Overnight coverage

[umass rower]

So, with the new work hour restrictions coming down the pipe, I have been working on the committee for my residency program to change our current schedule to fit the new rules. One of the things that has been the topic of some discussion is the issue of overnight coverage.

I would like to get some more detailed descriptions of how your programs do nights in posts, but the poll will address a basic question that may either support or weaken my side of the discussion.

The basic question: approximately how many patients is each intern (or intern equivalent, if for instance you have a ward covered solo by a junior) responsible for managing in a fairly busy night at your institution?

I am aware that interns need to have senior oversight, and I know that in pediatrics our census can vary drastically depending on the time of year, the day of the week, and the lunar cycle. Use posts to address more detailed descriptions if you would be so kind, such as your program size, number of inpatient teams, or any comments about varying acuity that alters your coverage.

Thanks in advance for the input.

 

[Sweet Tea]

For us, it very much depends on the service.

Our level 2 nursery has 48 beds. Sometimes this overflows into the level 1 nursery (usually if I'm on. I have a reputation for being a baby black cloud). Normally they have 30-40 kids in there.

The NICU is a 72 bed unit, with residents covering 1/2-3/4 of it and NNPs covering the rest. Sometimes it's full, sometimes there's empty pods.

We try to divvy up the wards by acuity; one intern is responsible for covering the heme/onc, post-op (non-ICU) cardiac kids, and the DKA (again, not ICU-level DKA). They tend to have about 20-25 kids max, but they're sicker kids. In asthma-flu-litis season, we can easily have 40+ kids on the general floors, but most of them are asthmatics, ALTEs, or rule out sepsis babies. Lower acuity, higher volume of patients.

In the traditional call schedule, the NICU and Level 2 nursery calls have historically been the most brutal for interns.

 

[BigRedBeta]

We have a night float system covering the wards from Sunday night to Thursday nights. The intern will cover 3 teams that include general peds, neuro, renal, and endocrine patients, while the upper level covers the remaining 3 teams which include Pulm, GI, Heme/Onc, and Cards patients. Given seasonal variability, this may mean that the intern is covering as many as 60 patients, sometimes more overnight. The upper level may have similar numbers, and is, of course, available to help the intern with any problems that arise.

On Friday and Saturday nights, interns will take 30 hour call (which of course will be changing for next year), and generally only have 2 teams. The upper level resident on duty covers Cards and has to see all new admits as well as supervising the interns. The remaining 5 teams are split. Usually off-service (family med, anesthesia, ER, occasionally PMR) interns will only have 1 team and peds residents will have 2. Rarely, there will only be 2 peds interns on, so one will get 2 teams and the other 3. Interns do the H&P's on admits to their team.

In the nursery...it's a little complicated - the Children's Hospital handles all surgical NICU cases as well as serving as the final destination for all NICU transfers from outside hospitals throughout the state (also does more advanced modalities such as head cooling and ECMO) and it has 85 beds - this is staffed exclusively by upper level residents and NNP's. But the University Hospital - about 2 miles away - is where all the high risk OB is done (as well as serving as a normal L&D ward). The nursery there is like 50 or 55 beds and while all the beds are capable of doing everything up to iNO and HFOV therapy, there are certain areas that are usually Level II care rather than Level I. As a nursery intern, they cover as many as 20 babies in couplet care along with any babies getting level II care which could be as many as 10-15, plus is required to go to all deliveries deemed non-routine (so all preemies, all c-sections, as well as term deliveries with things like meconium or fetal heart rate issues) as well as doing all term assessments on the term babies who had no issues during labor. The cases are essentially triaged by the L&D nurses. The Level I team has upper level Mole coverage and typically averages about 40 babies. The upper level goes to most deliveries but depending on their demands may skip some of the term deliveries, sometimes depending on who the intern is (again, family med interns rotating through get more supervision than peds interns who have proven themselves). In house coverage is provided 24/7 by either staff Neos, or a term nursery attending and a Neo fellow together, so if they are available, they may go supervise the intern at a term delivery while the Mole does other things.

 

[WestcoastMedicine]

At our hospital this is how the coverage at night goes:

NICU: 1 resident for the unit, we can accomodate a max of 36 babies in the unit. No attending in house at night, either an NNP or a fellow on with you. The NICU team attendings all delivers at after 6pm, the floor/imcu team covers any problems with the patients in the well baby nursery at night though unless they end up getting sent to NICU.

PICU: 1 resident, attending is available by phone. We can accomodate 12-16 patients, including postop hearts, BMT, SCT, Level 1 Trauma, and ECMO.

Floor/Intermediate Unit: 16 patient in IMCU, 40 floor patients. These beds include general peds and all other admitting services(cardio, pulm, gi, etc...). We have 1 resident and 1 intern that covers the patients from all of these services combined, attendings available by phone. We have an additional resident who covers admissions from the ED. The resident/intern team cover interfacility transfer admissions though.