Night Float, Part One: What is Night Float?

In a recent Slate article, Sandeep Jauhar, M.D. criticized the institute of Night Float. Since then, the venerable Dr. DB has responded with his own love/hate relationship with Night Float systems. Like anything in life, there's more than one perspective on Night Float, and this post will introduce my own.

First of all, what is Night Float?

Night Float defined: A residency rotation in which one or more residents are assigned to night duty, with little or no daytime responsibilities. Night Float responsibilities begin and end at set times. During the period of coverage, a Night Float resident will cover phone calls about already-admitted patients (cross-coverage) and admit new patients to the covered service. Daytime residents must sign out to Night Float residents in the evening, and receive sign out from Night Float the following morning. A Night Float system is meant to protect residency work-hour restrictions, ensure sufficient periods of rest for both day and night residents, and provide continuous coverage for hospitalized patients.

It is important to recognize that not all Night Float systems are created equal. The definition given above allows for almost unlimited versions of Night Float systems. For example:

• Dr. Jauhar's Night Float experience began at 5pm and ended at 7pm--a 14-hour shift. From his description, it sounds like he was responsible for admitting to and covering for internal medicine patients.
• A commenter on Dr. DB's post described a senior Night Float system in which a 3rd year resident was assigned to night duty, primarily to do new admissions.  The commenter did not specify the hours of coverage provided.  I have encountered some senior Night Float arrangements which began at 10pm or later, and were designed to pick up overflow admissions from several teams who would otherwise have been too busy.
• In my family practice residency, Night Float consisted of an R1, R2, and R3 team. This team ran Labor and Delivery, cross-covered Medicine, Surgery, Pediatric, Family Practice, ICU and NICU patients in the hospital, and did new admissions to these services. Night Float ran from 8pm to 8am, 5 days per week, and we did two 4-week blocks of it each year.

As you can see, Night Float systems can differ in the number of residents assigned, responsibilities, and services covered. Obviously, any discussion of the pros and cons of Night Float must address the specifics of the system under question. Like most of medicine, there is no one-size-fits-all solution.

Proponents of Night Float note that these systems help keep resident work-hours within the 80-hour weekly maximum.  In my residency experience, we would not have been able to adhere to the guidelines without Night Float. During the day, we had one or two residents assigned to the major services--Medicine, Surgery, ICU, Pediatrics, OB--and we staffed all those services in specialty clinics and wards as well as maintaining our own continuity clinics 1-3 days/week. To have required mid-week 24 hours calls on top of fulfilling daily rounds and clinics would have been punishing and would not have benefitted patient care. Night Float protected mid-week day residents from having to be awake all night, although we had standard overnight call on Friday and Saturday, which believe me was plenty bad. I have written several summaries of R2 and R3 call nights, and these give a pretty good overview of what kind of pandemonium we faced during standard 24-hour call. I can't imagine how depleted I would have felt if these nights had occurred on an every-third night schedule.

Dr. DB also notes that Night Float residents are more receptive to teaching rounds.  This has also been my experience.  One of the R3 Night Float's responsibilities was to organize brief teaching points for our morning report meetings.  This was possible--and even fun at times--because the Night Float team was relatively well-rested and could make use of down-time to prepare presentations.  This would never have been possible under a traditional call system, in which residents are usually comatose by the time they are reporting the next morning.

Critics of Night Float point to the fragmentation of patient care.  Instead of having the same residents follow the patient every day and 2-3 nights each week (assuming call every third night), Night Float systems require residents to transfer coverage for patients twice a day.  Such sign-outs of patient care have rightly been identified as entry points for medical errors.  Furthermore, by breaking up continuity of inpatient care, residents have fewer opportunities to "follow the arc" of a patient's progress.  Educators worry about this loss of continuity, and indeed it is true that a patient can improve or deteriorate within 6-12 hours of arrival in the hospital, and doctors need to learn about that range of possibilities.

I am a proponent of Night Float, although this is in part due to training bias because I went to a residency with Night Float.  I was also Chief Resident and was involved in a lot of discussions on how to balance the needs of patient coverage against the educational and personal needs of residents, and many of those discussions centered around Night Float and call.  In response to Night Float's critics I would argue that division of day/night responsibilities is how medicine is delivered in the real world of medicine.  Events in the arc of clinical progression are witnessed and managed by different physicians, and a patient may be in much better or worse shape when the daytime doctor shows up after a tough night.  I believe it is possible to witness and learn about the arc even when a doctor's participation is fragmented.  Ultimately, I think we need to emphasize communication between physicians over the need for continuous observation by an individual resident.  What cannot be replaced is the ability to present a patient's case to another physician as the patient's clinical status evolves, drawing on the observations of many physicians to create a unified narrative.

Because Night Float is a big topic, I have broken my examination down into several posts.  Future posts in the series will address:

• The benefit of Night Float systems to teach the art of cross-coverage of hospitalized patients.
• Problems that can derail Night Float systems, including poor patient sign-out.
• Suggestions on how to design a residency Night Float system to maximize patient care and educational opportunities.

Comments

[Tim]

I don't like night float. My girlfriend, a chief resident at a major northeast medical center is not adapting to the hours very well and is differant with me at home.

[Theresa]

Completely agree. Next posts in this mini-series are going to talk about cross-coverage and signing out. I don't think people are putting enough effort into thinking through how sign-outs fail. *Good* EMR will go a long way towards helping that, but we're at a transition point with EMR right now, and sign-out systems are wholly local. Thanks for stopping by, I know you're busy.

[James]

I think the real issue is improving quality of signout from one team to another. I think signout will continue to get better as electronic medical record systems are instituted and improved. But, in the end, I don't think it matters how you chop it up. It's impossible for the same team to take care of their patients continuously for an entire hospital stay. Patients can either be taken care of in shifts - the way nurses do it - or during the day +2 nights/week or whatever. But patient handoffs have always been a reality and I think making those as seemless as possible is the real challenge. I don't really understand how poor patient signout is a criticism of the nightfloat system. Signout has to happen when there is a call system as well. Plus, I don't know how we've labored this long under the delusion that the call system makes sense. I don't know of any other profession where a 30hr shift is considered reasonable.