Do We Deliver Great Care Even At Midnight?


By:  The Generation Y Surgeon (@GenYSurgeon)


Sick Patients Highlight The Issue


It was 1:00am, and I was at bedside with a complicated post operative patient in the ICU who had recently presented with upper gastrointestinal bleeding.  The resident surgeon and I (I’m a fellow now) were on the phone trying to get in touch with nuclear medicine, with GI, and with interventional radiology…and none of them were answering.  Ten minutes passed.  Then twenty.  I timed it because when patients are as sick as this guy, every minute feels like an hour, especially when you’re waiting for a call back.  I was curious how long it would take them to return a call.  Any of them. Why had all of our consultants turned into pumpkins after midnight?  This patient needed their help–and he was sick.


Two Hats & Misalignment


I can sympathize with providers who are forced to wear two hats: the elective, daytime hat and the emergency responder, middle-of-the-night hat.  The gastroenterologist I call doesn’t just have to get out of bed in the middle of the night, they also have to face a full day of elective cases and clinic patients in the morning.  The interventionist calls in an entire staff and is often left to struggle through elective procedures with a skeleton crew the following day.  The aftermath of responding to midnight consults must be a terrible deterrent for them.  Sympathies aside, many midnight consults cannot wait to be seen in the morning and patient welfare is at stake.


Oh, by the way, many docs are reimbursed related to the number of cases they do (and RVUs they produce).  Would it make sense for them to struggle for a few extra RVUs that are hard to get when it’s 2AM and the patient is critically ill only to struggle more to do the rapid turnover, elective cases the next day?  God forbid you’re so tired from the midnight work for that patient that you have to cancel some elective cases for the next day.  Does it make sense to them to work hard at 2AM with this patient and phone call, or instead just to sleep and focus on the elective “daytime hat” cases that their contract incentivizes them to do?  Could those same docs be faulted if they adopted the “they wouldn’t have survived anyway” mentality that I so commonly see providers use to make themselves feel ok about the difficult situation they’re in?  Yes, some people will pass away no matter what.  However, in one system in which I’ve worked, even people who “wouldn’t have survived anyway” did survive–and it was because the system was setup properly.


Hospitals really need to make sure they are incentivizing the kind of behavior that leads to the best (yet often labor intense) outcomes for critically ill patients–because, now, sometimes they don’t.


A Lesson From Taco Bell That We Should Learn


Did you ever notice that (if you need gas or a snack) there’s always a gas station open?  If you feel the need to harden your arteries at 3am, there’s usually even a Taco Bell that’s both waiting and willing to help you.  Walmart’s doors are open 24/7 (and holidays too!) for electronics, groceries, household items or people watching.  You can even get photos developed.  Why aren’t hospitals that provide care for critically ill patients 24/7 entities as well?  People need healthcare around the clock, emergencies don’t wait.  Maybe it doesn’t need to be all hospitals, but the ones that take care of sick people need to get this right.


By the way, did you know trauma tends to be “a disease of nights and weekends”? If you look at many trauma programs (that care for critically injured patients when time is short), there’s often an influx of patients at night time and on weeknights.  Those are the busy times.  And when are those programs the most short-staffed?  You got it:  those same nights and weekends.


Here’s an exercise: knowing what you know now as a provider (and assuming you had all the power and influence you would need) think about how you would run a hospital?  How would you schedule your physicians and staff?  What would the hospital look like at 8am, at noon, at 4am, or on Sundays?  Obviously, things need to change.


One System To Help Them All


Changes in a hospital system are tough to perform (there are some useful steps described here on the blog); however the Acute Care Surgery model (ACS) is an excellent example of positive change.  ACS is more of a system than a specialty.  Hospital with well-run programs are able to provide consistent access to surgeons for both patients and for consulting teams.  ACS also serves a sort of triage service for acutely ill patients, taking much of the brunt for their daytime colleagues and even for the consultants.  It turns out that general surgeons actually end up doing more cases when they aren’t burdened with emergencies that interrupt their flow and consume resources.  Having a fully-equipped surgeon who specializes in emergency care (and knows when and why to call in consultants) as part of a system is much more effective than other processes of dealing with critically injured or ill patients.  Having a provider like an ACS surgeon in-house takes a huge burden off the system, and the entire system grows in terms of cases performed even as the overall quality improves.  It’s the only real 24-hour specialty outside of emergency medicine.


Now You Know, So You Must Act


Our patients need us 24/7, so shouldn’t we be adequately staffed to provide care 24/7?  Shouldn’t the hospital be more like a Wawa (or Sheetz) than a bank?  In a perfect world, it would be….with the hum of the hospital sounding exactly the same, regardless of the hour or the day  or day of the week.  We should aim to get great outcomes for everyone all the time and now we face a choice because we know what it takes.  And so now we are obligated to act on what we know.