two possible systems for overnight coverage, the call system, where residents from the day stay on overnight a couple of times a week, or night float, where a different group of residents is on during the day and on the night. Basically when you are on night float, you work from the evening to the morning six days a week for up to a month. You often don't get access to a call room because it is presumed you are sleeping in the daytime, like a vampire. Your job is to finish up the stuff that didn't get done during the day, make sure everyone slated for morning procedures is NPO or gets their bowel prep etc, and generally just try to keep everyone alive and in more or less the same condition as they were handed off to you. Many patients decide to crash or code late at night, so it can be very busy, but since things only happen on an emergent basis overnight, there's a lot of routine phone calls you don't have to deal with in the wee hours.
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Thanks, you explained that very well... One more question, how often do you have to do this night float month???
 
Omiganlode said:
Thanks, you explained that very well... One more question, how often do you have to do this night float month???
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Varies by program and by residency size. I've seen anywhere from 4-12 weeks over the course of a year. There's probably even more of this now that interns can only stay in the hospital 16 hours in a row ( as compared to those of us who did 30 hour call shifts).
 
My program had us do 2 consecutive months of night float during certain years of our training. Now, with the additional intern restrictions, the night float time yearly has gone up to 3-4 months total for mid-level residents---but unless you schedule the rotations back to back (someone always does this thinking it will be better to get it done in a row), it is only 6-8 weeks at a time. All our rotations were 6-8 weeks in length, which is where that timeframe comes from. Certain years of training do not have to do night float in our program.
 
It means that you'll be more rested and in a better mood when we call you from the ED with a new admit.

The medicine service just implemented NF system this year and I can tell a world of difference in those guys during my night shift. They are MUCH more rested and on their a-game. Most of them seem to love it.
 
Groove said:
The medicine service just implemented NF system this year and I can tell a world of difference in those guys during my night shift. They are MUCH more rested and on their a-game. Most of them seem to love it.
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I wouldn't say that I loved it. But I definitely hated it less than 30h call.
 
night float is the way to go, especially if trying to keep to the 80 hour rule. it reduces overnight calls to maybe at most once per week per team, at best once every 2 weeks per team. living a night shift is terrible, but i also feel that it's not as bad as having more frequent overnight calls.

if you're disciplined, you can sleep in the day, even on weekends, and at least be rested. you have more time to do your work since there are no conferences or rounds. but you don't get much teaching. and crosscover pages can be a pain. you won't be able to go out much or take care of family during those 2-4 weeks in a row. but on overnights, the mornings are rough, and the drive home is full of nodding off on the highway. luckily, i haven't hit anyone, but people have hit me. :mad: the other day i saw one guy driving down the expressway with a slice of pizza in one hand and a cell phone in the other. when you get home the rest of the day is usually taken up by sleep.
 
gutonc said:
I wouldn't say that I loved it. But I definitely hated it less than 30h call.
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I would take the opposite view, having done both systems. You don't have too many 30 hour shifts per week until you hit your duty hour caps so you often end up with more days off between weekend and post-call days. With night float you are working 6 nights a week, probably not sleeping as well during the day, not even allowed to sleep at night (night float often doesn't get access to a call room because they are presumed to only be awake those 12 hours/ day).and for the same reason the day team leaves you more work at night, knowing you are coming in fresh. So you are always tired. And you don't really get a weekend to catch up because you go home Saturday morning, try not to waste the whole day in bed, are screwed up in schedule and won't fall asleep Saturday night, and are back at work Sunday night. With traditional call you are only wiped a couple of days a week and more often have the weekends off to play with.

Personally I would be happier if they just upped the permitted hours to 40 and let people work two days a week and have the other couple of days off. But then again I've always been a "pull the bandaid off fast " kind of person.
 
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Law2Doc said:
I would take the opposite view, having done both systems. You don't have too many 30 hour shifts per week until you hit your duty hour caps so you often end up with more days off between weekend and post-call days. With night float you are working 6 nights a week, probably not sleeping as well during the day, not even allowed to sleep at night (night float often doesn't get access to a call room because they are presumed to only be awake those 12 hours/ day).and for the same reason the day team leaves you more work at night, knowing you are coming in fresh. So you are always tired. And you don't really get a weekend to catch up because you go home Saturday morning, try not to waste the whole day in bed, are screwed up in schedule and won't fall asleep Saturday night, and are back at work Sunday night. With traditional call you are only wiped a couple of days a week and more often have the weekends off to play with.

Personally I would be happier if they just upped the permitted hours to 40 and let people work two days a week and have the other couple of days off. But then again I've always been a "pull the bandaid off fast " kind of person.
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I thought most programs have night float residents work 5 nights, not 6. At least, that's what I've seen at the places where I've interviewed so far. 5 isn't nearly as bad, since you get essentially the entire weekend off.
 
I've seen it both ways - Saturday nights off only, as well as Friday/Saturday nights off.

6 days on, 1 day off still works for hours since 13 hours/day x 6 days/week = 78 hours/week.
 
Law2Doc said:
I would take the opposite view, having done both systems. You don't have too many 30 hour shifts per week until you hit your duty hour caps so you often end up with more days off between weekend and post-call days. With night float you are working 6 nights a week, probably not sleeping as well during the day, not even allowed to sleep at night (night float often doesn't get access to a call room because they are presumed to only be awake those 12 hours/ day).and for the same reason the day team leaves you more work at night, knowing you are coming in fresh. So you are always tired. And you don't really get a weekend to catch up because you go home Saturday morning, try not to waste the whole day in bed, are screwed up in schedule and won't fall asleep Saturday night, and are back at work Sunday night. With traditional call you are only wiped a couple of days a week and more often have the weekends off to play with.

Personally I would be happier if they just upped the permitted hours to 40 and let people work two days a week and have the other couple of days off. But then again I've always been a "pull the bandaid off fast " kind of person.
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Agree. All things being equal (that is, total hours worked per week), I would rather 'work hard, play hard' rather than spread the hurt. At our program though, I kinda envy the new interns - they have a month of night float and they work 16-18 days per month. Only downside is the non-night float interns on the ward services HAVE to wait till 6pm to sign out to the NF team. Sucks on those preadmit days you have 3 or 4 patients and are raring to go at 3pm.

Surprisingly, the new duty hours haven't affected the upper levels much at our place, aside from residents having to write a few notes to cover post-call interns in the MICU.
 
Groove said:
It means that you'll be more rested and in a better mood when we call you from the ED with a new admit.

The medicine service just implemented NF system this year and I can tell a world of difference in those guys during my night shift. They are MUCH more rested and on their a-game. Most of them seem to love it.
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Do we have to happy about it? We still get to be grumpy about the admits right? Because I didn't sign up for this happy admit nonsense! :mad:
 
gutonc said:
I wouldn't say that I loved it. But I definitely hated it less than 30h call.
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At my old shop we still had traditional call in the MICUs, but night flight for wards at the U and VA.

I think I would say I would prefer a month (or two) of nights to 8 or 9 or more months of overnight (24-30hr) call every few days.

I do think there is some utility in being around for at least 24 hours in very acutely illy patients when they roll in dead and you make them alive, but MOST medicine (can't speak for other services) admits can easily be done by people at night with hand offs in the morning without losing much, if any, educational value.

Besides, shift work is the future of medicine.
 
gutonc said:
I wouldn't say that I loved it. But I definitely hated it less than 30h call.
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Me too. Night float schedule can be disorienting and tough in terms of being on a different schedule than the rest of the world. But I don't think I was ever as miserable during all of medical school as I was on my IM rotation when we were taking 30 hour call. To be doing it as an intern could only be worse.
 
QofQuimica said:
Me too. Night float schedule can be disorienting and tough in terms of being on a different schedule than the rest of the world. But I don't think I was ever as miserable during all of medical school as I was on my IM rotation when we were taking 30 hour call. To be doing it as an intern could only be worse.
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It sucked pretty hard, that's true. I don't feel like I personally ever learned more by following people for 30h at a time than I would in two days of normal daily shifts. Besides, who's to say that the first 30h of an admission are going to be the most active. And you can't stay in the hospital forever...at some point you have to hand off.
 
gutonc said:
... And you can't stay in the hospital forever...at some point you have to hand off.
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I think the point isn't always so much that the first 30 hours is most critical, but that the stretch of continuity of care, knowing what was tried, knowing what happened, etc over a long stretch of an admission is what's the value of those mega shifts. Thus the point is really that longer shifts can cut the number of handoffs in half. And handoffs are where many of the systemic errors are thought to creep into the system. You may not "learn" more in a 30 hour shift, but you aren't going to reinvent the wheel in terms of treatment twice each day because you aren't sure from your handoff scribble and the unintelligible note in the chart what the prior guy already did, was thinking, etc. And there will be fewer people fresh on service who don't know the patients each day. The point is that too many cooks can spoil the stew, and that the patient is usually better served having fewer doctors overseeing their care each admission. you can't stay in the hospital forever, but you certainly can minimize (halve) the number of handoffs per week by combining two 15 hour shifts into one 30 hour shift.

But that's irrelevant now -- the maximum is now 16 hours for interns. As I said above, Some of us found night float, particularly the 6 night per week, more work and no call room variety, far far more draining than a couple of 30 hour shifts per week with more golden weekends each month. Yes you are miserable that day, but better to die all at once than little by little each day.
 
I've done more than my share of both systems. I vote for night float. Nobody really likes call, but I feel night float's the lesser evil.
My experience on night float was that, even though you spend more total hours in the hospital, you're never as exhausted when you're at the hospital as you are during the low-points of a 30 hour call. During night float, I never found myself desperately trying to catch a few minutes of sleep slumped over a desk. For that matter, back when I was a med student, I remember hearing about an intern who slept so soundly on call that people couldn't get her up to respond to codes...so, yeah, I think that fewer totally fatigued docs will be a good thing for patient care.
Just make sure you get some good shades for your bedroom so you can sleep during the day and it'll be okay.
 
peppy said:
I've done more than my share of both systems. I vote for night float. Nobody really likes call, but I feel night float's the lesser evil.
My experience on night float was that, even though you spend more total hours in the hospital, you're never as exhausted when you're at the hospital as you are during the low-points of a 30 hour call. During night float, I never found myself desperately trying to catch a few minutes of sleep slumped over a desk. For that matter, back when I was a med student, I remember hearing about an intern who slept so soundly on call that people couldn't get her up to respond to codes...so, yeah, I think that fewer totally fatigued docs will be a good thing for patient care.
Just make sure you get some good shades for your bedroom so you can sleep during the day and it'll be okay.
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Blackout shades ftw. :thumbup:

I also have one of those light boxes for when I get up and it's already dark. It may be totally placebo, but I feel like it helps.
 
jdh71 said:
Do we have to happy about it? We still get to be grumpy about the admits right? Because I didn't sign up for this happy admit nonsense! :mad:
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Yea..you're right. The happiness is just...disarming. I mean, it actually makes me feel uncomfortable. It's like arming up in plate mail and armored steed for a joust, only to be stood up and find a note left saying "gone to Starbuck's...don't have time...just leave a note about the admit and I'll grab it on my way back and take care of it..." robbing me of all the mental preparation. It's actually quite inconsiderate.

Second thought, I hate night float for you guys....

I mean... I've actually got a case manager's protocol book telling me what all meets 23h obs and full admission criteria for the hospital that I actually have been known to reference before calling for the "quasi-weak" admit, anticipating the "that doesn't meet obs/admission criteria". That crap takes several minutes for me to look up. Have you opened one of those and tried to stumble through those god awful mazes of algorithms? You guys on night float barely try to pull that one on me anymore. Quit robbing me of that! ;)
 
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Groove said:
I mean... I've actually got a case manager's protocol book telling me what all meets 23h obs and full admission criteria for the hospital that I actually have been known to reference before calling for the "quasi-weak" admit, anticipating the "that doesn't meet obs/admission criteria". That crap takes several minutes for me to look up. Have you opened one of those and tried to stumble through those god awful mazes of algorithms? You guys on night float barely try to pull that one on me anymore. Quit robbing me of that! ;)
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I still ask for it just to keep you all on your toes. I've got a roughly 5% hit rate on getting obvious obs cases actually kept in obs. The rest just get discharged from the floor in the morning as soon as the attending comes in to round.
 
I think the hand-off issue goes two ways. For the past 8 days or so, I've been caring for a pretty sick patient. I take care of her during the day, and the same night float guy has been taking care of her at night. There's pretty good continuity going on - I just update him on what we did during the day, and he tells me what he did at night. Not a lot of new people picking her up and trying to decipher the chart.

On the flip side, the vast majority of my rotations use call, and there are only 3-4 of us on a team at a time. If you admit someone on Tuesday afternoon while on call, care for them all night, see them again in the morning on rounds, come up with a plan and share it with the other person on your team (over the 4-5 hours of overlap in your shifts, rather than a 2 minute sign-out), and then you're back the next day, I don't see a lot of hand-offs there.

I'd rather be on call. Now that it's "only" 28 hours, the post-call day is pretty generous, IMO. Especially in the winter, when it's dark when you come in and dark when you leave, it's nice to be at home at 11am with the sun streaming through the windows.
 
Buzz Me said:
I've seen it both ways - Saturday nights off only, as well as Friday/Saturday nights off.

6 days on, 1 day off still works for hours since 13 hours/day x 6 days/week = 78 hours/week.
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With no educational time allowed? Throw in M&M one day a week and didactics one day a week and now you are over every week. Also your plan assumes that the night float gets out exactly on time every day.
 
core0 said:
With no educational time allowed? Throw in M&M one day a week and didactics one day a week and now you are over every week. Also your plan assumes that the night float gets out exactly on time every day.
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Once or twice a month, you could give them an extra day off and just pull someone else in from an off-service rotation or a research resident.

If they're not getting out on time, tell them to be more efficient with their time ;) AKA, encourage lying on their hours by suggesting it's their own fault for going over.
 
core0 said:
With no educational time allowed? Throw in M&M one day a week and didactics one day a week and now you are over every week. Also your plan assumes that the night float gets out exactly on time every day.
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Again, it's not that poster's "plan", it's a schedule some of us actually worked. On night float you are allowed to miss didactics. Its only a month or two out of the year. And yes it does assume you get out exactly on time, as most schedules that flirt with the duty hour caps will similarly "assume". At many places your schedule on paper indicates that you stay within the duty hours. Whether you actually do or not may be a different story.
 
When I was an R4, we were night float chief at the country trauma hospital that did >20K trauma admissions a year. We worked 6 nights a week, 6P to 7A, every Saturday night off. We stayed til 8 on Friday mornings for M&M (since you were virtually guaranteed to be involved in most of them) and were scheduled to work 79 hours a week. PERFECT!!

Before the switch to night float, the 2 R4 and 2 R5 did Q4 call, and had a golden weekend every month, as well as were generally out by noon post call (we were able to stick to the plan, usually). I would have rather had the call than the night float.

The good thing about night float chief was that you literally knew every patient in the hospital, and did a ton of operating.
 
blue2000 said:
When I was an R4, we were night float chief at the country trauma hospital that did >20K trauma admissions a year.
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20k? :confused: You sure that isn't ER trauma visits, and not actual admissions? Even the busiest places in the country (USC+LAC, Shock Trauma, Cook County) only have 5-6k trauma admissions per year.
 
Buzz Me said:
20k? :confused: You sure that isn't ER trauma visits, and not actual admissions? Even the busiest places in the country (USC+LAC, Shock Trauma, Cook County) only have 5-6k trauma admissions per year.
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Sorry, my bad, 5600 trauma admissions in 2010. 19K total admissions, 80K ER visits.
 
Nightfloat=no prerounding, rounding, dealing with consult teams. Win.

Although I've only done ICU night float, not floor night float. So I didn't have to deal with a million and one pages about so and so needing their Dilaudid/zofran/Metoprolol.
 
Dral said:
Nightfloat=no prerounding, rounding, dealing with consult teams. Win....
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On some night floats you are expected to help out with some of the rounding before you leave in the morning, and to some extent may have to do a bit of rounding on your own early on so you know the patients a bit better and can make sure they are stable, have the appropriate NPO signs up pre procedure, are drinking their bowel prep etc. More of a mini speed round, but it's not like you can sit in the residents lounge all night waiting for a page. And I've absolutely received and called consults in the middle of the night. even if they don't come see the patient, if its something serious the chief is going to want to hear you already got that ball rolling.
 
Dral said:
Nightfloat=no prerounding, rounding, dealing with consult teams. Win.
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That's the way it is here too. It was pretty win. I didn't mind night float. It was less work than being on days, though I did lose out on normal social things since I was asleep all day. But most interns here only do 2-3 weeks the whole year so it's not a big deal.

We didn't have to stay for rounds or didactics. We also get every 4th night off while on float.
 
Buzz Me said:
Whoa, that's pretty generous. What field are you in?
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He made sure he found the easiest transitional year as possible I sure. I know he was looking.

But either way, it sounds like surgery is more work on the night float, because everyone talking about doing pre-rounds is a surgeon. My night float was admit and cross-cover, no pre-rounds - the only overnight consults that required calling was occasional renal and GI (dialysis need and scope, respectively), otherwise we just wrote for the consult and handed off the need to call them to the AM team.
 
jdh71 said:
...- the only overnight consults that required calling was occasional renal and GI (dialysis need and scope, respectively), otherwise we just wrote for the consult and handed off the need to call them to the AM team.
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so if a patient developed a new arrhythmia or afib you didn't consult cardiology until the next day? Or if a patient pulled his foley out and after a few traumatic failed attempts by the nurses to straight cath you wouldn't call urology? Or if a patient developed altered mental status or a rigid abdomen you wouldn't consult anyone for that until the morning? Of course you would. I've dealt with all of these while on night float. Consults in the middle of the night aren't rare, and at most places they expect the night person to be able to say what he did about it, not that something needs to be done. The days when the night person just minds the store and compiles lists of things to do pretty much have gone out the window with the new duty hour rules. If someone is there for 30 hours you ask less of them and expect them to grab a few z's in the call room. But when a person is only on for 12-14 hours, the attitude of the team is usually that they can sleep on their own time, and should at least start the ball rolling with these overnight happenings.
 
jdh71 said:
He made sure he found the easiest transitional year as possible I sure. I know he was looking.
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I don't think my TY is the easiest. It's a pretty good year though. There is at least one program with no overnights.

That said, I do like to balance out the hardcore medicine and surgery types on this forum. There are, of course, three types of internship.

I agree with L2D that in certain situations you absolutely need to call a late night consult or consultant. It's not terribly common for me though.
 
Law2Doc said:
so if a patient developed a new arrhythmia or afib you didn't consult cardiology until the next day? Or if a patient pulled his foley out and after a few traumatic failed attempts by the nurses to straight cath you wouldn't call urology? Or if a patient developed altered mental status or a rigid abdomen you wouldn't consult anyone for that until the morning? Of course you would. I've dealt with all of these while on night float. Consults in the middle of the night aren't rare, and at most places they expect the night person to be able to say what he did about it, not that something needs to be done. The days when the night person just minds the store and compiles lists of things to do pretty much have gone out the window with the new duty hour rules. If someone is there for 30 hours you ask less of them and expect them to grab a few z's in the call room. But when a person is only on for 12-14 hours, the attitude of the team is usually that they can sleep on their own time, and should at least start the ball rolling with these overnight happenings.
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I'm not a surgeon, I don't need a cardiology consult to deal with an arrhythmia ;)

If I thought patient need an emergent consult overnight of course I'd call one. Duh. I'm not even sure what you're going on about. MOST consults can wait until the morning. I know this is hard for surgeons to understand, but it's true. :laugh:
 
jdh71 said:
If I thought patient need an emergent consult overnight of course I'd call one. Duh. I'm not even sure what you're going on about. MOST consults can wait until the morning. I know this is hard for surgeons to understand, but it's true. :laugh:
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Ironic. We usually get the late night consults from hospitalists just to get "surgery on board."
 
Actually, I don't see it as ironic. The chances of me calling a consult in the middle of the night are proportional to 1/(my comfort or knowledge in that field). Hence, I'm unlikely to get a cards consult in the middle of the night, because I can manage afib or ischemia that doesn't need the cath lab myself. But, I'm not as comfortable with surgical stuff, and I hate being told "you should have called us earlier" which is exactly what you hear for the consult for the rigid abdomen.
 
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