Hospitals move to reduce risk of night shift

Hospitals are waking up to the fact that substandard care on nights and weekends is endangering patients - giving new meaning to the term "graveyard shift."

Patients suffer higher rates of death, complications and medical errors when they are treated during thinly staffed off hours. Now, some hospitals are taking steps to improve safety and reduce their own legal liability from mishaps.

Institutions that long relied on having doctors on call at home are hiring physicians known as nocturnists, who work only night shifts. Some hospitals have begun staffing intensive-care units round-the-clock with critical-care specialists who do double-duty coping with a crisis anywhere in the hospital. And new policies are being put in place to improve communications at the hand-off between the day and night shifts.

"People get sick 24 hours a day, but there is a stark discrepancy in the quality of care on nights and weekends" when 50 percent to 70 percent of patients may be admitted, says David Shulkin, chief executive of New York's Beth Israel Medical Center. Shulkin has been making midnight rounds at his hospital on a regular basis to evaluate the quality of care and the need for additional staffing. In a recent editorial in the New England Journal of Medicine, he called on counterparts at other hospitals to do the same.

Of course, with rising medical costs and a shortage of nurses and doctors, hospitals will never be as fully staffed on nights and weekends as they are during weekdays. Indeed, hospitals do quiet down at night, when patients sleep, support staff go home and a skeleton crew mans many units. But that's also the time when dangerous delays in care can occur for patients. In a study published last month in the journal Circulation of 62,814 heart-attack patients, more than half arrived off hours. And this group was 66 percent less likely than daytime patients to get an angioplasty - a critical procedure to open clogged arteries - within the 90-minute window recommended by the American Heart Association.

One solution gaining in popularity is to hire more nocturnists, a subset of the specialty group known as hospitalists - physicians who work as full-time staff doctors with no outside patients. As of last year, about 1,200 hospitals had either a nocturnist or hospitalist sharing night coverage, compared with just 700 hospitals with such staffing arrangements in 2003, according to the Society of Hospital Medicine.

Though only about 6 percent of the nation's 22,000 hospitalists are nocturnists, there is growing demand for their services. Some hospitals advertise higher salaries and shorter working hours. Larry Wellikson, the society's chief executive, says the job often appeals to younger doctors before they have children or those who aren't interested in daytime committee meetings.

While staffing hospitals with nocturnists adds an extra cost, "the benefits in what we save the hospital in terms of liability, and the goodwill we create with specialists who don't have to come in at night, are endless," says Edward Chun, a nocturnist at Overlake Hospital Medical Center in Bellevue, Wash.

By contrast, at hospitals without a night doctor, patients admitted may have brief "holding orders" written at 2 a.m., and then have to wait until the next day before being seen in person by the "day" doctor, says John Nelson, a hospitalist at Overlake. Even if nurses page a sleeping doctor, it may take a half-hour or more until a patient is seen.

Last week, for example, a patient was admitted after hours through Overlake's emergency room with a suspected infection in his leg. It was left to Dr. Chun to arrange for surgery. But Dr. Chun, suspecting it might instead be an injury, ordered a scan. The test showed that the patient had internal bleeding from a major artery, which required a minimally invasive fix with a special coil. "The ER doc's role is triage and their time is more limited," Dr. Chun says. "I have the time to think about these things and consider other possibilities."

Milind Gurjar, a nocturnist at Mercy Medical Center in Springfield, Mass., works 12-hour shifts, three to four nights a week. The schedule allows him time during the day to help care for his infant daughter. On duty, nurses may call on him if, for instance, a patient becomes acutely short of breath during the night, he says. Dr. Gurjar can determine the cause and may be able to stabilize the patient with medication or oxygen masks. This could prevent a worsening condition that requires the patient to be transferred to intensive care and placed on a ventilator - a more expensive intervention that carries greater risk for the patient.

Carilion Clinic in Virginia is looking to recruit as many as three nocturnists for its flagship hospital in Roanoke, so the 15 hospitalists on staff don't have to always cover nights. Ralph Whatley, chair of medicine, says it is preferable for a physician to regularly work nights, because hospitalists who alternate between day and night work may be at higher risk of "the kind of cognitive lapses that result in medical errors."

Some hospitals are also asking intensive-care doctors to take on extra night duties. At Baptist Memorial Hospital-Memphis in Tennessee, ICU specialists who work the 6 p.m. to 7 a.m. shift help staff Rapid Response Teams to cope with emergencies anywhere in the hospital. The teams include a critical-care nurse and a respiratory therapist. "If patients are admitted to the hospital and their condition is not stable, a night-time intensivist will go see them right away," says Emmel Golden, the medical director of the ICU. What's more, to improve communication between day and night shifts, day staffers do rounds each evening with the oncoming intensivist, nurses and respiratory therapist.

Teaching hospitals have long relied on medical residents and interns for overnight duty. But changes in work rules in recent years have forced them to reduce the number of hours medical trainees can work. This has resulted in shorter shifts and more frequent "hand-offs" of patients between shifts.

The risks of seeking after-hour care are well documented. Recent studies show higher death rates for patients who arrive at the hospital with strokes after hours. This is also the case for patients who have a cardiac arrest at night when they are already in the hospital. And Stanford University researchers who examined close to five million hospital admissions in three states reported last year that rates of complications are significantly higher on weekends for surgeries including vascular procedures and obstetrical trauma during cesarean sections.

Should a patient or family member encounter a problem in a hospital, don't accept being told, "'Sorry, there is nothing we can do at this hour,"' Dr. Shulkin says. "That's not true - there is always a process in place to make sure a patient's needs are met at any hour, and that goes all the way up to the CEO of the hospital."