Cross Coverage?

As I mentioned in my last post, I am currently on night float, and my responsibility is to cross cover all of the patients on the floor. I've learned some really important things over this last week and a half on night float.

1) Patients, especially really sick patients, get even SICKER at night
2) My upper level residents are great and always willing to help me out no matter WHAT time I call them
3) Cross coverage can lead to many issues that remain un-resolved and may actually impair patient care

This post will focus on dealing with the last point the most. As many people are now aware, residencies are required to adhere to an 80 hr work week for their residents (thank goodness for that!) But, there are some logistics issues with this that make it difficult to come up with the "perfect" system where both the residents are happy, doing good work, and patient care is not being compromised. The way things are set up at many hospitals to make sure the 80 hr rule isn't violated is to keep residents from taking overnight call, and instead having a cross-coverage come in and watch the patients. This is not a bad system in that in decreases the work load on the residents during the day allowing them to work better and more efficiently when they are at work. Everyone needs rest. BUT, the shortfall to this system is when the patients are signed out to cross-coverage without adequate information passed along to the night float, or even any other cross-coverage that occurs on other days/weekends as well. Little things get missed and not passed on from person to person which may end up adding to a big problem. Some things are avoidable, and other times when a patient starts to crash in the middle of the night, nothing could have been done to prevent it. My point is for those situations where SOMETHING could have been done earlier.

To make a comparison here: at my medical school, the on-call team actually admitted patients overnight, and cared for their own patients as well, while a nightfloat took care of all the other patients on the floor. Here, at this hospital, the on-call team does not stay overnight, therefore a nightfloat covers all the inpatient teams and admissions are also done by nightfloats. Both systems have their shortfalls and benefits. First is that with the second system, residents get more time off to make sure 80 hrs is not violated, and they are well rested and in a good state of health the next day for week. The shortfall is that every night, ALL inpatients are taken care of by a night-float who is not intimately involved with the patient's care. With the first system, residents are tired the next day after being on call all night, but at least their inpatients were taken care of by the actual team making sure that their issues are well known to the team. But, on the other hand, all the other teams' patients are covered by a nightfloat, so still the same problem exists. There really is no way to resolve this issue since a nightfloat coverage is needed otherwise EVERYONE would have to stay EVERYNIGHT to cover for their patients. It seems the best thing would be to make sure everything that needs to be done, followed up, etc be done PRIOR to the team leaving and not leaving tasks like that to be done by night float. A good, informative sign-out document should be passed on so that night-float knows what's going on with the patient if he/she gets called in the middle of the night.

I wonder how other programs have addressed this issue, or maybe this is just a problem across the board now with the 80 hrs. So that's my issue for the day. Soon, I'll be back on days, and no longer have to sleep in a coffin during the day and will hopefully get to see the sunlight!