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 Night Float

People learn better when they are not excessively fatigued.  We design our residents' experiences to be challenging but not overwhelming.  We have had night float for senior residents for many years.  Night float for first year residents started in 2006.

First Year Night Float

First year night float starts with sign-out at 6:00 pm Sunday night through Thursday night.  Teamed with a senior resident, the family medicine night float manages floor calls, emergencies, and admissions for the family medicine service.  With the senior resident by their side, first years direct codes on all hospital patients. 

After 9:00 pm, the first year also takes calls from any Pregnancy Care Center patient.  Under the direction of the Obstetrical or Family Medicine Attending, the first year manages labor and delivers PCC patients on the obstetrical floor.  If a Cesarean delivery is required, the first year will first assist. 

When the OB floor is quiet, the resident rounds on service patients and helps with admissions.  Floating ends with morning report as the night residents transition the care of the patients to the Family Medicine Service.

Senior Night Float

Senior night float starts with sign-out at 6:00 pm Sunday night through Thursday night.  The senior backs up the first year resident for all activities.  The senior sees all admissions and consults and does night rounds on the service patients.  The senior does not just handle emergencies, but gets to know each patient and helps fine tune their management.
 

Altoona Family Physicians

Night Float Goals and Objectives

Resident Year:                       PGY1, PGY 2 and PGY3

 AFP Faculty Contact:           Jennifer Good, MD

 Rotation description and general goals:

            The night float rotation is designed to provide continuity of care for hospitalized patients and to minimize frequent overnight in-house call.  A unique feature of the AFP night float rotation is that utilization of a “team” consisting of an intern and a senior resident allows for continuity of care, in that the same team cares for hospitalized patients each night (during the week) and also allows minimal disruption of the daytime inpatient team for work-hours rules because the inpatient residents are not taking overnight call.

             The residents spend 2 months on the night float rotation during their PGY1 year and one month during the PGY2 and PGY3 years.  In general the senior residents divide their month of night float into 2 ½ month blocks.  The residents at Altoona Family Physicians spend a total of 4 months on the night float rotation during their residency.

             While on this rotation residents are expected to arrive nightly for sign-out rounds at 6 pm.  The night float resident and intern are expected to be in the hospital until morning report is over at 8 am.  The night float team is expected to leave morning report at 8 am, even if it is not completed.  On rare occasions, it is necessary for a night float resident to be in the hospital later than 8 am.  In this instance, it is expected that they will not return that night until later, in order to ensure that they have a full 10 hours off (for example, if the resident is in the hospital until 8:30 am, he is not expected to return for sign-out rounds until 6:30 pm).  The “work week” for night float begins at 6 pm on Sunday evening and is completed following the resident’s office hours on Friday.  There is no weekend responsibility on this rotation (night float residents do not work Friday or Saturday night).

            The overall goal of the night float curriculum is to train family medicine residents to provide independent care for common medical problems requiring hospital admission and to utilize appropriate consultation with specialists when additional assistance is required.  Another purpose of the night float curriculum is to optimize continuity of care of hospitalized inpatients by having a consistent “night team” and also ensuring that there is minimal disruption of the daytime team.  The curriculum is structured such that residents gradually progress from care that is dependent on close supervision by senior level residents and faculty to unsupervised, independent care by the time the resident graduates. 

 Teaching Methods:  the night float affords many opportunities for teaching, including but not limited to:

·         Morning report:  Morning report occurs daily and most days a faculty physician is in attendance.  

·          Didactic teaching:  Residents are generally excused from noon conference during their night float rotation. 

·         Clinical teaching:  Residents are not expected to make inpatient rounds with the attending during their night float rotation.  The night float resident will call the on-call attending physician with any new admissions and acute problems occurring over, and this interaction will provide opportunity for clinical teaching.   

Supervision: 

·         PGY1 level residents have immediate supervision by a PGY2 or PGY3 level resident that is available in the hospital at all times. 

·         There is a faculty on-call at all times available by pager should assistance be required by any resident in dealing with questions while on the inpatient family medicine or night float rotation. 

·         Faculty are apprised of any procedure being done by the resident while on the inpatient service and are expected to supervise that procedure if either the resident or faculty feels supervision is necessary. 

Resident Evaluation:   

            Each resident on the inpatient family medicine rotation is evaluated using a competency-based evaluation tool at the end of the rotation.  These evaluations are reviewed by the family medicine faculty quarterly and reviewed with the resident at the resident’s quarterly evaluation.  Occasionally, situations arise which require more immediate feedback and in these situations the resident is given feedback by the faculty on the inpatient service, the faculty advisor or the program director.  Specific resident evaluations include: 

·         Evaluation by resident peers (senior resident is evaluated by the intern; the intern is evaluated by the senior resident). 

·         Evaluation by the faculty attending on inpatient.  (As each faculty is on inpatient for one week, the resident may by evaluated independently by three to four faculty members in a one month rotation). 

·         Evaluation by nursing staff and case management staff. 

Program Evaluation: 

·         Each resident (intern and senior resident) is expected to complete a written evaluation of the inpatient rotation and each inpatient faculty each month that they are on inpatient. 

·         The inpatient curriculum is reassessed annual as part of the Altoona Family Physicians annual curricular review. 

Educational Resources: 

www.utdol.com:  This is a subscription-based resource but is available at the Altoona Hospital Library.  It is a great place to get started with specific hospital medicine questions. 

http://www.jhcme.com/site/ce.cfm:  This website contains “modules” from the Johns Hopkins University Consultative Medicine Service about topics germane to hospital medicine.  Some of these modules include perioperative cardiac risk assessment, perioperative cardiac risk modification, perioperative anticoagulation management, the role of the medical consultant, hospital pain management, etc.  There are pretests and post-tests associated with these modules. 

http://ecg.bidmc.harvard.edu/maven:  This is an excellent site from Harvard Medical School with ECGs for review.  This can be done either in a “review” formal or a “quiz” format. 

www.med-ed.virginia.edu/courses/rad/cxr/index.html:  This is an outstanding web-based tutorial for chest x-ray interpretation.
 

SAMPLE SCHEDULE:   

PGY 1: 

 PGY 2 and PGY 3*: 

 *PGY 2 and PGY 3 residents typically do their night float month in 2 separate 14 – 16 day blocks (1/2 month).

PGY 1: 

·         Complete an admission history and physical examinations on all patients admitted to the inpatient medicine services.  These history and physicals will be dictated into the hospital dictation system at the time of admission.  These H & Ps are reviewed by the attending physician on the inpatient service.  Additionally, a small number of each resident’s H & Ps are provided to the faculty advisor for review. 

·         Write admission orders for each patient admitted to the inpatient service at the time of the patient’s admission.  It is expected that these orders will be legible, and reflect an appropriate diagnostic and therapeutic approach to the patient’s medical problems.  These admission orders are reviewed by the senior resident (either on AFP service or night float) and the inpatient attending. 

·         See each patient nightly (once by the daytime inpatient team and once by the night float resident) and writing a legible and informative progress note.  The progress note will follow a “SOAP” format.  These progress notes will be reviewed by the attending physician on the inpatient service. 

·         Complete a discharge summary on each of their patients upon discharge from the hospital.  These discharge summaries are to be done within 24 hours of the patient’s hospital discharge and follow a standard format (see resident handbook).  Compliance with this requirement is ensured by the Altoona Regional Health Systems HIM department. 

·         Complete all obstetrical responsibilities on the night float service as delineated in the resident handbook. 

·         Respond to all hospital code events and provide current ACLS-based treatments. 

PGY 2 and PGY 3: 

·         Be competent in all of the patient care skills expected of the PGY 1 resident, and is expected to complete the above tasks if the intern has obstetrical responsibilities.

 ·         Supervise the PGY1 resident in all of the above responsibilities. 

·         Perform inpatient family medicine consults on hospitalized patients upon request.  These consults are to be done within 24 hours of request (4 hours if the patient is in a critical care unit) and are reviewed by the inpatient attending. 

·         Respond to all hospital code events and provide current ACLS-based treatments. 

All Residents: 

·         Understand the diagnosis and treatment of common illnesses requiring acute hospitalization, including but not limited too:  acute respiratory failure, acute and chronic congestive heart failure, acute coronary syndromes, acute and chronic renal failure, acute neurological syndromes including stroke and TIA, common infections such as cellulitis, UTI, sepsis and respiratory infections.

·         Understand iatrogenesis and risks of hospitalization

·         Understand pain assessment and management in the hospitalized patient.

·         Understand nutritional support in the hospitalized patients

PGY 2 and PGY 3 Residents:

·         Understand the principles of pre-operative evaluation of the surgical patient, including cardiovascular risk assessment, pre-operative management of diabetes and hypertension, pre-operative anticoagulation management and pre-operative glucocorticoid management.

·         Understand the principles of post-operative care, including post-operative blood pressure management, post-operative diabetes management and post-operative nutritional support.

·         Understand the principles of post-operative pain management, including use of patient-controlled analgesia.

·         Understand principles of inpatient medical treatment of the pregnant patient.

 All Residents:

·         Read on a regular basis about the cases that they are seeing on the inpatient family medicine service.   

·         Present patients daily at morning report.  It is expected that these presentations be accompanied by a current, evidence based treatment plan.  These presentations will be assessed by the faculty members in attendance at morning report and the resident given feedback via rotation evaluations. 

·         Locate, appraise and assimilate evidence from scientific studies related to their inpatients’ health problems. 

·         Utilize information technology to optimize learning. 

·         Participate in the education of patients and their family members. 

·         Participate in the education of medical students and other residents through presentations and discussions at morning report and nightly sign out rounds. 

PGY 2 and 3: 

·         Serve as a model of problem based learning improvement for the more junior member of the team, and is expected to assist the residents and medical students in locating and appraising medical information, and occasionally providing that information for them.

Communication with colleagues/continuity of care

·         Communicate effectively with physicians, other health professionals and health related agencies.

·         Act in a consultative role to other physicians and health professionals. 

·         Maintain comprehensive, timely and legible medical records. 

·         Ensure safe transition of patient care with complete sign-out in the morning and evening and communication with primary care physician. 

Communication with patients 

·         Create and sustain a therapeutic and ethical relationship with patients. 

·         Provide appropriate patient education on diagnoses and treatment plans based on the literacy level of patients and their caregivers.

·         Responsibility in patient care by responding in a timely fashion (< 20 minutes) to all pages.  Their attention to this requirement will be assessed in rotation-end evaluations by nursing staff. 

·         Compassion, integrity and respect for others. 

·         Sensitivity and responsiveness to a diverse patient population, including, but not limited to diversity in gender, age, culture, race, religion, disabilities and sexual orientation. 

·         Respect for patient privacy and autonomy 

·         Regularly contact other health professionals caring for their patients in the hospital, including but not limited to nursing staff, case management staff, respiratory therapists, physical and occupational therapists and pharmacists.  This objective will be assessed in part by evaluations done at rotation end by nursing and case management staff.

·         Work effectively in the Altoona Regional Health System and cooperate with hospital-wide quality initiatives, such as DVT prophylaxis, infection control protocols, stroke protocols etc.

·         Request specialty consultation when indicated.

·         Incorporate considerations of cost awareness and risk-benefit analysis in patient care.

·         Work within interdisciplinary teams in order to provide quality, comprehensive inpatient care.

·         Participate in identifying system error and in implementing potential systems solutions.