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Night Rotations Curriculum

Cambridge Hospital Ward Medicine Night Rotation Curriculum

Revised: June 7, 2012

Rotation Director:
Priyank Jain, MD
pjain@challiance.org


Description of Rotation

One team comprised of one resident and one intern provides care to hospitalized internal medicine patients on two general medical wards (4W and 6N). Resident service patients are primarily located on 4W per our geographic rounding policy. All resident care of patients is supervised remotely by hospitalist attending physicians and primary care physicians from affiliated primary care clinics.

The night teams assume responsibility for the care of all the medical inpatients on the resident service which includes obligations to admit new patients, to address emergent patient needs, and to advance the care of all patients including preparation for the following hospital day such as ordering tests and requesting consults and completing necessary paperwork.

The night rotation serves as an important adjunct to the inpatient training provided during the ward rotations.  At night, residents receive a broad introduction to the initial evaluation of a wide variety of conditions in general internal medicine and gain experience in the management of emergent medical problems.  As described in the documentation for the ward medicine rotation, the inpatient population is diverse with approximately 50% of patients speaking primary languages other than English.   In addition to the routine case mix for general internal medicine and intensive care at a community hospital, the rotation provides a unique opportunity for residents to consider the complex relationships between health status and poverty including in depth clinical experiences with substance abuse, comorbid medical and psychiatric disease, geriatrics, HIV/ AIDS, homelessness, international and immigrant health.  Residents function with greater autonomy than during day time hours and the night curriculum places a high premium on self-directed learning.


Goals and Objectives

Broad goals and objectives for the inpatient night rotation are similar to those identified for the day time ward rotation with some objectives that are unique to night time clinical service and learning. Objectives are listed below and organized within the six core competencies identified by the ACGME.

Medical knowledge

During the inpatient night rotation, interns and residents should:

  • Access and critically evaluate current medical information and scientific evidence relevant to patient care
  • Build basic fund of knowledge related to clinical diagnosis and management of common and “cannot miss” diagnoses

Patient care

During the inpatient night rotation, interns and residents should improve their ability to:

  • Interview and examine patients
  • Define and prioritize patients’ medical problems
  • Generate and prioritize differential diagnoses
  • Assess patient stability and assist in triaging patients to appropriate levels of care
  • Develop rational, evidence-based management strategies
  • Perform basic clinical procedures and interpret common radiology studies
  • Manage common inpatient medical emergencies

Interpersonal skills and communication

During the inpatient night rotation, interns and residents should improve their ability to:

  • Communicate effectively with patients and families
  • Communicate effectively with physician colleagues at all levels
  • Communicate effectively with all members of the health care team
  • Present patient information concisely and clearly, verbally and in writing
  • Teach colleagues effectively


Professionalism

During the inpatient night rotation, interns and residents should:

  • Develop greater self understanding and appropriately acknowledge need for help and supervision
  • Practice self care
  • Behave respectfully with colleagues including effective conflict resolution, reliability, honesty, punctuality
  • Demonstrate a commitment to standards for lifelong excellence
  • Cultivate compassionate relationships with patients and family

Practice-based learning and improvement

During the inpatient night rotation, interns and residents should:

  • Demonstrate curiosity
  • Develop capacity to ask and find pragmatic answers to clinical questions
  • Complete a narrative reflection on a difficult situation encountered overnight and summarize key learning points

Systems-based practice

During the inpatient night rotation, interns and residents should improve their ability to:

  • Manage transitions of care effectively with the day-time ward teams
  • Use evidence-based, cost-conscious strategies in the care of hospitalized patients.
  • Advance the care of patients effectively overnight by anticipating patient day time needs
  • Participate in improving systems of care, including assurance that patients are appropriately staffed with the correct attending of record overnight
  • Participate in improving the inpatient night rotation as a resident clinical learning experience


Clinical Encounters and Learning Venues

During the night rotation, residents develop the above listed competencies through the following venues:

  • Initial evaluation of new admissions to the hospital and overnight management of hospitalized patients
  • Procedures including abdominal paracentesis, ABG, lumbar puncture, NG tube placement, thoracentesis, central line placement, EKG analysis
  • Consultation with other physicians on patient care including: the ED attending physician, the covering medical attending of record, medical subspecialists, surgeons, psychiatrists, podiatrists, gynecologists, and radiologists
  • Active participation in Morning Report

Principal Resources

  • On-line databases including UptoDate, Lexicomp
  • Primary and secondary medical literature accessible through full-text searching using PubMed
  • Textbooks of internal medicine including Harrison’s, Washington Manual, Wachter’s Hospital Medicine
  • Consultation with generalist primary care and hospitalist physicians and subspecialists


Rotation Schedule and Hours of Work

Work hours and nightly schedule

The night resident and the night intern work Sunday through Thursday nights, from 7pm to 9am.  On Friday and Saturday nights, a float night resident and one of the ward interns comprise the ward night team and work from 9pm to noon the next day. The ward night resident will work with the night ward intern to care for patients on the general medical wards.  Another team composed of a night ICU resident and night ICU intern manage the patients located in the intensive care unit. We expect that the two teams work together to maximize patient safety and fairly distribute labor in situations of medical emergency and at times of heavy patient flow.

At 7 pm Sunday through Thursday, and 9 pm on Friday and Saturday, the ward night team will take sign out from the day teams.  Formal bedside rounds are recommended for any complex or unstable patients. 

From 7:15-7:30 pm, the long call team resident team joins with the night resident and night intern, the night hospitalist, and the bed coordinator to review respective patient lists, clarify team assignments for any pending admissions, and review critically ill patients in what is known as the change of shift huddle.

Midnight rounds: At midnight, the night intern and resident should meet with the night nursing staff at the 4West nurses station to review any active patient issues.

During the night, the interns work under the supervision of the residents to admit new patients, to respond to concerns that arise in the management of hospitalized patients, and to advance the care of all inpatients in anticipation of the following day. As is the case during the day, the first call on new admissions from the ED goes to the triage hospitalist, who will assign patients to the Ward Teaching Service or the Attending Service based on a set of triage principles. The program expects that interns will admit a maximum of five new patients overnight, including any patients that might have presented before 7pm but were not admitted by the day intern due to restrictions on patient cap. In addition to these five new admissions, an intern may take up to two transfers. After the fifth new admission overnight, residents will admit patients without the assistance of the intern and write a “resitern” admission note.


Management and supervision

The resident has the responsibility of ensuring that all new patients are staffed with the attending physician of record and/or his or her coverage.  Patients admitted to the Ward Teaching Service with primary care attending physicians are discussed over the telephone with covering physician.  Patients admitted to the Ward Teaching Service with hospitalist attending physicians are staffed by the in-house nocturnist.  The nocturnist does not routinely evaluate every admission directly, but is available for bedside patient evaluation and review of secondary data at the discretion of the night resident.

Morning signout

Wards

Interns receive cross coverage signout on their patients between 7 and 8am.  During the course of the night, all patient events that need to be communicated to the day team should be compiled on the white board in the large 4 west workroom to ensure comprehensive sign out.

At 8am, the ward night resident and night intern join the on-call day team and the teaching hospitalist at morning report during which patients admitted overnight are presented and care is transferred to the day team.

Continuity clinics

Continuity clinics do not occur during night rotations for interns and residents.

Representative week for ward night rotation (interns and residents)

 

Night Team

Sun

Mon

Tue

Wed

Thu

Fri

Sat

Total

7pm-9am

7pm-9am

7pm-9am

7pm-9am

7pm-9am

OFF

OFF

70 hrs

 

Teaching and Learning

Residents and interns appreciate the relative independence of their night rotations and are encouraged in their self-directed learning in patient management.  Morning report provides a venue for resident on night rotations to practice their skills in bedside presentation and teaching.  Cases are formally discussed by the teams and hospitalist attendings.

On Wednesdays, the night team is expected to attend Department of Medicine Grand Rounds from 8am – 9am and morning report is held from 7:15am – 8am in the Macht Building room 414.

Evaluation

Resident Evaluation

Evaluation of resident performance during the night rotation is based largely on performance at morning report. The chief resident will provide feedback following morning presentations and will complete an evaluation at the end of the rotation.

Rotation Evaluation

Interns and residents are expected to complete an online evaluation form of the rotation.  Additional comments, questions, concerns, and suggestions for improvement are always welcome and should be directed to the rotation director.