Whether the precipitating factor is trauma or stroke or cardiac arrest, or being treated in an intensive care unit, recent studies have shown that hospital patients are more likely to die between the hours of sunset and sunrise.

 

It's easy to hypothesize why: Staffing is reduced overall, and at most U.S. hospitals, there is no physician within shouting distance except behind the walls of the emergency department (if the hospital even has one). The situation and patient outcomes are similar, for similar reasons, on weekends.

But the picture is changing, thanks to doctors like Ed Chun, a Bellevue, Wash., hospitalist who for the past six years has paced the floors, fielded nurses' questions, confirmed or modified the ED physicians' admitting diagnoses, written prescriptions, answered pages, cross-covered for surgeons and other specialists, routinely accompanied the rapid response team to the bedside when patients suddenly decompensate, and in myriad ways provided an expert physical doctor's presence at Bellevue's Overlake Medical Center between the hours of 9 p.m. and 7 a.m. seven days a week.

Chun is what has come to be styled a "nocturnist," a doctor whose day job is a night job. He prowls 349-bed Overlake after sundown for 10 hours (often a bit more while coordinating handoffs with his morning relief) for seven days straight. Then he's got two weeks to himself, except for a couple of six-hour evening shifts, to recover. He shares the schedule in rotation with a pair of equally noctivagant colleagues in his 18-physician hospitalist practice.

John Nelson, M.D., who heads that practice, often is credited with inventing the term that has now come into general usage to describe doctors like Chun who specialize in moonlighting. Hospital medicine is a category of internal medicine (it has its own board exam, but no separate residency yet, notes Nelson, so it is not a true subspecialty); thus, with a play on the word internist in mind, Nelson some years ago suggested that night hospitalists should be called nocternists. But the more conventional spelling — from the adjective nocturnal and perhaps with a nod to composers John Field and Frederic Chopin — seems, to Nelson's chagrin, to have won out.

Night Chats and Coffee

Absence of physicians in house at night is not a problem at a teaching institution like Cincinnati Children's Hospital Medical Center, the nation's second largest pediatric facility. Each of five medical teams caring for the hospital's inpatients — on a recent night 444 of the 490 beds were occupied — is led by a senior resident on site, backed up by at least one intern, with an experienced attending physician supervising from a distance, but anticipating scheduled wee-hour consultation calls.

Nevertheless, a worrisome near miss — that is, "any event that has the potential to result in patient harm or is perceived by families as an error in care" — was being recorded every 3.8 nights on average in the neurosurgery unit at Cincinnati Children's in 2007. The longest period between unnecessary treatment delays or deviations from appropriate care in the nighttime was all of 10 days. A quality improvement team determined that 57 percent of those lapses could be traced to poor communication among caregivers or lack of "situational awareness" that would have helped them pick up anomalies in vital signs.

Things are different today. A new protocol developed in the Cincinnati Children's neurosurgery unit, and now in use throughout the hospital, drastically has reduced the frequency of such near misses, according to Christine White, M.D., assistant professor of pediatrics at the University of Cincinnati School of Medicine and a director for general inpatient services at Cincinnati Children's. Indeed, after the new approach was implemented, a follow-up study found that almost seven months passed — 201 days — without a preventable error that might have led to more serious breaches of patient safety.

The difference-maker? Night talks: mandatory confabs at 1:30 a.m. between the duty intern and the patient care facilitator (otherwise known as a charge nurse), each of whom personally has posed a set of standardized questions to each bedside nurse on the unit, who in turn has ascertained the condition of each of his or her patients and discussed with the patient's parents any concerns they might have.

If questionable vital signs or parental apprehensions are noted in the night talk, the intern, the charge nurse, the senior resident and the bedside nurse are required to go to the patient's room, perform an assessment and agree on a plan. The intern then reports the substance of the night talk by telephone to the attending physician for review and approval.

Because it is not unusual for children to be admitted between 10 p.m. and 1 a.m., says White, "a lot of them were being missed" when the intern and patient care facilitator made pre-night talk rounds. So a comparable huddle, called a coffee talk, has been added at 3 a.m.

"Convincing the pediatric chief residents that a phone call every night in the middle of the night would improve patient care and patient safety is a continuing challenge," White acknowledged in a description of the program she co-authored with Javier Gonzalez del Rey, M.D., in the fall 2009 issue of The Permanente Journal. But resident buy-in "has improved as the data … demonstrated an impact," she added.

Moreover, "a discussion at night between intern and attending physician offers another opportunity to learn and teach." Finally, she proposed, "Night talks forced action on the residents so that decisions were made when issues arose instead of [being] delayed to the morning, holding the residents to a higher degree of accountability to prevent adverse events."

Cincinnati Children's night talks and coffee talks "have been very well received" throughout the hospital, says White. "The nurses now feel part of the team. And the attendings are alerted to situations they wouldn't have been informed about until morning" under the old system.

It's not a panacea, she admits. "We still have a problem at night. Most of the senior people aren't here. And you're working with a skeleton crew."

Rare Breed of Physician

"If I were the king of health care," declares Overlake's Nelson, "I'd mandate that every hospital with more than 80 beds have a doctor in the building all night long, outside the emergency room. As it is, I'd say only a little more than half do now."

The most recent American Hospital Association and Society of Hospital Medicine data confirm that 44 percent of U.S. hospitals have no physician on the premises overnight. Hospitalists provide 24-hour physician coverage either on-site or on call for about two-thirds of non-academic U.S. medical centers, but only 16 percent of hospitalist groups rely on nocturnists exclusively to care for inpatients after sundown.

No wonder. It's a strange calling. "I can't do it," exclaims Nelson, who for all his championing of the role has never been a nocturnist himself. "In a crisis I'd do it. But I'd never willingly get on that schedule."

Chun is something of an outlier for his longevity as a pure practitioner of the black art, as it were. But even he calls it "a young doc's game." At 42, he admits, he's aware of the physiological toll: "I'm groggy the day before and the day after. I feel a bit sluggish at 4 a.m. Maybe that's a hint as to how long I can go on doing this. The occupation of hospitalist itself is very intense and draining."

Night duty offers many compensations, though, he emphasizes. They're why he's clung to the topsy-turvy schedule despite regular opportunities to switch to a more normal routine. (He originally accepted the nocturnist position as a temporary prelude to a promised daytime practice.) He calls the one-week-on, two-weeks-off rotation "a golden cage."

The big upside for him is the character of the work. "It's more acute care, more problem solving," he summarizes. "I'm not sending grandma to the nursing home. Being a night doc, you have only admissions, no discharges. If there's a problem, you address it. There's no follow-up. You're kind of in charge of your own time. You avoid meetings and politics and oversight … you do your own thing and then you have a lot of time off. I never leave the hospital until everything's complete. I never take work home. In outpatient medicine it never ended."

Chun also values the opportunity his schedule affords him to get away on vacations with his wife, and to take his 21-month-old son to "Gymboree and water babies, ride my bike and maintain the house." Even on the weeks he works, he says, after sleeping from 11 a.m. to 6 p.m. he has ample time for a family dinner and play.

Leslie Flores, of La Quinta, Calif., who consults on hospital medicine practice management in partnership with Nelson, strongly recommends that groups of 10 or more hire at least one nocturnist to cover at least half the nights, if for no other reason than knowing they can sleep more soundly in their beds "makes it a lot easier to recruit daytime hospitalists."

But to lure physicians into nighttime wakefulness on a regular basis, she cautions, hospital medicine practices have to promise them they'll either be "paid a lot more money or work a lot less." Agrees Nelson: "You can't staff by waiting for people who just want to do it."

Probably Improving Patient Care

So far, no definitive studies affirm that the presence of a physician in a hospital at night affects its incidence of patient mortality. But Chun understandably believes he's helping.

A patient considered "stable" by the emergency physician on an admission holding order, for example, is commonly "not as stable as was thought," he points out. If the patient has to wait until morning to be seen by the daytime hospitalist, bad things can happen. But the ER physician may be too busy to come to the floor to reassess the patient when a vigilant nurse calls, so 12 hours or more might drag by before the patient receives appropriate therapy.

When a patient is resuscitated by the rapid-response team, he continues, the patient's doctor is notified but, rather than jump out of bed, the off-site physician "typically will find a reason to delay. Nobody wants to come in at night."

If a nocturnist is at hand, the problem goes away. Dr. Chun is on the case.

"Anecdotally," maintains Chun, "I feel I've saved the hospital on liability. And, yes, I think I've made a difference — probably a pretty important one. But it's hard to prove."

Nelson acknowledges the lack of hard evidence. Yet it stands to reason, he argues, that "having a doctor awake, and expecting to work, in close proximity is a big advantage and what we need to be aiming for. I'm pretty confident a dedicated [hospitalist] night shift should lead to improvement in patient care."

David Ollier Weber is the principal of The Kila Springs Group in Placerville, Calif. He is also a regular contributor to H&HN Daily.