Traditional Vs. Night Float

[Aphtalyfe]

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Could we maybe get a list going of residency programs that use a traditional call system vs a shift based with night float?

I'll start:

Robert Packer Hospital in Sayre, PA - Night Float w/ weekend call like 2-3 weekend days a month.

 

[LucidSplash]

Pretty much all programs have night float now unless they are not using interns in the "call" schedule. I am not aware of any program who have the manpower to cover their night-time junior residents duties using only mid-level residents.

 

[Mr Cookie Pants]

We have 2 different ways (Southeast Academic).

Trauma is a 6-7 float 6 days a week. Gives an hour of overlap on each side for checkout. Realistically its about 6-9 as theres 50 floor patients and 30 unit patients + consults.

All other services (GI, Onc, Vascular, VA, Samaritan etc) are Q2 home call. While this sounds brutal, it's for floor things only. Any consults/surgery are staffed by ESS (Emergency Surgical Services) which all non trauma/CT residents staff 1x week in house. So one night youll be in house, and up to 5 you COULD be, but residents seem to like the Q2 home call. Most light services you can make it through with 1-2 interruptions.

 

[LucidSplash]

We have 2 different ways (Southeast Academic).

Trauma is a 6-7 float 6 days a week. Gives an hour of overlap on each side for checkout. Realistically its about 6-9 as theres 50 floor patients and 30 unit patients + consults.

All other services (GI, Onc, Vascular, VA, Samaritan etc) are Q2 home call. While this sounds brutal, it's for floor things only. Any consults/surgery are staffed by ESS (Emergency Surgical Services) which all non trauma/CT residents staff 1x week in house. So one night youll be in house, and up to 5 you COULD be, but residents seem to like the Q2 home call. Most light services you can make it through with 1-2 interruptions.

Still not sure what you are doing with your interns? My program and many others have interpreted the "direct supervision" of interns to mean no home call for interns. Just out of curiosity, where do your interns fit into this schedule. Do they only take trauma night float or has your institution put interns on home call?

 

[SouthernSurgeon]

Still not sure what you are doing with your interns? My program and many others have interpreted the "direct supervision" of interns to mean no home call for interns. Just out of curiosity, where do your interns fit into this schedule. Do they only take trauma night float or has your institution put interns on home call?

the problem there is that the ABS was so vague with the "direct supervision" definition that nearly every program has come to a different understanding of what that means, ranging from "no home call for interns" to "no in house call for interns without a senior in house too" to "if there is a senior resident on call somewhere then the interns are fine"

 

[LucidSplash]

You mean the ACGME right, not the ABS? Of note, there is a clarification document on the ACGME website with FAQ. On page 10 it addressses this issue, and specifically states:

"Can PGY-1 residents take at-home call, and if so what are the work-hour restrictions for this?

PGY-1 residents are limited to a 16-hour duty period and are not allowed to take at-home call. PGY-1 residents are not allowed to take at-home call because appropriate supervision (either direct supervision or indirect supervision with direct supervision immediately available) is not possible when a resident is on at-home call. Program directors should review the specialty specific FAQ related to this requirement for further clarification."

http://www.acgme.org/acwebsite/dutyhours/dh-faqs2011.pdf
http://www.acgme.org/acwebsite/dutyhours/dh_index.asp

 

[SouthernSurgeon]

You mean the ACGME right, not the ABS?

yes my brain is not working today

 

[DrNick Riviera]

So my question is, what is the difference between an intern on home call with an upper level at home as backup and an in house intern with senior back up at home? None as far as I can tell, but if I read the ACGME FAQ correctly, the first is not allowed, but the second is?

 

[LucidSplash]

No. Interns must have "direct supervision" or "indirect supervision with direct supervision immediately available." These terms are specifically defined in the 2011 Standards. To quote:

Direct Supervision – the supervising physician is physically present with the resident and patient.

Indirect Supervision with direct supervision immediately available – the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide Direct Supervision.

Therefore interns should have a senior in-house with them.

Honestly I didn't realize this was a problem. Even before these recs, my program functions on weekday nights with 3 interns/junior level residents in-house, a senior resident as trauma chief in-house, and one other senior resident in-house for the non-trauma services. Our chiefs take home-call and will come in if someone on the Chief Service needs an emergent operation. I guess I kind of took it for granted that all programs had at least one senior resident in-house (or in our case two) at all times.

 

[45408]

Pretty much all programs have night float now unless they are not using interns in the "call" schedule. I am not aware of any program who have the manpower to cover their night-time junior residents duties using only mid-level residents.

My program does, but it's not because we have a lot of people. We're just on call a lot.

 

[thedrjojo]

We have 3 hospitals, and a different setup at each hospital.

Hospital A, private hospital. PGY4 chief inhouse nightfloat, does the operating and overseeing, PGY2 midlevel nightfloat sees all ER consults, occasional operating, helps answer intern questions if not busy, and Intern "nightfloat" (which rotates one of the interns from the day teams every week to be this, so its not a dedicated night float, just one week from the month) which cares for all the floor patients, does the 10-20 post op checks a night, etc.

Hospital B, VA hospital, has a PGY2 or 3 which takes care of the "ICU" and oversees the intern, which is on a "nightfloat" system similar to the setup at hospital A, where the intern cares for the floor patients and sees ER consults. PGY5 is chief and is on home call

Hospital C, University public hospital has multiple different teams. Trauma is Q3 for everyone save interns. The 3 teams consist of: Team A is PGY4 and PGY2, Team B is PGY5 and PGY3 rotator from Columbia, and Team C is Trauma Fellow and PGY3. There are also various rotators from ER programs, which if not interns then get put into one of the above teams. Interns do essentially shift work, primarily night shifts, but no set pattern. For general surgery, there is an intern night float (true night float, 1 month assigned rotation of just nights), the midlevel (PGY2/3) takes call at Q3-Q6 depending on how many PGY2's and 3's are currently available for the call schedule (We have prelim 2's and plastic surgery 2's and 3's which get placed seemingly at random onto the teams there is not a standard amount of people covering the 4 teams that feed into this midlevel pool, but always atleast 3, and can be upwards of 5-6). Chiefs of the various services are on home call (which is a PGY5 for General, Oncology, and Vascular, and a PGY3 for thoracic). SICU is Q3, and the SICU has a PGY3, PGY2, and either a prelim2, plastics2, or 2 interns (which I'm not quite sure how the interns in the ICU will work, last year we were just Q3 but with the new hours, thats why it's 2 interns at a time...). There is a trauma attending in house all the time and the Trauma chief will serve as backup for whoever needs it in house as well, but if general surgery operating is to be done, the service chief comes in from home.

So thats how we have not gone to a pure night float system and have managed to stay compliant, or so I believe... not sure on the VA...

 

[covegirl15]

My program is functioning on a graduated schedule (I believe a person in the earlier post actually referenced it).

For the first 3 months, junior and senior level residents alternated taking at home call while the intern was only in house during the day. Currently services function with a day intern and a night intern with the 2 switching places each week. The night intern fields the floor calls at night, sees and writes notes on all the patients, and dictates and completes discharge paperwork for patients that are going home the next day. The idea is that interns need to get used to taking primary call for their services at night. It also prevents cross cover. I'm not particularly wild about the system, but I think it probably is better for patient care in the long run, and the upper level residents love not getting the 3 am calls about potassium replacement.

Upper lever residents do take in house call for new admissions through the ESS (emergency surgical service). The number of upper level residents on your service determines how often you take call, generally it ends up being 4 week days a month with one weekend day/night call. The interns also take turns taking ESS call while on their week of nights, thus preparing them for when they are upper levels doing the admits.

As mentioned earlier, trauma functions something like a night float system with 2 people on during the day and one person on at night and people rotating each week.

All in all, I think life would be far better for everyone if interns could just take call.

 

[LucidSplash]

I find all the variation here very interesting.

At my program, we group our services at night so that we have 3 night-float interns (or junior residents as PGY2s will probably take a month or so of night float) Sunday-Thursday. One covers trauma, one covers acute care surgery and our chief-run service, and one covers vascular, general surgery, and peds. We always have one senior -level resident in-house to cover all services but trauma and that's on a traditional call schedule, and one senior-level who is trauma chief. Our chiefs rotate taking home-call and come in if someone on the chief-run service (or a new admit) needs to go to the OR; additionally senior/trauma chief will give the chief a heads up if something in their area of interest is going to the OR.

Weekends our cross-cover groupings are the same except that a PGY-2 or PGY-3 takes home call for peds all weekend until the night float guy comes in Sunday night at 6pm. Interns will take a "half" call (12-13 hours) AM or PM, so that we typically have two interns rotating coverage AM/PM for a coverage pool. If a PGY-2 or PGY-3 is in the mix for the weekend, they may do a 28-hour shift on a Saturday with an intern covering Friday night and Sunday morning.

Agreed that everyone would probably be happier (interns included) and it would be less complicated if interns could just take traditional call again.

Otherwise, our critical care service still runs on a traditional call schedule. We have a rotation where we operate at the three community hospitals in town and that has always been a home-call.