Background: The landmark adoption of the 80 hour work week by the Accreditation Council for Graduate Medical Education (ACGME), followed by shift-length restrictions has forced both hospitals and residency programs to restructure who provides acute medical care and in what fashion. Academic Medical Centers have increasingly relied on hospitalists as traditional teaching attendings, in the management of patients not covered by resident inpatient teams, and in the care of patients and supervision of trainees during the overnight hours.Multiple studies demonstrate the perception by residents and attendings alike that onsite, engaged attending presence results in an improvement in the educational atmosphere for residents, and higher quality care for patients. This study is an effort to better understand the direct impact of overnight hospitalist supervision through reviewing the specific changes attendings recommended to resident plans.
Methods: This is a retrospective study of overnight hospitalist data logs from July 1, 2016 through June 30, 2018 at the Michael E. DeBakey Veterans Affairs Medical Center, located in Houston, Texas. Faculty hospitalists worked 12 hour overnight shifts during which they performed independent admissions when the residents had completed their allotment or as needed in order to expedite care when multiple patients are being admitted. Hospitalists discussed all resident admissions and saw patients in person as needed. Further, they reviewed medical consults and oversaw residents during rapid response or code blue calls.Hospitalists kept a nightly computerized log of their activities in which data entry was expected, but voluntary. The log had basic admission data and an entry field for “changes made to plan based on hospitalist input”. The study authors transferred the free form text into categories for basic data analysis.
Results: The residents completed 5612 admissions and the hospitalists performed 1731 independent admissions. Hospitalists recorded responding to 161 rapid response calls and 97 code blue calls; they supervised 95 general medicine consultations and 31 procedures. Hospitalists documented changes to resident plans on 1485, or 25.0% of patients. Antibiotic changes were made in 3.9% of all patients, while other medication changes occurred in 7.1% of patients. 4.2% of patients were advised to have a change in imaging or stress testing. In nearly 2% of admitted patients, the hospitalist identified that an Intensive Care Unit consultation should per obtained, and more than 70% of these patients were immediately accepted.
Conclusions: Hospitalists make a significant contribution to patient care, beyond performing independent admissions during overnight shifts. While this study has the weakness of being a voluntary, self-report of interventions, it is unique in the medical literature for concretely identifying the frequency and types of changes put forth by attendings during the overnight hours. One may argue that many of the adjustments would have been made the following morning while on rounds, but the value of expediting care should not be underestimated. The identification of patients in need of transfer to the Intensive Care Unit by attending physicians was crucial for patient safety, and this onsite and immediate feedback about patient acuity was vital resident training. This study gives weight to the perception that overnight hospitalist supervision truly impacts patient care and resident education.