No weekday overnight call or nightfloat?

[Papa MD]

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I wanted to toss an idea out there and see what all you bright minds thought...

My current IM program is a large, urban, tertiary center that covers a few different hospitals. Since the advent of night float on general med floor rotations, some of our resident numbers in certain rotations have been thinned by diverting residents to the night float across these hospitals, thereby increasing the workload on these services. Also, there is concern that there is less educational experience for the night floaters from decreased teaching conference opportunities and having the medicine B (i.e. hospitalist) staff cover as back-up attendings for residents at night.

CURRENT SYSTEM (skip if you want): Just for background, ours is a traditional night float system where 2 residents admit 6 patients from 8pm to 7am Sun-Thurs, as well as runs cross-cover responsibilities. We have excellent volume, and usually reach our cap of 6 admissions relatively early in the night, after which time medicine B admits patients to their service. The day teams run a q4 schedule, working until night float comes on Sun-Thurs, and overnight on Friday and Saturday. Day teams admit 8 when on call plus 2 handed over from night float for total of 10. Other night float admissions are distributed between the post-post call (1), pre-call (1), and medicine B teams (2). Again, good volume so capping early is a given, after which medicine B again picks up the slack.

PROPOSED SYSTEM: Replace the night float residents with entirely medicine B coverage, who will then pass on admissions to the academic teams in the a.m. Overnight call remains on Friday and Saturday.

The rationale is that the admitting contribution by the night float is pretty negligible. Also, most of the cross-coverage decision making goes unchecked until it is evaluated the next day by the day team (i.e. the day team's attending), and unless there is a major mistake, feedback rarely makes its way back to the night float resident. The day teams will continue to see the same number of patients, the former night floaters can be redistributed to replenish depleted resident numbers in other services, and more residents can maximize their attendance at didactics.

Let's, for the sake of discussion, assume that it is fiscally possible for the hospital system to finance purchase of hospitalists/moonlighters to make this work.

I would love to get your opinions on this idea... Pros? Cons? What do you think from a resident recruiting standpoint?

Thanks!

 

[Code Blue]

where do interns fit into the grand scheme of things here (like when you say 2 residents on night float -- do you mean 1 intern, 1 R2/R3 or do you mean 2 upper levels? and do your upper level residents in the MICU and CCU still stay in house overnight? how many hospitals are you guys covering and are you running night float at all the hospitals?

at my program, we used to have something similar to your medicine B team in which an attending team would pick up "non-learning cases" (ie: cellulitis that needs IV abx for a couple of days), but that has since been nixed.

 

[Papa MD]

Thanks for the response, Code. Kind of thought that the idea of doing away with the bulk of overnight call would draw more replies, since it seems like a pretty novel thing.

To answer your questions, our night float runs at 3 hospitals, all comprised of R2 or R3's, except for a VA service which has an intern plus R2 or R3. This "Medicine B coverage" proposition applies only to general medicine months... ICU and CCU residents/interns stay overnight and will continue to do so.

at my program, we used to have something similar to your medicine B team in which an attending team would pick up "non-learning cases" (ie: cellulitis that needs IV abx for a couple of days), but that has since been nixed.

I like the idea of your attending team, as it would seemingly triage the better cases to the teaching services. Why did they give it the axe?

So what about this idea to kill the night float?!? Does it have wings? Anyone hear of anything similar to it?

BTW, this concept has been floated past administration and they are actually looking into it. I'm still trying to figure out if I like it or not. Thanks.

 

[Code Blue]

I think the reason it got nixed was partially a financial one since we just didn't have enough hospitalists to run the resident inpatient teams plus the hospitalist/attending non-teaching cases team.

So it sounds like the interns don't stay overnight or participate on night float on ward months except at the VA? If that's the case, then that should already be a pretty good selling point.

As for education, I still say that there's something to be said about keeping some continuity on a ward team (esp when your census starts approaching 20-25) and for the interns to learn how to deal with cross cover BS and codes. I learn better that way than through noon conferences, but morning report is usually pretty good.