On occasion, we will call in the other nocturnist to help out when admissions are too numerous for one physician to handle. This typically occurs towards the end of the work week. We usually require “double coverage” approximately 6–8 nights per month.
Since we instituted the nocturnist program 2 years ago, we have seen great improvements in ED throughput, inpatient bed utilization, patient satisfaction, average length of stay (both in the ED and inpatient), and quality of care. As soon as the emergency physician makes their decision to admit the patient, one of us is already interviewing, examining, and writing admission orders on the patient. This speeds up the process of the patient’s evaluation and allows the patient to be immediately transferred to a quiet room. Furthermore, this allows us to develop a rapport with the patient in the middle of the night, instead of feeling rushed in the morning to round on as many as 20 new patients. This also ensures a good night’s rest for the patient and improves the bed utilization. Moving patients to the floor in a timely fashion also allows for the ED to treat more patients.
Having a nocturnist in the hospital throughout the night allows for a more precise and accurate physical exam, formulation of an impression, and execution of a treatment plan. Physicians who are on-call at home often do not get the complete or correct story from the ED, which can lead to incomplete admission orders and delayed treatment plans. This can lead to unnecessary increases in length of stay. For example, I often admit “chest pain” patients, who by morning have already “ruled out” for an acute coronary event, had a stress test, and are ready for discharge before the “daytime” physician has seen the patient. Another example is diabetic ketoacidosis. I am able to be very aggressive with the treatment plan throughout the night, again decreasing length of stay and hospital costs.
Nocturnism is not only advantageous to the hospital and patients, but also to the nocturnist himself/herself. Dedicated nocturnists have less fatigue and stress. I work only nights, so I do not become excessively tired. My sleep schedule is completely reversed from the norm. This also has many advantages to my personal life. One of these is that I never miss a package delivered to my home!
Indeed, developing this program was a challenge. Initially we sold the idea through a combination of patient safety and revenue. The hospital cannot bill for holding patients in the ED. If we admit patients and move them to an inpatient bed, the hospital can generate this otherwise lost revenue. As with any new idea, we did meet resistance and opposition along the way. However, we were able to overcome these obstacles and build upon them. Once the administration saw the improvements and our productivity, they were immensely pleased. In fact, the administration is already looking at expanding our staffing and our services. Our billing and collections have shown we pay for our cost and generate additional funds for the hospital, despite a poor payer mix. I am excited to see what the future holds for nocturnists, not only in our institution, but across the country. Groups that employ nocturnists probably wonder how they ever survived without them in the past.
Dr. Sabharwal can be contacted at [email protected].