Developing Efficiency on Nights.

[Redpancreas]

I need help from some veteran internal medicine nocturnists. @tantacles if he’s/she’s still around. We have 10 admissions on 12 hr night shifts and I don’t feel embarrassed to say it’s really tough plus cross coverage from interns who need lots of help now where 2-3 times per night I’ll have to see a sick patient who may need transfer etc. These patients are actually pretty complex if you take the time to do the thorough H&P process and I have noticed that the admitting H&P is really critical because the academic team usually anchors on my initial assessment and reasoning. There are a couple things I’ve noticed are major time drains:

1.) Incorrect assessments by ED providers which require me to take time to facilitate/step on toes to redirect care/triage to grump people who don’t want to he woken up. I’m not saying the ED is stupid but sometimes I guess they’re rushed with all the garbage that comes in, 5-10% of which is actually an emergency.

2.) Dependent patients with 20 medical comorbids from nursing facilities where I have to chase down records, MARs, families, and confirm/readdress goals of care especially when they’re sick with COVID with maybe superimposed PNA vs alternate Sepsis, drains that need management, presenting on NRB but have full code status documenting full code at 85.

3.) Patients from other facilities where I have sparse paper records with every 10th paper being important with some rare FUO or other issue someone else can’t figure out.

How do you guys navigate this? I’m still hellbent on writing thorough H&Ps with accurate details but it’s getting draining and I’m getting burnt out. I’m handling it well and have receive feedback that H&Ps are excellent and thorough and all the times looking back I did the right things and never missed anything like a brewing infection, etc. It’s just very draining and I think there’s got to be ways to streamline the process and want to hear from some veterans who’ve been doing this for a while.

I also recognize medicine admits aren’t super critical/emergent and there’s ways to cut corners like not getting the full history overnight, leaving detective work to day teams, etc. but I don’t think that’s the right thing to do and I strongly believe the point of the admission is the time to reconcile meds, figure out the story, because later on the day team is busy with other patients and families are at work. It’s a balance I suppose. Wanting to hear from others.

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[rokshana]

been a awhile since i did nocturnist work, but your job is to take care of the most emergent, acute things...get as good a story you can get, especially helping with some chart review that is pertinent to the admission, getting the work up started by ordering labs and imaging that can be available to the day team, (especially if some test take a while...this gives them a head start)...important to note any discrepancies with medications (hopefully nursing or pharmacy will do the detailed med rec) and note the relevant medications for the admission (say hypothyroid with a TSH of 100 and has not been taking levothyroxine for the last 6 months).

the daytime person will want a quick and dirty of what brought the pt in overnight, anything pertinent to the work they need to continue, and what you have done and/or ordered so they know what to follow up on.

you don't necessity need to teach or back up your rationale like you did as a resident. If its common (say CHF with fluid overload) you don't need to explain your treatment...just state what you are doing and plan to do.

things can be bullet pointed instead of paragraphs...easier for day person to read quickly and not have to sift through things.

put A/P at the top of the note...most hospitalist are going to look at that first and read the rest later...especially if they are just coming onto service.

don't worry about chasing down a lot of paperwork overnight...they may have 20 comorbidities, but they are being admitted for 1-2 things...focus on that...the day team, especially if they have residents and students have more manpower to work on those the next day. Ge the stuff relevant for the admission...that will be nice for the day time to have in the morning to go through.

make sure you have good templates for the most common things that will take the least amount of time to fill out...go back and look at the last months admissions, and for your top 5 admissions, make a template...this will help ease the paperwork.

and maybe talk to your day counterpart and ask them what they want overnight...you may find its not as much as you think it needs to be.

 

[wamcp]

I need help from some veteran internal medicine nocturnists. @tantacles if he’s/she’s still around. We have 10 admissions on 12 hr night shifts and I don’t feel embarrassed to say it’s really tough plus cross coverage from interns who need lots of help now where 2-3 times per night I’ll have to see a sick patient who may need transfer etc. These patients are actually pretty complex if you take the time to do the thorough H&P process and I have noticed that the admitting H&P is really critical because the academic team usually anchors on my initial assessment and reasoning. There are a couple things I’ve noticed are major time drains:

1.) Incorrect assessments by ED providers which require me to take time to facilitate/step on toes to redirect care/triage to grump people who don’t want to he woken up. I’m not saying the ED is stupid but sometimes I guess they’re rushed with all the garbage that comes in, 5-10% of which is actually an emergency.

2.) Dependent patients with 20 medical comorbids from nursing facilities where I have to chase down records, MARs, families, and confirm/readdress goals of care especially when they’re sick with COVID with maybe superimposed PNA vs alternate Sepsis, drains that need management, presenting on NRB but have full code status documenting full code at 85.

3.) Patients from other facilities where I have sparse paper records with every 10th paper being important with some rare FUO or other issue someone else can’t figure out.

How do you guys navigate this? I’m still hellbent on writing thorough H&Ps with accurate details but it’s getting draining and I’m getting burnt out. I’m handling it well and have receive feedback that H&Ps are excellent and thorough and all the times looking back I did the right things and never missed anything like a brewing infection, etc. It’s just very draining and I think there’s got to be ways to streamline the process and want to hear from some veterans who’ve been doing this for a while.

I also recognize medicine admits aren’t super critical/emergent and there’s ways to cut corners like not getting the full history overnight, leaving detective work to day teams, etc. but I don’t think that’s the right thing to do and I strongly believe the point of the admission is the time to reconcile meds, figure out the story, because later on the day team is busy with other patients and families are at work. It’s a balance I suppose. Wanting to hear from others.

You are already leagues ahead by recognizing the inherent complexity and thoroughness required for dealing with these sick patients.

You are in training. Focus on doing everything the right way, over and over again. Don’t cut corners or build up bad habits. You gain efficiency by experience. This will serve you and your patients well into the future. You’ll be a better PCP/hospitalist/fellow by becoming a great internist in the first place.

The only thing I would say you could do outside of hospital hours…is read. Uptodate or google search a review article on topics relevant to last night’s admissions.

EDIT: ok i am not sure if you are describing your experience as an attending or resident. I guess the same applies…

 

[obiwan]

Just recognize that there is only so much that you can do as one person admitting all these patients and doing cross cover. Obviously you need to prioritize acute issues/sick or unstable patients but knowing that going over 200 pages of SNF records at 2:00 AM of which alot of it will be useless is probably not the best utilization of your time when you are 2 admissions behind. Also, one thing that I notice with the nocturnists in my group is that they limit note bloat and just have clear/direct assessment/plans without a lot of fluff and so they are not listing 15 problems with #11 being anemia where the H&H is 12/38.

 

[chessknt]

How much ancillary support is present during the daytime? Can you just consult pharmacy to do a med rec in the AM saving you the effort of calling the nursing home overnight if they didn't send anything over and punt it to the day team? Is there a unit clerk that can request records? If so just write that records have been requested and will be followed up when available. If they come back overnight ignore them unless it is critical to something that needs to happen that night.

You don't need to get in to a full code status discussion with all of these old people on admit unless they look like they are heading to the ICU. Especially with 10 admits just make sure you capture people who have appropriately already wanted to be DNR etc but dont pull up a chair and prepare this deep goals of care discussion for a pneumonia on 2L of O2 in an 83 year old that will probably be fine. To that effect I would not call family overnight either on patients (assuming they were not present in the ER) unless something is going wrong. They can call and get some info from the RN who should also tell them the doctor with call during the daytime with a more complete update.

Write a differential diagnosis if you are not sure what is going on, order some follow up testing, and move on. Day team can sift through it all later and narrow it down. EG-If it is abdominal pain with a white count and a benign CT scan and tachycardia then start abx, get cultures, write pain meds, maybe write bowel meds if you think it is constipation induced, reconcile chronic issues that you can, and hand it off to the day team who can get a HIDA scan or some crap if they want to bark up that tree or might do nothing if they are all better. You don't need to plan the next 3 steps ahead in your admit note.

Also I guarantee nobody is going to whine about anything you do as long as patients are generally safe because nobody wants to work at night. You are working hard too, 10 admits a night with cross cover is a pretty hard job even for experienced people especially if any of them are higher acuity. You set your standard too high I think.

 

[rokshana]

You are already leagues ahead by recognizing the inherent complexity and thoroughness required for dealing with these sick patients.

You are in training. Focus on doing everything the right way, over and over again. Don’t cut corners or build up bad habits. You gain efficiency by experience. This will serve you and your patients well into the future. You’ll be a better PCP/hospitalist/fellow by becoming a great internist in the first place.

The only thing I would say you could do outside of hospital hours…is read. Uptodate or google search a review article on topics relevant to last night’s admissions.

EDIT: ok i am not sure if you are describing your experience as an attending or resident. I guess the same applies…

I think he just finish residency.

 

[Redpancreas]

Still in IM training. Some ways to go.

-I think H&Ps can be a little more condensed. The thing is when I dictate, things get long.
-I agree with the stop thinking 3 steps ahead part. I’m the sort of person who hates it when I miss a dx. the day team finds even if it’s a non-urgent one.
-I had a pull-up a chair code status discussion on an 80 year old female on 2L the other day.

I think the biggest take away is I need to focus on doing my job. Sometimes it’s unclear exactly what that is overnight role. Some attending are defensive and want everyone on board by the AM. Some AM attendings have messaged me when it’s really the night attending who drove the consults saying there was no need to consult ID/Nephro/Endo (insert non procedural IM specialty) overnight to which I absolutely agreed.

 

[Redpancreas]

been a awhile since i did nocturnist work, but your job is to take care of the most emergent, acute things...get as good a story you can get, especially helping with some chart review that is pertinent to the admission, getting the work up started by ordering labs and imaging that can be available to the day team, (especially if some test take a while...this gives them a head start)...important to note any discrepancies with medications (hopefully nursing or pharmacy will do the detailed med rec) and note the relevant medications for the admission (say hypothyroid with a TSH of 100 and has not been taking levothyroxine for the last 6 months).

the daytime person will want a quick and dirty of what brought the pt in overnight, anything pertinent to the work they need to continue, and what you have done and/or ordered so they know what to follow up on.

you don't necessity need to teach or back up your rationale like you did as a resident. If its common (say CHF with fluid overload) you don't need to explain your treatment...just state what you are doing and plan to do.

things can be bullet pointed instead of paragraphs...easier for day person to read quickly and not have to sift through things.

put A/P at the top of the note...most hospitalist are going to look at that first and read the rest later...especially if they are just coming onto service.

don't worry about chasing down a lot of paperwork overnight...they may have 20 comorbidities, but they are being admitted for 1-2 things...focus on that...the day team, especially if they have residents and students have more manpower to work on those the next day. Ge the stuff relevant for the admission...that will be nice for the day time to have in the morning to go through.

make sure you have good templates for the most common things that will take the least amount of time to fill out...go back and look at the last months admissions, and for your top 5 admissions, make a template...this will help ease the paperwork.

and maybe talk to your day counterpart and ask them what they want overnight...you may find its not as much as you think it needs to be.

Thanks @rokshana

 

[DrMetal]

We have 10 admissions on 12 hr night shifts and I don’t feel embarrassed

That's a lot. And you're a resident? Hell as an attending we cap at 8 at night, rest go to the day team. And you're not learning when you're running around like that. Your program should be capping you at 6 to 8.

Don't feel bad. Nobody manages that well when you have to admit that many and do crosscover. I go blank after admit # 5 or 6. Nice thing about being an attending is nobody can call you on it when you cut some corners or defer things to the day team . . . and believe me, we do that plenty. Why we don't allow our residents that same latitude is beyond me, it's very hypocritical in the way we teach.

But then again, there's a lot of hypocrisy in medical education!

 

[Señor S]

I think the advice you've gotten so far is good. I would say the following:

1. You're probably spending too much time writing H+Ps. Try to be more concise.
2. You don't need to track down all these SNF records unless there's some urgent issue that needs to be addressed. And you don't need to call outside facilities unless, again, it's something that can't wait until the morning. In my experience those nighttime calls are very low-yield anyways.
3. Don't worry about code status. If they say Full Code then that's what they are. You shouldn't be spending more than 30 seconds on this conversation overnight unless, as chessknt said, you think they really might need to go to the ICU (but shouldn't).
4. Follow Occam's razor. If the story the ED is telling you is consistent with the vitals/labs/imaging/history then go with it. If not, come up with a next most-likely diagnosis and go with that. Start the work-up, have a low threshold to order imaging, have a low threshold to culture and start antibiotics, then leave the rest for the day team.

This is what I do now as a hospitalist; it's what all hospitalists do, from what I've seen. Time is precious and you have to develop a triage mentality.

Attendings should not be anchoring on the diagnosis of an overnight resident, but if they are then that's their problem, not yours.

 

[DrMetal]

I think the advice you've gotten so far is good. I would say the following:

1. You're probably spending too much time writing H+Ps. Try to be more concise.
2. You don't need to track down all these SNF records unless there's some urgent issue that needs to be addressed. And you don't need to call outside facilities unless, again, it's something that can't wait until the morning. In my experience those nighttime calls are very low-yield anyways.
3. Don't worry about code status. If they say Full Code then that's what they are. You shouldn't be spending more than 30 seconds on this conversation overnight unless, as chessknt said, you think they really might need to go to the ICU (but shouldn't).
4. Follow Occam's razor. If the story the ED is telling you is consistent with the vitals/labs/imaging/history then go with it. If not, come up with a next most-likely diagnosis and go with that. Start the work-up, have a low threshold to order imaging, have a low threshold to culture and start antibiotics, then leave the rest for the day team.

All great advice . . . for an attending. The problem is, the OP is in residency, during which you're expected or told to seek all of the SNF records, to have a 45-minute conversation with each patient about Code status, to come up with an exhaustive differential diagnosis including ridiculous zebras.

This is all well and good for a resident, if you have 3 to 4 admissions. If you have 10, that's just not feasible.

Of course, we never do any of the above as attendings. If you come with records, I use them. If not, I give myself carte blanche to do WTF I feel is reasonable, to play doctor. Wanna be full code? Sure, that's a 60 second conversation. We'll pound on your chest all night.

 

[Señor S]

All great advice . . . for an attending. The problem is, the OP is in residency, during which you're expected or told to seek all of the SNF records, to have a 45-minute conversation with each patient about Code status, to come up with an exhaustive differential diagnosis including ridiculous zebras.

This is all well and good for a resident, if you have 3 to 4 admissions. If you have 10, that's just not feasible.

Of course, we never do any of the above as attendings. If you come with records, I use them. If not, I give myself carte blanche to do WTF I feel is reasonable, to play doctor. Wanna be full code? Sure, that's a 60 second conversation. We'll pound on your chest all night.

Bolded is exactly my point. If he's doing 10 admissions a night then he's doing what a hospitalist does. Individual attendings in residency have all kinds of stupid little rules they expect you to follow, but most people are basically reasonable...and if they're not, at some level that's their problem. I wouldn't worry about the day team being busy as OP says; they have stuff to do for sure, but the average IM teaching service is way less busy than how OP describes himself.

 

[rokshana]

All great advice . . . for an attending. The problem is, the OP is in residency, during which you're expected or told to seek all of the SNF records, to have a 45-minute conversation with each patient about Code status, to come up with an exhaustive differential diagnosis including ridiculous zebras.

This is all well and good for a resident, if you have 3 to 4 admissions. If you have 10, that's just not feasible.

Of course, we never do any of the above as attendings. If you come with records, I use them. If not, I give myself carte blanche to do WTF I feel is reasonable, to play doctor. Wanna be full code? Sure, that's a 60 second conversation. We'll pound on your chest all night.

Agree to some extent… I did think he had just finished residency and was struggling with the transition from resident to nocturnist.
But still think the main job of night float is to get the admission done, gather as much info for the day team, and keep the pt alive til the morning.
The H&P should be still concise with what relevant information and what you did and what is left to follow up…again there is more staff available during the day to do the scut.
And let’s face it, there generally is less teaching during NF, though the autonomy of NF is an education itself.

 

[tantacles]

I need help from some veteran internal medicine nocturnists. @tantacles if he’s/she’s still around. We have 10 admissions on 12 hr night shifts and I don’t feel embarrassed to say it’s really tough plus cross coverage from interns who need lots of help now where 2-3 times per night I’ll have to see a sick patient who may need transfer etc. These patients are actually pretty complex if you take the time to do the thorough H&P process and I have noticed that the admitting H&P is really critical because the academic team usually anchors on my initial assessment and reasoning. There are a couple things I’ve noticed are major time drains:

1.) Incorrect assessments by ED providers which require me to take time to facilitate/step on toes to redirect care/triage to grump people who don’t want to he woken up. I’m not saying the ED is stupid but sometimes I guess they’re rushed with all the garbage that comes in, 5-10% of which is actually an emergency.

2.) Dependent patients with 20 medical comorbids from nursing facilities where I have to chase down records, MARs, families, and confirm/readdress goals of care especially when they’re sick with COVID with maybe superimposed PNA vs alternate Sepsis, drains that need management, presenting on NRB but have full code status documenting full code at 85.

3.) Patients from other facilities where I have sparse paper records with every 10th paper being important with some rare FUO or other issue someone else can’t figure out.

How do you guys navigate this? I’m still hellbent on writing thorough H&Ps with accurate details but it’s getting draining and I’m getting burnt out. I’m handling it well and have receive feedback that H&Ps are excellent and thorough and all the times looking back I did the right things and never missed anything like a brewing infection, etc. It’s just very draining and I think there’s got to be ways to streamline the process and want to hear from some veterans who’ve been doing this for a while.

I also recognize medicine admits aren’t super critical/emergent and there’s ways to cut corners like not getting the full history overnight, leaving detective work to day teams, etc. but I don’t think that’s the right thing to do and I strongly believe the point of the admission is the time to reconcile meds, figure out the story, because later on the day team is busy with other patients and families are at work. It’s a balance I suppose. Wanting to hear from others.

I’ll respond fully to this a little later, but I already know what the TL;DR is. You have to be less thorough on nights. There is no choice. You do the amount of work that each patient allows and not an iota more; otherwise patients die because you’re focusing on subacute issues or you deteriorate because your overdoing it.

 

[DrMetal]

otherwise patients die

Meehh . . . .To be fair, you're hardly ever responsible for a patient's death. Most who die come in already set on this trajectory, usually not much you can do.

 

[ReviewOfSystems]

I am a career nocturinist. But I just realized you are a resident, so the advice for a supervising resident at an academic facility, is different for an attending. When I was a resident, if we didnt track down records, call consults, have full code status discussions, accepts all ED admits lying down, come up with a thorough differential diagnosis, assessment and plan for every medical problem, as well as leave no patients pending for the oncoming team, we were chewed out in the morning. Almost none of that matters as an attending, at least not to the same degree.

 

[DrMetal]

Almost none of that matters as an attending, at least not to the same degree.

It's so stupid how we teach one thing and completely practice another.

 

[tantacles]

I need help from some veteran internal medicine nocturnists. @tantacles if he’s/she’s still around. We have 10 admissions on 12 hr night shifts and I don’t feel embarrassed to say it’s really tough plus cross coverage from interns who need lots of help now where 2-3 times per night I’ll have to see a sick patient who may need transfer etc. These patients are actually pretty complex if you take the time to do the thorough H&P process and I have noticed that the admitting H&P is really critical because the academic team usually anchors on my initial assessment and reasoning. There are a couple things I’ve noticed are major time drains:

1.) Incorrect assessments by ED providers which require me to take time to facilitate/step on toes to redirect care/triage to grump people who don’t want to he woken up. I’m not saying the ED is stupid but sometimes I guess they’re rushed with all the garbage that comes in, 5-10% of which is actually an emergency.

2.) Dependent patients with 20 medical comorbids from nursing facilities where I have to chase down records, MARs, families, and confirm/readdress goals of care especially when they’re sick with COVID with maybe superimposed PNA vs alternate Sepsis, drains that need management, presenting on NRB but have full code status documenting full code at 85.

3.) Patients from other facilities where I have sparse paper records with every 10th paper being important with some rare FUO or other issue someone else can’t figure out.

How do you guys navigate this? I’m still hellbent on writing thorough H&Ps with accurate details but it’s getting draining and I’m getting burnt out. I’m handling it well and have receive feedback that H&Ps are excellent and thorough and all the times looking back I did the right things and never missed anything like a brewing infection, etc. It’s just very draining and I think there’s got to be ways to streamline the process and want to hear from some veterans who’ve been doing this for a while.

I also recognize medicine admits aren’t super critical/emergent and there’s ways to cut corners like not getting the full history overnight, leaving detective work to day teams, etc. but I don’t think that’s the right thing to do and I strongly believe the point of the admission is the time to reconcile meds, figure out the story, because later on the day team is busy with other patients and families are at work. It’s a balance I suppose. Wanting to hear from others.

Ok ok ok I'm back. Reading all the already existing replies, didn't realize that you're a resident. That changes things somewhat, but the core of what I want to say is the same.

At a certain point, particularly on nights, you just have to do your best with the information you have and accept that you're not going to be complete. You document what you were able to find and what you weren't, and you don't need to explain why in your note beyond the records were unavailable. You should not be tracking down nursing home records to get a med rec if you have 10 patients to admit in a night. I know it doesn't feel good to be incomplete, but on nights, completeness is not the goal; surviving (and helping the patients survive) is the goal.

@DrMetal, patients do die sometimes. And many times, yes, they were on that trajectory anyway. but it's our job to see the critically ill patients as a top priority to ensure they don't decompensate if that's even remotely possible. We keep patients out of the ICU. We keep ICU patients from dying (when possible). That's the job. And if looking for records interferes with that, you have to just accept that it's not going to happen and move on.

Incompleteness as a nocturnist attending, of course, is a little less frowned upon because, at least in my hospital (before I quit because I started hating my life and found hospital medicine boring), you're the only one there. There is one doctor. You tell the nurses they need to not page you about mundane things (and they never get the message because they're not trained to know what is critical and protocol dictates they must for certain things and the charge nurse interferes or whatever) and you ignore the parts of the history that aren't relevant and you don't worry about functional status because overnight that just can not be your priority. You will miss the actual important things.

My system at night before I saw any patient:

1. Admission orders with urgent medications like antibiotics
2. Write ED course
3. Find past medical history available in chart
4. Go visualize patient
5. Write note
6. ONLY IF I DON'T HAVE ANYTHING ELSE TO DO - try to find out more history if it's available.

And of course, if I get four patients at once, I typically do the first step all 4 times then the second step all 4 times then the third step 4 times etc.

But those first five steps is where you need to STOP if there's another patient to see on nights.

As a resident, you may be in a different situation where the expectation of you is different. Sorry about that. The medical system abuses residents. but this is how nights need to work, particularly if you have cross cover.

Good luck.

Edit: Oh, and try to clarify code status if at all possible, but sometimes they are just FULL CODE by default. It happens. It sucks, but it happens.

 

[rokshana]

It's so stupid how we teach one thing and completely practice another.

I once had the band director ( when I was in middle school) say… I’m going to teach you how to do it the normal way so you know how it’s supposed to be… only then will you be able to make changes …
You need to know how things need to be done, to know what safely can be eliminated…otherwise…dunning Kruger…I’m other words… you have the knowledge of a midlevel….

 

[rokshana]

Meehh . . . .To be fair, you're hardly ever responsible for a patient's death. Most who die come in already set on this trajectory, usually not much you can do.

Your job at night is to keep them alive til 7am…unless they are a dnr and the code, otherwise you jeep them alive too.