Background: Hospitalists generally work one week on, one week off. Different hospitalists group switch on different days of the week, with almost all days of the week reported as switch days in the literature. It is unclear if choosing a particular day of the week as the switch day has an impact on length of stay. There is some concern that switching service later in the week, such as Thursday or Friday, leads to a longer length of stay. It is proposed that attendings are less likely to discharge patients on the day they switch, and a Thursday switch day pushes discharge disposition decisions to the weekend when most facilities have limited in the availability of logistical support. Our forty daytime Full Time Equivalent (FTE) faculty hospitalist group transitioned its switch day from Tuesday to Thursday in January 2019. We present the impact of switching the attending switch day from Tuesday to Thursday on length of stay on general internal medicine teams at our institution.
Methods: We have fourteen general internal medicine ward teams at our institution. Five of these teams are house-staff teams (one hospitalist attending, one senior resident, two interns, three medical students) while the other 9 are direct care teams (one hospitalist attending, one advanced practice provider, one to two students). We compared the length of stay for patients care for by our hospitalist faculty six months before and after we switched the attending switch day from Tuesday to Thursday. Our senior residents switch on the twenty-eighth day of the month, while our APPs work Monday to Friday. We present an adjusted comparison of length of stay six months before and after the change in attending switch day from Tuesday to Thursday.
Results: The Length Of Stay (LOS) on our general internal medicine teams increased by 0.06 days (95% Confidence Interval 0.01-0.11) after we changed our service switch day from Tuesday (N=2092) to Thursday (N=2192). The difference persisted after adjustment for demographics including age, gender, payer status and race (increase 0.05 days, 95% CI 0.003 to 0.10). However, the increase in length of stay was no longer significant after adjusting for Diagnosis Related Groups (DRGs), discharge disposition (home, subacute rehabilitation, skilled nursing facility, long term acute care facility and hospice) and risk of readmission (0.03 day increase in LOS, 95% CI -0.03 to 0.09).
Conclusions: Our results indicate that length of stay does not increase after changing attending switch day from earlier in the week (Tuesday) to later in the week (Thursday). LOS remains a critically important quality metric that is impacted by many system based factors. Moving attending switch day to later in the week does not seem to influence LOS. We believe our results fill a crucial gap in the literature and will allow groups to take other factors such as group preference, impact on attending work-life balance, learner needs and institutional needs in determining an appropriate switch day for the group.