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Night Owls

July 20, 2011
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Hospitals are turning to nocturnists to address care quality issues during night shifts

A few years ago, the concept of a “nocturnist” was completely novel; but, as a Kaiser Health News/ Washington Post feature by Sandra G. Boodman, published last month, found, more and more hospitals are turning to these new-ish specialists to address patient care quality disparities between daytime and nighttime shifts in hospitals.

So just who are these “nocturnists”? Some are boarded in internal medicine; some are hospitalists who have moved over from the day shift to the night shift. And, according to some reports, nocturnists are getting paid more for doing the same thing at night that their diurnal counterparts do while the sun is shining. Why so? Because, as the clinical literature has found, there continues to be a significant quality gap between daytime and nighttime care outcomes.

As the Kaiser/ Post story noted, “A 2008 study published in the Journal of the American Medical Association found that patients who suffered a heart attack in the hospital during off hours—when 50 to 70 percent are admitted—were less likely to survive than those who had a cardiac arrest during normal business hours.” It also mentioned a University of Pennsylvania study from last year that found that the quality of cardiopulmonary resuscitation at three urban teaching hospitals was poorer at night than during the day.
The Kaiser/Post story also recounted a tragic situation that unfolded in May 2007 in St. Louis, when a 13-year-old boy was admitted to a hospital there for surgery to fix a blocked shunt that had been implanted in his head as part of a successful treatment for brain cancer that the boy had had as a baby. In that case, it appears that the fact that the boy was treated by a resident rather than an attending made a life-or-death difference, and the boy died.

Enter the nocturnist, who has the authority, prestige, and experience of an attending physician, and who is thus far better-positioned than his or her resident counterpart to “grease the wheels” and initiate and prod forward key care delivery processes. According to John Nelson, M.D., a pioneering hospitalist who coined the term “nocturnist,” about 1,500 hospitals now employ at least one nocturnist, compared to fewer than 100 that did so a decade ago.

And while this phenomenon has unfolded rather quietly, one of the things that immediately struck me in reading the Kaiser/ Post story is that one absolutely critical element in the success of any nocturnist-facilitated care program will be a truly robust electronic health record (EHR) with strong physician and nursing documentation, a strong electronic medication administration record (eMAR), and so on. One of the great elements in having a nocturnist or nocturnists on staff at a hospital is the ability to eliminate nighttime on-call periods for attendings. But without very strong clinical information systems, the tremendous potential for care delivery improvement can’t be achieved.

But, given optimal implementations of strong clinical IS, innovative approaches to care delivery like nocturnist programs could really make a difference to outcomes over time. In other words, this is yet another reason, along with the many dozens we already know, that it’s past time to create and optimize the information systems that can support the highest-quality care that patients, their families, and our society deserve, and that are within reach by patient care leaders who dare.