Shift Differences
Different studies have approached this issue in different ways, comparing business hours (e.g., 7 a.m. to 6 p.m.) with evenings, nights, and weekends, or days and evenings up to 11 p.m. with nights. Weekends are compared to weekdays but also to weekend nights.
The size of the hospital did not explain the shift differences found in Dr. Peberdy’s study. For hospitalists trying to address the underlying problems of after-hours quality, the size of the hospital is relevant. Only larger hospitals can afford hospitalist groups large enough to cover night and weekend shifts. For those that can, are all members of the group taking their turns at night, does this duty fall to the junior members, or is the group lucky enough to employ nocturnists who want to work at night? (See The Hospitalist, May 2006, p. 27, for an article on nocturnists in hospital medicine.) Whether the hospital has an academic emphasis also can influence who responds to crises after hours—attendings or house staff (in other words, sleep-deprived residents).
If hospitalists work nights, they are more likely to notice what isn’t available or what doesn’t work as well as what contributes to nocturnal quality problems and what might help to compensate for these differences. Even if hospitalists are not present in the facility at night, technology can help guide appropriate response to cardiac crises, suggests David Grace, MD, area medical officer for the Schumacher Group’s Hospital Medicine Division and a hospitalist at Southwest Medical Center in Lafayette, La.
“Several weeks ago a patient in the hospital was having chest pains,” he recalls. “A nurse called me at home and I ordered an electrocardiogram.” The electrocardiogram’s (EKG) computer program indicated “nonspecific changes” in the patient’s cardiac function, but Dr. Grace asked the nurse to scan the printout and send it to his Web-based fax number.
“I looked at the EKG on my PDA,” he continues. “It was subtle, but it seemed to me that this patient was having a myocardial infarction[MI]. I told the nurse to do the blood work for a suspected MI, give the patient an aspirin and take another EKG, which more clearly showed the MI. If I had not had the ability to look at the printout, I would have had to trust the nurse’s observation or the EKG computer program. As it was, we caught it early and the patient did well.”
Cooperation and Staffing
“I have lived it. I certainly understand the research showing different outcomes from MIs at night,” Dr. Grace observes. “At night, patients are usually asleep, so processes that begin with early warning signals, such as chest pains, may go further down the path before they are identified, especially if the patient has taken a sleeping pill. Often, nurse-to-patient staffing ratios are dramatically different at night—and somewhat reduced on weekends. I’ve also worked in hospitals where on weekends, unless it was a true life-threatening emergency, you could not get an MRI. So if you ordered one on a Saturday, it wouldn’t happen until Monday. There are things you pick up on the MRI that you miss on the CT scan; for example, bleeding, which can affect your management of the patient.”
“I would not be surprised to hear of worse survival for any of these acute decompensations—it goes for acute GI bleeds, stroke, and hemorrhage, as well as MIs,” adds Steven Liu, MD, of Emory University Eastside Medical Center in Atlanta. “We dealt with the problem in this hospital five years ago and addressed a lot of these quality issues by partnering with hospital administration and specialists.”