Rapid Growth
These expanded changes to the system soon proved fortuitous. Within one year after the inception of IHC, admissions to the medicine services had consistently swollen to between 20 and 30 patients each night—a record for even the busiest periods in the history of the institution. The surge of patients being admitted through our emergency department to medicine proved to be an enduring change, which progressed unabated until Katrina struck. By necessity, the number of “unresidented” services quickly grew to accommodate our patients’ needs and concerns.
In addition, residency-review guidelines governing capitation of resident admissions were also carefully maintained to provide a consistent teaching environment for the house staff. Though stalling momentarily after Katrina struck, medical admissions have continued to climb seemingly without limit. The capacity of our six inpatient medical services with residents is now matched by an equal number of services managed privately by attending physicians alone.
Post-Katrina, the responsibilities of our three primary “nocturnists” have grown in tandem with the increasing number of patients on the wards to now cover the sub-acute nursing facility patients, geriatric nursing home patients, and acute preoperative clearances throughout the night. The lion’s share of time is still spent assisting and facilitating the admissions process for our patients through the emergency department.
In the past several years the role of the night hospitalist has become an integral part of our emergency department. In effect, most of the night is now spent in the emergency department providing consults, triage help, and early assistance with the care of patients ultimately bound for medicine admission. Besides the pragmatic benefits of expedited care, new interpersonal bonds of understanding and empathy have been forged between the two departments. I now count most of the emergency department staff, from physicians to nurses and secretaries, as personal friends and colleagues. The beleaguered admitting process has gradually transformed into a more cooperative, harmonious transfer of patient care between trusting teams.
Tracking Patients
With so many patients now spilling over the next day to various teams, one of the most vital functions of the IHC staff is to provide complete and accurate information about each patient assigned to the accepting teams the following day. This has required cooperation from both emergency staff in writing temporary floor orders, proper information flow between the on-call resident, night float resident and IHC staff, and proper notification of direct admissions arriving on the floor of patients accepted from the on call medicine staff during the day.
Currently each patient is simultaneously tracked by name, clinic number, and diagnosis by both the IHC staff and the overnight resident. The lists are frequently compared for accuracy, and in the morning an individual e-mail notification is sent to every physician on service for the day of every admission, distribution, and diagnosis by the IHC staff. As a second line of defense against error, the resident places an individual phone call to each physician receiving an overnight admission to reiterate any clinical problems.
As a department we have crafted fixed schedules of admission for the following morning so each day a physician knows whether to expect patients on the service or not. These numbers are forwarded to admissions for that day in order to keep each of the services as numerically equitable as possible. These careful tracking mechanisms, expectations of good communication between our physicians, and months of trial and error have proven invaluable during the months of highest volume when essentially every patient admitted overnight must be redistributed to various teams in the morning.
In addition to securing safe transition of the patient between teams and ensuring proper medical care, each patient is greeted in his or her room in the emergency department by the IHC staff, who take a moment to explain the admission process, the future plan of care, and who will assume the patient’s case in the morning. This has continuously provided an early opportunity to establish bonds of trust with each patient and assuage any lingering questions the patient may have after evaluation by the resident physician. Many of our patients are now displaced, frightened, and homeless. The value of providing face-to-face, 24-hour attending level care for our patients cannot be overstated.