Nocturnists help avoid night, weekend danger

Trend grows among hospitals

When you finally pack up on Friday afternoon and go home for the weekend, what is happening at your hospital? Unfortunately, the risk of death and adverse events goes up dramatically.

That's the conclusion from research showing increased risk on nights and weekends, and that risk is prompting some hospitals to hire "nocturnists," experienced physicians who understand the challenges of care during off hours and work during those times to improve patient safety and outcomes. Nocturnists are a subspecialty of hospitalists.

In one study, people admitted to the hospital on the weekend were 10% more likely to die than those who checked in during the week.1 The study was based on an analysis of nearly 30 million people admitted to hospitals in 35 states over a five-year period. It was not the first study to uncover a "weekend effect," in which patients are likely to fare worse during the weekends, and other work has shown a similar effect for night-time admissions during the week.2,3

The risk might have been exacerbated by changes in graduate medical education work rules in recent years that have resulted in a reduction in the number of hours medical trainees can work, says Carol A. Burkhart, RN, MS, ARNP, CPHRM, CHC, senior vice president with Marsh/Clinical Healthcare Consulting in Chicago. In some facilities, those changes resulted in shorter shifts and more frequent handoffs of patients, she says.

Many medical issues are handled as crises at night or on weekends, as opposed to how they might be handled more prospectively at other times, says William Hanson, MD, professor of anesthesia and critical care and the chief medical information officer at the University of Pennsylvania School of Medicine in Philadelphia. He also is author of the new book, "Smart Medicine: How the Changing Role of Doctors Will Revolutionize Health Care" (Palgrave Macmillan, 2011).

"There is a tendency among nursing staff at night to handle things on their own so as not to wake somebody up, and in worst cases, people tend to neglect things," Hanson says. "If the nocturnist is an active player, on their feet, rounding and responding, that's going to change things."

Some research has suggested that organizational and staffing issues could explain the increased risk on weekends, Burkhart says. The research noted factors such as decreased physician-to-patient ratios, unavailability of board-certified intensivists, physician fatigue, and difficulty obtaining complex diagnostic tests, she says. The risk is higher for some patients, such as those experiencing cardiac arrest on nights and weekends, she says.

More hospitals are turning to nocturnists, Burkhart says. "The difference between a nocturnist and a resident or a doctor who is tasked with covering during the night is that these are experienced physicians," Burkhart says. "They also are acclimated to working the night shift, and that is a huge plus for safety. These are physicians who are dedicated to this particular type of medicine and not the unlucky doctor who got assigned to night duty this week."

Nocturnists were rare only a decade ago, numbering perhaps 100 in the country, she says. Now the best estimate is that there are about 1,500 nocturnists working in the United States, Burkhart says.

"That is a significant increase in just 10 years, and it's even more significant when you look at who's hiring them," she says. "It's the heavy hitters: Johns Hopkins, Cleveland Clinic, the providers who are respected and on the leading edge of medicine."

Burkhart notes, however, that improved patient safety and outcomes come not just from having dedicated physicians working off hours but also by improving communications and patient assessments.

"It can be a whole compendium of how work is organized and accomplished at night," she says.

References

  1. Ricciardi R, Roberts PL, Read TE, et al. Mortality rate after nonelective hospital admission. Arch Surg 2011; 146:545-551.
  2. Hamilton P, Mathur S, Gemeinhardt G, et al. Expanding what we know about off-peak mortality in hospitals. J Nursing Admin 2010; 40:124-128.
  3. Shulkin DJ. Assessing hospital safety on nights and weekends: the SWAN tool. J Patient Saf 2009; 5:75-78.