No More Call

[justwondering]

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so our intern was postcall today, and i (a med student) found that she forgot to write orders for glucose checks and tx for our new admit, a type 2 diabetic. when i asked her (before i was sure there were no orders), she said she was pretty sure she had written orders.

anyways, those orders weren't there, soi had the other intern that took over put them in. it wasn't a really big deal, but it was just a reminder of the mistakes that we will probably make because of sleep deprivation. most of the time, we're not going to have someone checking our work like i was able to.

so what is really the reason for primary care residencies to have people on call? wouldnt we learn equally well (and the same stuff) if we had interns/residents who did night float so that everyone working (regardless of the time of day) would be more well-rested? is this just a money issue (possibly needing to hire more residents)?

i find that excuse that we will lose opportunities to learn to be pretty weak for a lot of primary care residencies providing all residents still do night float rotations and do admissions.

 

[Pox in a box]

so our intern was postcall today, and i (a med student) found that she forgot to write orders for glucose checks and tx for our new admit, a type 2 diabetic. when i asked her (before i was sure there were no orders), she said she was pretty sure she had written orders.

anyways, those orders weren't there, soi had the other intern that took over put them in. it wasn't a really big deal, but it was just a reminder of the mistakes that we will probably make because of sleep deprivation. most of the time, we're not going to have someone checking our work like i was able to.

so what is really the reason for primary care residencies to have people on call? wouldnt we learn equally well (and the same stuff) if we had interns/residents who did night float so that everyone working (regardless of the time of day) would be more well-rested? is this just a money issue (possibly needing to hire more residents)?

i find that excuse that we will lose opportunities to learn to be pretty weak for a lot of primary care residencies providing all residents still do night float rotations and do admissions.

What inate activity is implied in the word "resident" or "residency"? You make some strong points but most older attendings will bring back stories of "back in the day when things were how they should be."

 

[colbgw02]

so our intern was postcall today, and i (a med student) found that she forgot to write orders for glucose checks and tx for our new admit, a type 2 diabetic. when i asked her (before i was sure there were no orders), she said she was pretty sure she had written orders.

anyways, those orders weren't there, soi had the other intern that took over put them in. it wasn't a really big deal, but it was just a reminder of the mistakes that we will probably make because of sleep deprivation. most of the time, we're not going to have someone checking our work like i was able to.

so what is really the reason for primary care residencies to have people on call? wouldnt we learn equally well (and the same stuff) if we had interns/residents who did night float so that everyone working (regardless of the time of day) would be more well-rested? is this just a money issue (possibly needing to hire more residents)?

i find that excuse that we will lose opportunities to learn to be pretty weak for a lot of primary care residencies providing all residents still do night float rotations and do admissions.

PiaB touched on this already, but it's just an issue of convention. it's the way things have been since our modern training system started in the last 3/4 of a century. there's no proof that one way is better than the other.

 

[randomedstudent]

PiaB touched on this already, but it's just an issue of convention. it's the way things have been since our modern training system started in the last 3/4 of a century. there's no proof that one way is better than the other.

It's not just for convention, there are legit reasons to have residents take call. For one, many, if not most, primary care docs will be expected to take call in their jobs after residency, so it's probably a good idea to get in the habit of it. And I think the most compelling reason is the more often residents change "shifts" and check out to each other, the more likely mistakes will be made. Now many programs do have night float systems, esp. for weekdays and it probably works out fine in most cases, but personally I see potential for mistakes when you take check out on dozens of pts. you have never seen before and know virtually nothing about and then get awoken from sleep at 3 am all groggy, and expected to answer questions regarding their treatment. There are def. negatives with both systems, and that's why you'll find both out there. If you prefer one to the other, then make sure to ask when you interview.

 

[angel80]

When I was choosing an internal medicine residency, I needed to decide which programs to rank higher: those with the traditional overnight call system, or those with night float. I saw both systems as a med student, and I definately prefer the tradional overnight call system. There's something to be said about continuity of care. In the night float system, many times the patients are admitted overnight by the night float person. In the morning they get transferred over to you. You pretty much have to go and redo the whole H&P and your own A&P anyway, since you can't trust what other people do, plus you have to know the patient if you are going to be their primary doctor in the hospital. In addition, night float people are just there for labor. They get no teaching for the entire month, since they are not there for morning report, teaching rounds, and noon conference. Another thing is that in most night float systems, you consistantly break the ACGME 10 hour off-duty rule. Many programs that tried night float for a year or two changed back because of that reason. I ended up at a program with a Q5 overnight call system and I don't regret it at all. Some people prefer night float. It's good that both systems exist, so that you can choose which one you like.

 

[colbgw02]

It's not just for convention, there are legit reasons to have residents take call. For one, many, if not most, primary care docs will be expected to take call in their jobs after residency, so it's probably a good idea to get in the habit of it. And I think the most compelling reason is the more often residents change "shifts" and check out to each other, the more likely mistakes will be made. Now many programs do have night float systems, esp. for weekdays and it probably works out fine in most cases, but personally I see potential for mistakes when you take check out on dozens of pts. you have never seen before and know virtually nothing about and then get awoken from sleep at 3 am all groggy, and expected to answer questions regarding their treatment. There are def. negatives with both systems, and that's why you'll find both out there. If you prefer one to the other, then make sure to ask when you interview.

your points are valid ones, but until someone actually studies the systems it's all just theory. we can opine that more mistakes will get made with a nightfloat system, but it's not fact, yet.

as far as "practicing" for call, i've never been a believer in that. i've never seen anything to make me believe that a physician who graduates from a nightfloat residency would be less effective if he/she went to a practice with an on-call system. the vast majority of principles that work at 2pm also work at 2am. just my 2 cents.

 

[8744]

...In the morning they get transferred over to you. You pretty much have to go and redo the whole H&P and your own A&P anyway, since you can't trust what other people do...

Well, if that's the case why not run your own labs, read your own films all the time, and follow the respiratory therapist around all day to make sure she does everything right? Why go home at all? Why not just cat nap at the hospital and stay there 24/7 against the possibility of missing something?

I understand what you're trying to say but when you pick up the patient all you really need to do is confirm the H & P and review the A & P which should take a lot less time than doing them de novo. You should review the A & P every morning regardless.

Call blows for the simple reason that as mammals we need to sleep every day and it is un-natural (if I can use that word) to go without it. It is idiotic to suffer for any job which does not involve killing the enemy, the only true career which should require operating around the clock on a routine basis. I don't even care if we are or are not less effective when sleep deprived in the sense that I don't feel it is necessary to fall back on that argument to defend my aversion to call. Even if you could produce studies showing that sleep deprivation had n o adverse rffects on patient safety I'd still be agianst call because I like to sleep every day for a certain amount of time.

Medicine is just a job. I didn't feel the need for martyrdom when I was an engineer and I don't see the need now.

 

[EctopicFetus]

Panda.. as always.. *Applause*

 

[angel80]

Well, if that's the case why not run your own labs, read your own films all the time, and follow the respiratory therapist around all day to make sure she does everything right? Why go home at all? Why not just cat nap at the hospital and stay there 24/7 against the possibility of missing something?

I understand what you're trying to say but when you pick up the patient all you really need to do is confirm the H & P and review the A & P which should take a lot less time than doing them de novo. You should review the A & P every morning regardless.

Call blows for the simple reason that as mammals we need to sleep every day and it is un-natural (if I can use that word) to go without it. It is idiotic to suffer for any job which does not involve killing the enemy, the only true career which should require operating around the clock on a routine basis. I don't even care if we are or are not less effective when sleep deprived in the sense that I don't feel it is necessary to fall back on that argument to defend my aversion to call. Even if you could produce studies showing that sleep deprivation had n o adverse rffects on patient safety I'd still be agianst call because I like to sleep every day for a certain amount of time.

Medicine is just a job. I didn't feel the need for martyrdom when I was an engineer and I don't see the need now.

I understand what you're saying and I know a lot of people who feel the same way that you do. I'm just saying that in Internal Medicine, both types of programs exist, and you can choose what programs to interview with. Unfortunately, not all specialties have that option. I'm just saying that personally, I prefer call to night float.

 

[peptidoglycan]

The idea that more handoffs lead to higher patient morbidity is not unfounded or theoretical. Many studies have been performed and the following 2 articles give the findings fairly succinctly.

http://www.webmm.ahrq.gov/case.aspx?caseID=55
http://findarticles.com/p/articles/mi_m0NUZ/is_12_12/ai_n15998737

 

[fang]

I understand what you're saying and I know a lot of people who feel the same way that you do. I'm just saying that in Internal Medicine, both types of programs exist, and you can choose what programs to interview with. Unfortunately, not all specialties have that option. I'm just saying that personally, I prefer call to night float.

I'm happy to hear someone else saying this... every time I bring it up I feel like a loser. With night-float, I'm genuinely disappointed when the team gives the patient to the day team the next morning. After talking to him/her and thinking through what they have and what to do next, I feel responsible and really want to see how everything works out. Also, when I'm on the accepting team, I feel like I'm missing information by not seeing the patients when they came in... they're just another piece of paper with some barely legible handwriting, instead of (for example) a wrinkly old man who came in for shortness of breath but used to be a chemistry professor and can recite the last 20 presidents backward. I think the patients admitted by their own primary teams get better care (don't have data to support that right now.)

 

[8744]

I understand what you're saying and I know a lot of people who feel the same way that you do. I'm just saying that in Internal Medicine, both types of programs exist, and you can choose what programs to interview with. Unfortunately, not all specialties have that option. I'm just saying that personally, I prefer call to night float.

I am not busting down on you and I apologize if you thought I was. I certainly respect your opinion on this issue.

 

[deleted50478]

so our intern was postcall today, and i (a med student) found that she forgot to write orders for glucose checks and tx for our new admit, a type 2 diabetic. when i asked her (before i was sure there were no orders), she said she was pretty sure she had written orders.

anyways, those orders weren't there, soi had the other intern that took over put them in. it wasn't a really big deal, but it was just a reminder of the mistakes that we will probably make because of sleep deprivation. most of the time, we're not going to have someone checking our work like i was able to.

so what is really the reason for primary care residencies to have people on call? wouldnt we learn equally well (and the same stuff) if we had interns/residents who did night float so that everyone working (regardless of the time of day) would be more well-rested? is this just a money issue (possibly needing to hire more residents)?

i find that excuse that we will lose opportunities to learn to be pretty weak for a lot of primary care residencies providing all residents still do night float rotations and do admissions.

I'm just coming off a call where I was up all night, so my fatigue may be clouding my judgement. I think call sucks, but I also don't think you are addressing the main issue. We take call because someone has to work at night. Patients come in at night and current patients have new acute issue arise at night. If night work wasn't a necessary part of the job, then I'd see your argument about minimal educational benefit. Don't forget that we're there to take care of patients number one. I shouldn't even be writing this since it's so obvious, but I am I'm sleep deprived some what do I know...

 

[8744]

I'm just coming off a call where I was up all night, so my fatigue may be clouding my judgement. I think call sucks, but I also don't think you are addressing the main issue. We take call because someone has to work at night. Patients come in at night and current patients have new acute issue arise at night. If night work wasn't a necessary part of the job, then I'd see your argument about minimal educational benefit. Don't forget that we're there to take care of patients number one. I shouldn't even be writing this since it's so obvious, but I am I'm sleep deprived some what do I know...

I learn more on night float whatever the case. I think that rounding with the attending is often very low-yield, especially for me last year at Duke, compared to being the guy on the spot and having to look things up and think about a good plan for the patient. During the day you are more of a clerk than a doctor.

The problem with rounding at Duke, by the way, is that the discussions were at such a high level, usually having to do with one study or another, that the practical patient care subjects get neglected.

 

[tr]

It seems to me that the overnight-call system is the worst in terms of signouts vs continuity-of-care. Each night there is a different covering intern, who is naive to all of the patients except his/her own list.

With the night-float system, at least the same 2 teams take care of the same patients. Sure, they don't see the 24-hour development of each case; but they know all the patients and continue to care for the same ones throughout their hospital stays.

 

[f_w]

I am not sure what kills more patients: sleep-deprived interns or dropped handoffs.

Through internship and residency, I had everything, traditional call, night-float and 3-shift car-factory type schedules.

-- If you do the night-float or shift style work, you need to have a stringent system of standardized sign-outs. We had a 'book' that had pre-printed sheets for every patient on the service with the to-do lists and new issues that had come up over night. And as someone pointed out, the night-team gets to know the patients fairly well, often acting as a source of continuity in their care. We took night-float a month at a time (you tended to loose quite a bit of melanin during that time, but it was actually a good learning experience). At the end of the month, you started to get angry with the day-team that interfered with the care of 'your' patients.....

-- One thing I never understood with traditional call was this: Why do we start in the morning and based on the 30 hour rule where expected to leave the next morning therefore loosing continuity of care on our admissions during the initial inpatient day when most of the diagnostic testing and clinical decisons are being made ? I suggested to start call at 5pm and end it at 5pm the next day, but somehow people didn't get the concept (how are you going to attend noon-lecture ??). That way, you admit your patients, you follow them through the first day and hand them off to someone else in the team over the course of a day rather than a hurried sign-out in the morning.

- the car-factory thing worked remarkably well. It was an ICU. You showed up, you did your work, you moved on. Not a lot of teaching though.

 

[Lizard1]

i'm doing a lumbar & thoracic laminectomy thanks to a resident. pt admitted 9/7 @ 0130 and admit orders included mg/kg lovenox q12. pt admitted for L arm weakness with top of diff being CVA vs MI. before they can get a doppler of carotids, echo, r/o enzymes, etc... this resident does an LP at 0700. lp note says he used an 18g needle that required multiple attempts but no comps

pt complains of new onset leg weakness, sensory deficits in B LE, cannot void bladder, and no rectal tone. resident and attending(?) starting to think maybe the LP was a good idea as this could be MS??????? WTF????? meanwhile, pt continues to be given lovenox.

finally on 9/14 they consult neurology who gets MRI of thoracic spine(not lumbar for some reason) MRI normal. but neurosurgeon gets whiff of this, gets Lspine MRI and sees HUGE epidural hematoma that is now week old -poor lady 🙁

so now we're doing this case and the resident just poked head in asking what we think the cause is. we flat out tell him of his negligence and he is in total denial - thinks pt must have c/s defiencency(sp?). friggin ignorant

i'm fuming right now......so do you think this is sleep deprivation or just plain a DUMB resident

 

[shane_doc]

I agree with angel80 and fang. I prefer traditional call. I am also classic Type A personality. Maybe its because its what I spent most of residency doing. There is no simple, clear-cut answer to the problem. You have to see a certain number of cases to feel comfortable treating patients but at the same time I AM supposed to be learning something (not just slave labor for hospital). A lot of the attendings at my program acknowledged the need for work hour restrictions but they still pissed and moan when residents had any legitimate complaints. And those who complained a lot were accused of being lazy behind their backs. There are lots of areas for others to take up slack, like the clerical work. For example, if I was trying to send an infant with Short gut home, I had to consult SW, fill out medical necessity forms, ague with people about why X and Y should be paid for. This could take up 1-2 hours out of actual patient care.

 

[48 hours]

It's not just for convention, there are legit reasons to have residents take call. For one, many, if not most, primary care docs will be expected to take call in their jobs after residency, so it's probably a good idea to get in the habit of it. And I think the most compelling reason is the more often residents change "shifts" and check out to each other, the more likely mistakes will be made. Now many programs do have night float systems, esp. for weekdays and it probably works out fine in most cases, but personally I see potential for mistakes when you take check out on dozens of pts. you have never seen before and know virtually nothing about and then get awoken from sleep at 3 am all groggy, and expected to answer questions regarding their treatment. There are def. negatives with both systems, and that's why you'll find both out there. If you prefer one to the other, then make sure to ask when you interview.

Well, just to discuss your first point.... if we could change the system so that residents didn't have call, then I think we could also alter the system that primary care docs use, too, you know?

And as far as continuity of care goes, what kind of system do you have at your hospital now? I mean, if you are q 4, then you have someone else cross-covering your pts 3 nights in a row anyway not to mention half of the post call day, too, when arguably MOST of the work on a new admission gets done. So, how do you think this system provides better continuity of care than a night float system where theoretically a pt would only have 2 docs (obviously excluding when interns are switching services, etc)???

Anyway, basically I guess I just don't understand your reasoning?

please elaborate.....

 

[48 hours]

I'm happy to hear someone else saying this... every time I bring it up I feel like a loser. With night-float, I'm genuinely disappointed when the team gives the patient to the day team the next morning. Maybe I'm a control freak, but after talking to him/her and thinking through what they have and what to do next, I feel responsible and really want to see how everything works out. Also, when I'm on the accepting team, I feel like I'm missing information by not seeing patients when they came in... they're just another piece of paper with some barely legible handwriting, instead of (for example) a wrinkly old man who came in for shortness of breath but used to be a chemistry professor and can recite the last 20 presidents backward. I think the patient admitted by their own primary teams get better care (don't have data to support that right now.)

So, I still don't get this arguement... when you guys are post-call, don't you sign out your pts? Or do you stay at the hospital until you know the dx on every pt? Or worse yet, until every pt is d/c'd? So, I know I'm being facetious, because obviously everyone leaves the frickin' hospital at some point...but I don't get how having a different doc each night for 4 nights in a row is better than having a day doc and a night doc or whatever?

 

[48 hours]

Sorry for all the posts in a row.... can you tell I'm actually on a slow call night right now?

Anyway, in the MICU, at least, we now have NPs that day float for us ...basically, their job is to get the post-call team out on time by picking up the extra work on the new admissions and old post-call team pts. Obviously, it doesn't really do much for continuity of care, but I was wondering if you guys have seen this at your own hospitals and what you thought of it? Personally, I think I love it, and I just wish I could get them to come in on the weekend, too (our NPs just work M-F). 🙄

 

[8744]

Well, just to discuss your first point.... if we could change the system so that residents didn't have call, then I think we could also alter the system that primary care docs use, too, you know?

And as far as continuity of care goes, what kind of system do you have at your hospital now? I mean, if you are q 4, then you have someone else cross-covering your pts 3 nights in a row anyway not to mention half of the post call day, too, when arguably MOST of the work on a new admission gets done. So, how do you think this system provides better continuity of care than a night float system where theoretically a pt would only have 2 docs (obviously excluding when interns are switching services, etc)???

Anyway, basically I guess I just don't understand your reasoning?

please elaborate.....

It's like justifying going over eighty hours by saying that "patient care comes first." It sounds good and serves as an effective tool to shame residents into silence until we reduce it to the absurd and point out that if this were the case, then why not (as you point out in your later post) stay at the hospital all the time? I mean, if patient care comes first than to hell with days off, long showers, and anything that would detract from caring for those patients.

 

[8744]

Call as an attending is considerably different than call as a resident. First of all, as an attending you don't have the nurses calling you every five minutes with legitimate but trivial patient care questions. Second, you are not cross-covering as many patients but only those belonging to your practice.

You also typically take call from home. My family medicine doctor has call five or six times a month and he does not sleep at the hospital, and generally can answer most questions from patients and the hospital from his bed.

Not to mention that he knows less about the patients he covers than a resident, usually not even gettign a sign-out at all unless it is for something very unusual.

 

[pedidoc]

I'm in a peds residency and we just this year changed our rotations so that we have a few months with night float (PICU and a mole inpatient month) and a traditional call system the rest of the year. I can tell you after having done both types that there are benefits of both systems.

If you have a family, the night float system is hard if you're the float. My kids didn't see me all week except for two nights a week when I was off. It was nice for the patients because we were covering the same patients each night (and the same resident during the day). The PICU attendings loved it!! The patients were much better cared for than having somebody new everynight.

The traditional call system allows you to be part of the decision making team during the day, writing orders, rounding with the attending, and seeing the patients when they are awake. I just know that with our call being super busy-usually no sleep and very stressful that we aren't really taking the best care of our patients. When you have a million things going on and are pulled in a million directions cross-covering 25-30 patients, you are really not providing good continuity of care overnight.

Personally, I like the traditional call system better, but everybody has different preferences. The important thing is to make sure that whatever residency you apply to that you know ahead of time how the system works.

 

[dpmd]

The strategy used in the medicine residency for my school was to have multiple teams consisting of four people (two interns, a second year and a third year). Each team had one person from it on call each night. Each call night the admissions would be divided according to how the third year wanted it. Usually this meant the interns got the majority, and the third year would take none or maybe 1-2 patients. This way the new patients were taken care of by the team that had discussed their management on team rounds instead of just signed out. Also, this meant that you only got call about patients you had seen before and had a little knowledge about (the teams divided up the patients among the four of them for their day to day assessments and notes, but we discussed everybody at sit down rounds before going to see the new ones). This seemed to work ok, and the interns had med students on call with them so they weren't totally screwed having to do all the H+P. I don't know what the real solution is, but I am sure it will be specialty dependent.

 

[AmoryBlaine]

Disclaimer: I've only been an M3 for a few months.

Opinion: Night float is a disaster. I know it is a man-power issue etc, but unless some people sit down and do a DETAILED sign out it just causes problems. Mostly you get a 20 sec sign out on each new admit and then the next resident has to go scour the chart to see what's really going on. It is especially problematic if the day resident doesn't really trust the night float (which happens quite a bit).

 

[colbgw02]

Disclaimer: I've only been an M3 for a few months.

Opinion: Night float is a disaster. I know it is a man-power issue etc, but unless some people sit down and do a DETAILED sign out it just causes problems. Mostly you get a 20 sec sign out on each new admit and then the next resident has to go scour the chart to see what's really going on. It is especially problematic if the day resident doesn't really trust the night float (which happens quite a bit).

it's the responsibility of the accepting resident/team to get a good sign out. if you're not getting all the information you need, then don't let them go home until you do. of course, a good resident/team will give a comprehensive sign out without being prompted.

 

[AmoryBlaine]

it's the responsibility of the accepting resident/team to get a good sign out. if you're not getting all the information you need, then don't let them go home until you do. of course, a good resident/team will give a comprehensive sign out without being prompted.

Ha ha. I think the point is that you don't KNOW if you're getting a good sign out or not b/c you don't already know the story...

 

[colbgw02]

Ha ha. I think the point is that you don't KNOW if you're getting a good sign out or not b/c you don't already know the story...

i humbly disagree, although i see your point. sure, there are unforeseen problems that will come up in the middle of the night that no check out could account for, but the vast majority of cross-cover issues are small things that can easily be anticipated, e.g. lab orders, pain control, blood pressure control, sleeping aids, diet orders, etc., etc., etc.

if somebody checks out to you, "we think that mr. x may have had a stroke" and just leaves it at that, then there are several questions that should spring to mind which require an answer before completing the checkout. of course, it's still conceivable that the checkout team could completely omit a critical piece of information, then you're SOL.

i guess my point is that giving/getting a good checkout comes with time, like interviewing a patient or writing a note. after awhile you realize what's important and what's not.

 

[48 hours]

Ha ha. I think the point is that you don't KNOW if you're getting a good sign out or not b/c you don't already know the story...

And again, I must say.... why is a sign-out from night float to day and vice versa inherently thought to be crappier than your average sign-out in the traditional call system? Couldn't the same info be omitted here as well or not?

 

[DRDARIA]

And again, I must say.... why is a sign-out from night float to day and vice versa inherently thought to be crappier than your average sign-out in the traditional call system? Couldn't the same info be omitted here as well or not?

Exactly. With the night float system, at least after a day or so, the night float knows all the patients from the teams they are covering, versus traditional call where there are 4 different interns (in a Q4 system), so while they may know the five patients they admit, they don't know the ones on the team they're cross covering. The next night, another intern doesn't know the patients they're cross covering, for four nights, versus night float when after two nights, the night float would know something about most of the patients (at least the ones that are high demand).

Plus, the night float is, in theory, fresh, and more able to think, come 0200 when the patient they don't know (and the call intern wouldn't have know, because it is a cross-cover patient) begins to crash. Given that neither intern is likely to know the patient well, which do you want making decisions, the one that has now been working for 18 hours, or the one that has been working for 8?

 

[GasEmDee]

Couldnt agree with you more. The irony is that the military is far more vigiliant about making sure personnel get adequate rest.

Well, if that's the case why not run your own labs, read your own films all the time, and follow the respiratory therapist around all day to make sure she does everything right? Why go home at all? Why not just cat nap at the hospital and stay there 24/7 against the possibility of missing something?

I understand what you're trying to say but when you pick up the patient all you really need to do is confirm the H & P and review the A & P which should take a lot less time than doing them de novo. You should review the A & P every morning regardless.

Call blows for the simple reason that as mammals we need to sleep every day and it is un-natural (if I can use that word) to go without it. It is idiotic to suffer for any job which does not involve killing the enemy, the only true career which should require operating around the clock on a routine basis. I don't even care if we are or are not less effective when sleep deprived in the sense that I don't feel it is necessary to fall back on that argument to defend my aversion to call. Even if you could produce studies showing that sleep deprivation had n o adverse rffects on patient safety I'd still be agianst call because I like to sleep every day for a certain amount of time.

Medicine is just a job. I didn't feel the need for martyrdom when I was an engineer and I don't see the need now.

 

[8744]

Exactly. With the night float system, at least after a day or so, the night float knows all the patients from the teams they are covering, versus traditional call where there are 4 different interns (in a Q4 system), so while they may know the five patients they admit, they don't know the ones on the team they're cross covering. The next night, another intern doesn't know the patients they're cross covering, for four nights, versus night float when after two nights, the night float would know something about most of the patients (at least the ones that are high demand).

Plus, the night float is, in theory, fresh, and more able to think, come 0200 when the patient they don't know (and the call intern wouldn't have know, because it is a cross-cover patient) begins to crash. Given that neither intern is likely to know the patient well, which do you want making decisions, the one that has now been working for 18 hours, or the one that has been working for 8?

Hey, when I did cardiolgy call I was cross-covering something like seventy patients. There is no way to get a good sign-out for that so, and I hate to put it like this, unless it was something out of the ordinary, we just signed over the pager and that was it.

 

[secretwave101]

You pretty much have to go and redo the whole H&P and your own A&P anyway, since you can't trust what other people doQUOTE]

You can't? Wow. We have a night-float system and I think it works pretty well. Then again, I trust my other R-1's and R-2's implicitly. These are good doctors who care about their patients.

Plus, check-out can often be a farce. "Good" checkouts are frequently just presentations of extra-detailed crap that nobody remembers anyway (e.g. is this the guy with the fat dog or the Hgb that was 22 last month?). Impending issues are all that's important for the night team, and it's rare that this stuff is dropped. As mentioned, the night-team gets to know the patient pretty well also, which makes for better continuity on any patient here longer than the proverbial 36.

And what R-1 is going to give a better check-out after 36 hours of sleep deprivation than an R-1 who's regularly working 12's?

 

[8744]

You pretty much have to go and redo the whole H&P and your own A&P anyway, since you can't trust what other people doQUOTE]

You can't? Wow. We have a night-float system and I think it works pretty well. Then again, I trust my other R-1's and R-2's implicitly. These are good doctors who care about their patients.

Plus, check-out can often be a farce. "Good" checkouts are frequently just presentations of extra-detailed crap that nobody remembers anyway (e.g. is this the guy with the fat dog or the Hgb that was 22 last month?). Impending issues are all that's important for the night team, and it's rare that this stuff is dropped. As mentioned, the night-team gets to know the patient pretty well also, which makes for better continuity on any patient here longer than the proverbial 36.

And what R-1 is going to give a better check-out after 36 hours of sleep deprivation than an R-1 who's regularly working 12's?

I did a medicine rotation last year at Durham Regional which is a part of the Duke system. We had four teams with traditional q4 call. They had a day float to help the post call team get out by 1:00 PM (which we always did). Since each team had a census of anywhere from four to 15 patients, potentially at signout for call you might have to be made aware of 45 patients, most of whom you knew nothing about. On call and "short call" I typically admitted five and one patients respectively meaning that I probably knew a lot about ten or so patients. The rest were a mystery except for the few rocks who everybody knew about.

For signout, my colleagues did not sit down with me and review a detailed history and physical for each of their patients. They generally gave me a one-liner as well as a list of critical lab values to follow over-night. Sometimes it was as simple as, "Mr. Smith, nothing to do on him." To do the kind of signout envisioned as the ideal would take hours. Nobody wants to take this kind of time particularly because since most patients are fairly stable, over night you will probably not hear about any of them from the nurses. It's not as if anybody gets their signout and then goes and rounds on the combined census. I mean, I always rounded on my team's list sometime in the evening if I had time but there's no way to check up on 45 to 50 patients most of who you have never met.

Our team admitted to itself on long and short call so we were always more-or-less up on our own patients and never had to take signout on a patient admitted to our team by one of the other teams.

You'd better believe that at 1:00 PM post-call after a busy night all I wanted to do was get out of there. I'd like to think that I still give the same quality of care when I'm sleep deprived but of course I don't. I wouldn't say I drop the proverbial ball but I don't go looking to stir things up either.

I mentioned cardiology at Duke. I think my friend Apollyon who was also a resident at Duke and did cardiology there as an intern will confirm that there are so many patients and such a rapid tunrover that you cannot possibly know anything about most of them.

I know the ideal is to admit, follow, and discharge all of your patients but this has not been typical of my experiences so far. (And it won't matter to me after this year anyways, thank God.)

 

[Apollyon]

I mentioned cardiology at Duke. I think my friend Apollyon who was also a resident at Duke and did cardiology there as an intern will confirm that there are so many patients and such a rapid tunrover that you cannot possibly know anything about most of them.

Dude, you are NOT kidding. I've said that the worst call at Duke is Plastic Surgery, when PSx is covering CMF, general plastics, and hand. Second is cardiology, because it's in-house, disorganized, busy as hell, and the rapid turnover. Neurosurgery had a comparable census, but was MUCH more straightforward.

It turned to just making a list of: time, patient name/room number, and problem. The problem was then further subdivided into "now, later, tomorrow morning".

Best thing about cardiology at Duke is finishing the block.

 

[Museless]

but personally I see potential for mistakes when you take check out on dozens of pts. you have never seen before and know virtually nothing about and then get awoken from sleep at 3 am all groggy, and expected to answer questions regarding their treatment.

This was proposed as a reason night float is "bad" - but how is this any different from the traditional call system? I get the three other interns' patients signed out to me, I know little about them, and am asked questions about their treatment while exhausted and dead on my feet. Only difference is, unlike a night float - I've already been at it all that night, AND all the day before.

 

[8744]

This was proposed as a reason night float is "bad" - but how is this any different from the traditional call system? I get the three other interns' patients signed out to me, I know little about them, and am asked questions about their treatment while exhausted and dead on my feet. Only difference is, unlike a night float - I've already been at it all that night, AND all the day before.

Exactly. Night float rules because generally you come in at a set time, work through the night (or watch TV, study, or chat with the nurses if it is slow) and then go home at more or less set time. No BS. No rounding. No hanging around waiting for someone to decide if you're done.

 

[madtowngirl]

The key seems to be having a succinct, detailed census sheet with the information needed on each patient. The basics: name, MR#, age, diagnosis. Also the current important meds, tests, results, and a TO DO column. And as was mentioned before, giving the incoming call team a heads up on labs that need checking, postops, potential problems overnight, is also key. This can go on the aforementioned sheet as well.

That being said, good signout still can take almost an hour. Its inefficient, but so is staying in house until your patients go home

 

[48 hours]

The key seems to be having a succinct, detailed census sheet with the information needed on each patient. The basics: name, MR#, age, diagnosis. Also the current important meds, tests, results, and a TO DO column. And as was mentioned before, giving the incoming call team a heads up on labs that need checking, postops, potential problems overnight, is also key. This can go on the aforementioned sheet as well.

That being said, good signout still can take almost an hour. Its inefficient, but so is staying in house until your patients go home

Yea, that's pretty much the standad sign-out we use at our hospital already... doesn't everyone?

 

[nitemagi]

The only addition in our medicine NF system is an area for pertinent o/n issues- basically foreseeable problems that could arise for the patient and the NF get called on, including suggestions on interventions. If nothing else, it makes you make sure you have your patients tucked in before you sign them out to NF.