Holland Hospital, a 213-bed facility, provides around-the-clock hospitalist coverage in its eight-bed ICU, according to VanDort. That change was precipitated by the nursing staff’s decision to pursue Magnet Status, which was awarded in 2007 by the American Nurses Credentialing Center (ANCC). For inpatient coverage, the hospital-owned HM group Lakeshore Health Partners, headed by Bart D. Sak, MD, MA, FHM, maintains six FTE hospitalists on a rotating block schedule. Each night, one physician works from 4 p.m. until midnight, overlapping with a nonphysician provider (NPP), a member of the hospitalist group, who works a 7 p.m. to 7 a.m. shift.
“We have two providers in-house when admissions from the ED are heating up, and then we have an NPP in-house to cover the one to three additional admissions that may come in after midnight and to field floor calls,” Dr. Sak says.
The physician who worked until midnight is on call for backup support and might come back to the hospital if things get too intense in the pre-dawn hours. “This arrangement works quite well for a program of our size,” Dr. Sak says. “It takes a team-oriented approach and experienced NPPs who can work independently.”
The Holland approach simply wouldn’t work at Kaiser Permanente’s East Bay site in Oakland, Calif., where Tom Baudendistel, MD, FACP, is part of a 50-member hospitalist group and director of the internal-medicine residency program. “Between codes, cross-cover, ICU, and floor admissions, there is simply too much acuity and volume,” he says.
The peak hours for East Bay admissions are mid-afternoon to midnight. Two overnight hospitalist shifts (one from 8 a.m. to 8 p.m., another from 7 a.m. to 7 p.m.) are supplemented with two swing shifts (one from 2 to 10 p.m., another from 4 p.m. to midnight). Four full-time nocturnists cover 10 of the 14 overnight shifts per week, which allows for vacation and some protected administrative time. The balance of the overnight shifts are covered by the rest of the hospitalist group, which has 50 members.
The contracted nocturnists are incentivized with additional compensation at the end of the year, when the chief of hospitalists allocates bonuses. They also work fewer shifts a month than the other members of the group. “One thing our group agrees on is that the night docs should get a little more,” Dr. Baudendistel says. “It’s a very fair tradeoff for everyone.”