I recently began a rotation at the hospital as one of the night float interns. As part of this responsibility, I manage the care for approximately fifty patients each night. Day after day, I perform the same routine in preparation for the night ahead: Grab my stethoscope and pager, claim one of the code pagers, pick up a time sheet to fill in the nightly team to-do’s and mentally prepare for the wave of fellow interns waiting to hand off their lists so they can go home. It takes about one hour to get sign-out from all of the providers, averaging just less than one minute per patient when I take into account the time needed for interns to physically switch positions.
And then I own those patients for the rest of the night. Regardless of what happened during the day or how they were managed, their problems become my responsibility and my role is simple: keep them alive and (hopefully) stable. Over the course of the night, I rely on three things to get me through most of the problems that come up:
- The countless people who keep me informed about my patients’ statuses and who help me place the correct orders when things aren’t going well — all in an effort to help me fulfill my end goal (as a reminder, that’s to keep the patients alive);
- The quality of the sign-out document itself, with accurate and up-to-date information about a patient’s clinical condition; and
- The vitality of my pager to keep me connected with the front-line nursing staff who always seem a world away when I get the page at 3 a.m. about a patient who has chest pain and needs to be evaluated at bedside.
Strength in numbers
Lucky for me, I’ve never been at a loss for someone to help me through a problem that I wasn’t sure if I could handle. I’m constantly amazed, not only by the number of questions I still have about how to manage acute patient concerns even after four years of medical school, but also by the eagerness of pharmacists, nurses, residents and even attending physicians to help me figure them out (despite it being 4 a.m.). As an intern, the night float rotation has both increased my degree of autonomy and enhanced my understanding of why hospital medicine works best with team-based care.
Regarding the second key point, I’ve quickly realized how the handoff process in medicine is a place where communication can break down. Some studies even estimate as many as 80 percent of medical errors occur due to an ineffective handoff process. What’s more, the number of errors is higher in teaching hospitals and, not surprisingly, occurs in higher frequencies at the beginning of the academic year when new house staff members are learning the system. At my hospital, the sign-out process is facilitated by an electronically updated document each day. Updates are managed by the covering intern on the team, which means that as a night covering provider, I rely on the information to be accurate with the most recent and pertinent details. Unfortunately, this isn’t always the case, due to the lack of a standardized process. From what I’ve learned so far, in order for handoffs to the night team to be effective, they must include written guidance for at least the following:
- Chief complaint and only relevant past medical history;
- If the patient has been stable or unstable during the day shift;
- What am I following up on, when is it due, what am I looking for and what do you want me to do about the results;
- What to do for major “what ifs”: high blood pressure (with goal parameters), fevers, insomnia, pain, etc.; and
- What to do for patient-specific “what ifs”: shortness of breath in the patient with congestive heart failure, worsening chest pain in the patient with suspected acute coronary system, etc.
Attention: The hospital paging system is down
Finally, as a technologically-dependent provider, having a computer or paging problem during the day shift is annoying; during the night shift, it’s debilitating as there are only a few key physicians covering the entire hospital. For institutions such as mine that still rely on a hospital-based paging system, relying on personal cell phones as a back-up only works if there is adequate coverage throughout the facility. I recently experienced the detriment of this reliance when the hospital experienced a paging system outage at the start of my shift. I was approached by an eager nurse manager who took my cell phone number for the nurses to call with questions and concerns. While my phone had access to the Internet, it was not able to receive phone calls and texts in a timely manner. I’m just happy that on that particular night, I didn’t receive any calls about any life-threatening concerns. So what’s the alternative for hospitals that don’t have the monetary resources to purchase hospital-issued phones for all of the house staff?
- Limited cell phone use. Purchase a limited number of hospital-issued phones (with only texting and phone call capabilities) under the most reliable cell phone carrier for use by providers on the night shift; the phone could be handed off.
- HIPAA-compliant messaging. Consider the use of apps similar to HippoMsg or HIPAAText, which, from what I’ve read, seem to provide options for clinicians and health care providers to send HIPAA-protected messages amongst one another; however, they do require other users to download the app also.
- Paging using Internet-based apps. While it wouldn’t be HIPAA-compliant to text-page a provider with the name of a patient and his/her room number, nurses could utilize apps such as WhatsApp, which rely on internet access on a phone rather than the phone carrier’s network access.
With each new rotation I’ve encountered, I have taken on a new level of responsibility. The key to surviving this rotation has been keeping an open mind and being willing to ask for help. Night float, while challenging, has been both helpful for my professional growth and personal confidence as a provider.
Kerri Vincenti is a medicine resident. This article originally appeared in The American Resident Project.