> If it were so automatic and repetitive, it would be easy to pass the information to the next medic and have normal length shifts.
Ward call for residents generally works like this:
I have an inpatient list of 15-20 patients I’m covering overnight, some of them I likely know as I’m often part of one of the relevant day teams (unless I’m flying in from another clinical service to help out).
I start by receiving handover from one of the day team members. We sit down together (or by phone) and go patient by patient on the list asking what their reason for admission is, any labs/results I need to follow up on from the day (e.g. patient A had a fever and a cough, we ordered a chest X-ray if it shows pneumonia start antibiotics), patient specific management plans (e.g. patient B may have a seizure overnight, he’s known for this and if it happens give drug Y.) and any patients that I specifically need to see (e.g. patient C was complaining of some belly pain this morning but has been fine the rest of the day, eyeball him in the evening and make sure nothing is brewing).
I then write these action items and notes down (either on paper or in an EMR patient list) for my shift and carry out the relevant actions from 5pm to ~10pm.
Between 5pm and ~10pm I’m following things up and seeing any patients I need to see. Depending on my service I may be taking ED/inpatient consults but that’s not the point here so I won’t get into that.
At 10pm I do what’s called “tuck in rounds” and call up to the nursing station and ask if any of the nurses have issues they want me to address. Often this is something like morning labs that haven’t been ordered, laxative orders, etc. If there are any patients I’m worried about (uncommon on routine inpatient wards) I will pop my head in the room to make sure everything is alright. Cumulatively, the evening usually represents 1-2 hours of active work (again disregarding consults because that workflow is very different).
After that, and until the next morning, I am either asleep in a call room bed or at home. I will only be practicing medicine if there is an overnight issue that needs addressing (e.g. a patient is short of breath, their heart rate is elevated, decreased level of consciousness). These acute ward issues are beaten into every physician from the beginning of medical school and we follow very routine diagnostic workups (i.e. CBC, lytes, glucose, VBG), many of which are codified in algorithms such as ACLS.
If a patient is really unstable I call the RACE/code team (an in-house service to deal with unstable issues staffed by an ICU trainee, RT, and ICU nurse with advanced training) who assume care while I provide support and context as the home service/MRP resident.
This is a very safe system. It is really hard to kill an inpatient with a medical error in an acute setting.
Now let’s pretend I handed over to a night resident starting at 11pm. Two potential sources for error arise:
1. We would go over the same process of “running the list” and discussing patients, except now it’s second hand information I’m relating (versus my initial handover was from the primary team/MRP who knows the patient intimately). Broken telephone / forgotten action items becomes more likely.
2. An acute situation happens overnight and the 3rd shift person alerts the RACE service, except now the resident from the home team/MRP has never actually met the patient (you don’t go round and familiarize yourself with sleeping patients) and has no idea what they’ve been like all day except from what I’ve told them. This creates a huge problem because now they’re reading through the chart/notes to make sure this is a new symptom and not something I forgot to tell them about, they’re also reading the chart to see if there were any action items I addressed in my evening shift that didn’t merit handover but may be related to the acute concern. Whereas with the same resident on a 16-24 hour shift you have a much better understanding of the patients and their unique circumstances.
Many, many, many studies have shown medical errors happen a lot more due to handover than physician fatigue. You can argue that we should have better systems/IT in place to make handover safer, but we do not. Even places with systems like Epic/Cerner, it takes too much effort to maintain the handover list with accuracy and direct verbal communication remains the mainstay.
Furthermore, it’s important to keep in mind that dealing with ward issues between 12am and 7am is also pretty uncommon unless there is a late admission or someone that’s active, but that’s atypical. On-call is for emergency coverage not active medical practice.
Ward call for residents generally works like this:
I have an inpatient list of 15-20 patients I’m covering overnight, some of them I likely know as I’m often part of one of the relevant day teams (unless I’m flying in from another clinical service to help out).
I start by receiving handover from one of the day team members. We sit down together (or by phone) and go patient by patient on the list asking what their reason for admission is, any labs/results I need to follow up on from the day (e.g. patient A had a fever and a cough, we ordered a chest X-ray if it shows pneumonia start antibiotics), patient specific management plans (e.g. patient B may have a seizure overnight, he’s known for this and if it happens give drug Y.) and any patients that I specifically need to see (e.g. patient C was complaining of some belly pain this morning but has been fine the rest of the day, eyeball him in the evening and make sure nothing is brewing).
I then write these action items and notes down (either on paper or in an EMR patient list) for my shift and carry out the relevant actions from 5pm to ~10pm.
Between 5pm and ~10pm I’m following things up and seeing any patients I need to see. Depending on my service I may be taking ED/inpatient consults but that’s not the point here so I won’t get into that.
At 10pm I do what’s called “tuck in rounds” and call up to the nursing station and ask if any of the nurses have issues they want me to address. Often this is something like morning labs that haven’t been ordered, laxative orders, etc. If there are any patients I’m worried about (uncommon on routine inpatient wards) I will pop my head in the room to make sure everything is alright. Cumulatively, the evening usually represents 1-2 hours of active work (again disregarding consults because that workflow is very different).
After that, and until the next morning, I am either asleep in a call room bed or at home. I will only be practicing medicine if there is an overnight issue that needs addressing (e.g. a patient is short of breath, their heart rate is elevated, decreased level of consciousness). These acute ward issues are beaten into every physician from the beginning of medical school and we follow very routine diagnostic workups (i.e. CBC, lytes, glucose, VBG), many of which are codified in algorithms such as ACLS.
If a patient is really unstable I call the RACE/code team (an in-house service to deal with unstable issues staffed by an ICU trainee, RT, and ICU nurse with advanced training) who assume care while I provide support and context as the home service/MRP resident.
This is a very safe system. It is really hard to kill an inpatient with a medical error in an acute setting.
Now let’s pretend I handed over to a night resident starting at 11pm. Two potential sources for error arise:
1. We would go over the same process of “running the list” and discussing patients, except now it’s second hand information I’m relating (versus my initial handover was from the primary team/MRP who knows the patient intimately). Broken telephone / forgotten action items becomes more likely.
2. An acute situation happens overnight and the 3rd shift person alerts the RACE service, except now the resident from the home team/MRP has never actually met the patient (you don’t go round and familiarize yourself with sleeping patients) and has no idea what they’ve been like all day except from what I’ve told them. This creates a huge problem because now they’re reading through the chart/notes to make sure this is a new symptom and not something I forgot to tell them about, they’re also reading the chart to see if there were any action items I addressed in my evening shift that didn’t merit handover but may be related to the acute concern. Whereas with the same resident on a 16-24 hour shift you have a much better understanding of the patients and their unique circumstances.
Many, many, many studies have shown medical errors happen a lot more due to handover than physician fatigue. You can argue that we should have better systems/IT in place to make handover safer, but we do not. Even places with systems like Epic/Cerner, it takes too much effort to maintain the handover list with accuracy and direct verbal communication remains the mainstay.
Furthermore, it’s important to keep in mind that dealing with ward issues between 12am and 7am is also pretty uncommon unless there is a late admission or someone that’s active, but that’s atypical. On-call is for emergency coverage not active medical practice.