Night Float, Part Four: A Modest Proposal

Since beginning this series, a few other bloggers and commenters have raised several points important to any discussion of resident work-hours or Night Float:

• DB's Medrants reminds us we need to make Night Float educational for residents.
• James Logan, M.D. correctly implicates the real problem as sign-out, rather than Night Float vs. traditional call systems.
• Dr. Wes, writing about work-hour restrictions in general, discusses the redistribution of scut as resident work-hours are protected and fellows/attendings find themselves doing work traditionally assigned to residents.

There are some strong opinions out there, but I believe there is also some common ground. None of us wants to endanger patient care by assigning it to exhausted residents. None of us wants to release new doctors from residency when they have not been adequately trained to evaluate patients. Most of us hope implementation of electronic medical records may alleviate some of the burden of residency training, but EMR is not yet widely implemented and I suspect will not immediately solve all the problems of providing continuous flow of information between shifts of doctors.

I'd like to keep the focus of this series on the benefits of Night Float. In this post, I'm going to outline a Night Float proposal which addresses some of the concerns mentioned above. Again, I want to emphasize that there is no single Night Float solution. Different residencies will have different needs. The following proposal can be modified to suit individual program needs, but covers the basics of an educational Night Float system.

First, a few assumptions:

• Night Float should be an integrated part of a residency curriculum, not merely an appendage to an existing curriculum.
• Educational opportunities should be built into Night Float systems from the moment these systems are implemented.
• Night Float residents need adequate supervision, and this includes the sign-out process occurring at the beginning and end of each Night Float shift.

With these assumptions in mind, here's how I would structure a Night Float system:

1. A Night Float rotation should have its own curriculum and learning objectives, including:

• Limited reading list, consisting of 6-10 topics relevant to night-time coverage issues such as evaluation of fever, management of delirium, evaluation and management of acute respiratory distress, evaluation of suspected medication reactions, etc.
• Emphasis on physician-to-physician communication. Night Float residents should spend some time perfecting the art of concise, relevant verbal and written patient presentation. Constructive feedback to daytime residents about the adequacy of their progress notes should be encouraged.
• Checklist of common management problems.
• Identify opportunities to obtain experience in procedures (central lines, arterial lines, diagnostic taps, etc.) Elicit support from anesthesia and ER attendings to offer these procedures to Night Float.

2. Limit Night Float to 12 hours of coverage.

• Shift start/end times should fall between 7-8pm. Firm shift change time.
• Sign-out times should be scheduled 30 minutes prior to shift change.

3. Ensure at least two residents are assigned to Night Float

• One intern or junior resident, one senior.
• If residency size limits staffing, the intern/junior should be Night Float and the senior resident can be simultaneously assigned to co-managing another service, such as ICU/CCU. The two residents should be assigned to the same hospital.
• If a senior resident has responsibility for supervising junior residents on more than one service, he or she can be designated a "Team Leader." The Team Leader should not have primary responsibility for covering a service, but be a resource person for other residents.
• Assignment of two residents ensures that intern/junior has a more experienced resident to consult at night. This also provides valuable leadership experience to the senior resident.

4. Explicit delineation of Night Float responsibilities.

• Emphasis on providing continuity of daytime services.
• Principles of cross-coverage should be taught resident-to-resident, with intern/junior encouraged to call senior with questions.
• If heavy ER volume, residency must address caps on new admissions.

5. Supervision of sign-out process.

• Ideally, during the first half of the academic year, the attending physician should be present during sign-out.
• Second half of the year, senior resident can take over attending's supervisory role.
• Morning sign-out can be lightly formalized to include brief teaching topics by attending or senior resident.
• Daytime and Night Float residents should meet face-to-face for sign-out, even if patient information is stored/delivered electronically.
• Sign-out time should be protected time--ER and nursing staff should be alerted to postpone phone calls, etc. until sign-out is completed.
• The process of sign-out should be streamlined so that residents can complete the transfer of information and face-to-face meeting within 30 minutes.

6. Daytime responsibilities for Night Float residents should be minimized, and Night Float residents should be committed to obtaining sufficient rest during daylight hours.

• Some specialities, such as family practice, do not permit prolonged absences away from continuity clinics. In these cases, Night Float residents may have some daytime clinic responsibilities, but these should be minimized to protect sleeping time.
• As mentioned earlier in this series, Night Float residents should be expected to devote their daytime hours to sleeping. This should be made explicit in residency policy and procedures for disciplining residents who schedule too many activities during daytime spelled out.
• At the beginning of the academic year, a brief session on how to optimize day/night reversals and shift work should be offered. Tips such as white noise, artificial darkness, and appropriate use of sleep aids should be addressed, because new interns will not be familiar with these methods.

7. Acknowledgement of Night Float's integral role in supporting the entire residency.

• Celebrate the end of a Night Float rotation with a ritual. In my residency this used to be a round of applause for the outgoing Night Float team at the morning report, followed by the team going out for breakfast. I think this should be subsidized by the residency program.
• Residency culture should be geared towards supporting one another, and this includes Night Float. Daytime residents can be encouraged not to "scut out" night residents by getting their services "tucked in" before shift change.

Obviously this is not a Master Plan for All Night Float Systems. However, I hope it places the educational value of Night Float at the center of any proposed system of coverage, and provides a framework for supervision of Night Float residents. Night Float is ultimately only a part of the solution to protecting resident's work hours, but I think it is a better alternative than staying with traditional call systems, and it mimics real-life working conditions in hospitals pretty well. By implementing strong Night Float programs, we can prepare young physicians for the real world of professional medicine.