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Making your choice: On-call overnight physicians versus 24/7 staffing

Hospitalist Management Advisor, August 1, 2008

When it comes to overnight shifts, the decision to either staff your hospitalist program with around-the-clock physicians or on-call physicians can greatly affect your program’s budget, staffing, and effectiveness.

Although programs are increasingly choosing the 24/7 staffing route, the decision still comes down to what is best for your program, as industry experts continue to debate whether having attending physicians on the floor is always necessary.

On-call versus 24/7 staffing

In an ongoing retrospective analysis, Kenneth Epstein, MD, MBA, director of medical affairs and clinical research at IPC The Hospitalist Company, Inc., a leading physician practice group, and a faculty member at the University of Colorado School of Medicine, both in Denver, says he finds scant evidence of a difference between quality indicators of patient care in departments that use on-call physicians and those that use attending physicians at night (nocturnists). Epstein says there seems to be little difference between the programs in terms of length of stay (LOS), readmission rates, and patient satisfaction.

However, David J. Shulkin, MD, president and CEO of Beth Israel Medical Center and professor of medicine at Albert Einstein College of Medicine, both in New York City, says that based on his experience in rounding overnight at his hospital, he finds a clear difference in the quality of overnight care provided in hospitals without nocturnists compared to those with them.

The case for on-call coverage

Although no one would ever say it’s a bad thing to have a hospitalist physician on the floor at all times and ready to attend to patients, Epstein questions whether 24/7 coverage is necessary and financially feasible for all facilities.

Epstein originally reported his findings in a 2007 abstract at the Society of Hospital Medicine’s annual conference. He is currently concluding his research in a retrospective analysis article to be published in 2009.

Epstein studied 85 IPC hospitalist programs; some are 24/7 programs, and some use a traditional on-call system. He found no measurable advantage to 24/7 programs. 

“Hospitals are paying a lot for 24/7 coverage, and there is no data in the literature that it improves quality, reduces mortality, or shortens LOS,” he says.

One reason for this lack of difference in the data is admission times, Epstein says. At most hospitals, the majority of admissions come in during the day shift or the evening portion of the night shift. Most of the night shift is simply about being in-house and available for emergencies, he says, although, at some of the busier programs, the night shift doctors are occupied all night with admissions. Similarly, like admissions, most patient encounters occur during the day.

Because quality measures don’t drastically change in 24/7 programs, says Epstein, the night shift is a cost that does not pay for itself since it creates more admissions and billable services and, therefore, requires hospital subsidy.

Epstein notes that there are hospitals where nocturnists can be quite beneficial, mostly the larger facilities that have a lot of overnight admissions. In these facilities, nocturnists are more likely to cover their salaries by seeing more patients and performing more services, while helping to “significantly reduce the daytime workload of the other doctors,” he says.

Although hospitals that need nocturnists for night admissions and busier workloads can more easily justify the costs of having around-the-clock coverage, hospitals without that need may be spending too much money for quality improvement that isn’t necessarily taking place, Epstein says.

One reason this improvement might not be occurring is a general lack of extra resources and less staffing during the night and weekend shifts, Epstein says.

“Most programs usually only have one doctor on at night,” says Epstein. “Also, [hospitals] can use nurse practitioners [NP] and physician’s assistants [PA] during the daytime easier because more physicians are available for backup.” 

On the other hand, there are benefits to an on-call program as opposed to a 24/7 program, Epstein says, including:

  • Lower costs
  • The ability for physicians to go home if it is quiet and then come back to the hospital if needed
  • The difficulty of finding physicians who are willing to work overnight frequently

The case for nocturnists

Shulkin positions himself on the other side of the overnight hospitalist argument. Although the numbers may not show it, Shulkin says, there is a clear difference in the quality of care during the overnight shifts at most hospitals, especially those without an attending physician on hand all night. Patients do not get the same attention at night if they are relying on a nurse, PA, or NP to call a physician at home with changes in status, he says.

Even though many hospitalist services, such as teaching hospitals, only have in-hospital staffing during 12-hour daytime shifts, overnight patient care tends to decline in those cases, Shulkin says.

“Fewer people can mean that there are weaker responses during emergencies and crisis,” he says. “[It] can also mean that staff can be stretched thin, especially during times of volume surge.”

Shulkin adds that even in 24-hour models, many of the physicians staffing the night shift aren’t as experienced as their counterparts from the day shift. “Finding qualified hospitalists to work nights and weekends is a challenging task in a competitive market,” he says. The more experience most physicians gain, the more they want to work predictable, 9 a.m.–5 p.m. hours, he adds.

Effective nighttime coverage depends on a strong system in all areas of the hospital. Having attending physicians at night is a good start, but then you need to work on systems and communication channels, says Shulkin.  Simply adding nocturnists doesn’t improve quality of care if you aren’t integrating them correctly and using the same hiring standards to staff all shifts, he says.

Admissions occur at all hours in a hospital, and “since the most critical time for many patients is during those first few hours of admission, this need can be impacted by who and what services are available,” says Shulkin.

For example, when you admit a patient, you need the diagnosis to be correct, the management plan to be established, and the treatments started right away. You are diminishing the quality of care if there are limitations in any of the resources needed to accomplish these tasks.

Not having specialists available or not being able to run a test that is needed to assist in diagnosis or a treatment will reduce the effectiveness of patient care, says Shulkin. When starting an around-the-clock program, these are issues you must consider to ensure that hav-ing the nocturnists is worthwhile.

Your staffing levels don’t necessarily have to be the same at night as during the day to successfully run a around-the-clock program, Shulkin says. “Staffing patterns should correspond to the workload. If a hospital had more admissions at night, then, yes, it should be staffed that way. The key is that the staffing must align with patient needs,” he says. “The nocturnist must have good handoffs and access to information. They must have support from specialists and intensivists if needed, including radiologists and others.” 

To improve your care during overnight hours, you should also look for weaknesses in the system, especially in medication practices and other ancillary support services.

Shulkin says there are data that show that large teaching hospitals perform better on many key quality measures. He notes that adding attending physicians at night will only improve those statistics. 

“The key is that in hospitals, the more people around, the more redundant systems, the better the chance to avoid complications and error and improve outcomes,” he says. “Junior residents, senior residents, chiefs, fellows, attendings, and specialists all feed off each other and provide this level of redundancy and safety.”

Shulkin says financial constraints often make it difficult to ideally staff the hospital at night, and on-call physicians can be extremely responsive. “However, if the system is designed so that the attending physicians do not ever come in and the staff is left to fend for themselves, then the system can be flawed,” he says.

Mixed findings

Shulkin and Epstein say there is no system that works for all hospitals.

Although some facilities clearly need overnight staff members to handle the patient volume, others would be wasting valuable resources by having a physician constantly present during the night for minimal amounts of patient care.

The field is always changing; the important thing for hospitals to do is to analyze their own situation and make the decision that is best for their patients, Epstein and Shulkin say.

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