But here’s the problem with studies such as this, says Dr. Cram: “Patients admitted on evenings and weekends are not the same as those admitted 9 to 5 on weekdays.”
During weekdays, admissions combine patients with emergent issues and those scheduled for elective procedures. On weekends, “you get only emergencies—you don’t have low-risk patients,” he points out. “So, even with optimal 24/7 staffing, you would still expect those patients coming in at night, and on holidays, to have worse outcomes because they are coming in with more acute problems. It remains an open question whether 24/7 staffing will improve off-hours outcomes.” More research, Dr. Cram adds, is needed to establish whether full in-house staffing is the best solution.
Dr. Epstein has compared on-call versus in-house night staffing. In a 2007 study, he found no difference when using indicators such as length of stay, readmission rates, and patient satisfaction.4 However, he noticed positives from in-house coverage. “Although there are no data supporting the value of hospitalists on these parameters, having a nocturnist in-house increases nursing satisfaction, because they are responsive to pages when there is a question about a patient,” he says. “It’s also a service to hospital medical staff, because they can handle rapid responses and codes.”
There is some evidence that working nights can be deleterious to physicians’ and nurses’ health. One study found that interns were more likely to be involved in collisions after leaving extended night shifts; another found an increased risk of needle-stick injury at the end of a long night shift; and data from the long-running Nurses’ Health Study indicate that long-term night work can result in increased risk of colorectal and breast cancers.5,6,7,8 The increased risks of cancer could be related to lack of exposure to light at night and the body’s decreased production of melatonin, although this remains a topic of ongoing research.
“No Easy Answers”
VanDort, the nursing director, is “passionate” about having 24/7 coverage and reports that her nursing staff is happy with the hybrid model currently used at Holland Hospital. “I do envision a day when we’ll have physicians here around the clock,” she says. “Patients are sick during the middle of the night, so you can’t staff your system one way during the daytime hours and your nighttime differently. It’s not fair to those patients.”