In the last post in this series, I discussed the necessary evil of nighttime cross-coverage and the need for adequate communication between doctors to ensure this coverage is optimal. This post delves deeper into a couple of factors that can derail such communication:
1. INSUFFICIENT DAYTIME SLEEP
It should be obvious that residents who work at night should sleep during the day. This is easier said than done. Most of us are not natural night people and find it difficult to sleep when the sun is out. For me, appropriate doses of sleep aids, white noise (a box fan) and artificial darkness (eye shades) were enough for me to get a reliable 6-7 hours of sleep every day. However, these tips won't help if a resident decides to run errands or socialize with their partners during the day. This is a common temptation and should be addressed openly before a resident enters a Night Float rotation. I think it should be written in policy manuals that residents are expected to obtain adequate sleep during the days they are on Night Float. I had personal experience with an R3 Night Float resident who moonlighted for eight hours every day after her night shifts--exceeding the maximum hours of moonlighting allowed by our residency, by the way--then returned to the hospital after a brief nap to start her night shift. By the end of her last Night Float month, she became acutely ill with gastroenteritis and I had to cover her last night shift, which turned out to be the gnarliest night from hell of my third year. Now, she might have gotten sick even if she had been sleeping during her days, but I think four weeks of sleeping 2 hours a day contributed to her illness. Take home point: Residents have to be dedicated to a strict night/day schedule for Night Float to be effective.
2. INEFFECTIVE SIGN-OUT BETWEEN PHYSICIANS
A common complaint when raising the question about restricting resident work hours is that doing so increases the number of patient hand-offs or sign-outs between doctors.
Sign-out defined: The summary of clinical information about patients that is delivered between one physician to another when coverage for the patient changes hands.
The single advantage to having, say, Internal Medicine residents take traditional call every 3rd night is that every weekday and 2-3 nights out of every week will be covered by doctors who know the patients on the service extremely well. A Night Float arrangement would limit the number of nights the Internal Medicine residents were obligated to cover to no more than two per week; some Night Float programs eliminate night-time coverage completely. If you do the math, you'll see that Night Float only involves a few more sign-outs than a traditional call system.
What constitutes a basic sign-out? For each patient, the following information is usually summarized:
- Room number, medical record number
- Main diagnosis (reason for admission) and pertinent comorbidities
- Medication list, with emphasis on most important therapeutic medications
- Brief synopsis of hospitalization to date (2-3 bullets or sentences), covering issues that may recur during the night
- To-do list of labs or XRays to check and what to do if these values are abnormal
- Code status
This is the minimum amount of information provided in a sign-out, and it is usually organized on paper or computer. Most residents will also do a very fast face-to-face sign out as well. People will debate the relative merits of paper-based or computer-based sign-outs for hours, and truthfully both methods have their pros and cons:
- Paper-based sign-out: Usually most accurate, as it is written from scratch each day. Easy to lose an original, so I usually advise making photocopies. Need to re-write information over again the following day.
- Computer-based sign-out: Main problem is that residents tend to make very superficial changes to the sign-out if it is saved in a database. For example, once I was given a computerized sign-out that indicated a patient was intubated. When I walked into the ICU, he was sitting up in bed eating dinner. It is far too easy to let outdated information carry over from day to day when using a computerized sign-out. This is a failure of human effort, not systems.
When people criticize Night Float systems or other methods of limiting resident work-hours, they tend to fall back upon a concern for the adequacy of sign-out. Medical errors have been tied to these moments of transfer of information, where omissions and misinformation can lead to mistakes in management. I believe more energy should be placed into the supervision of resident sign-out. In my experience, there is practically no supervision of this important process. Residents usually establish some kind of paper or computer-based system as well as a face-to-face meeting between incoming and outgoing residents, but attending physicians or other faculty are rarely involved.
In the next post in this series, I will outline an optimal Night Float system and discuss the need to invest more time in teaching cross-coverage and sign-out.