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Night Rotations Curriculum

Cambridge Hospital Ward Medicine Night Rotation Curriculum

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

Description of Rotation

One team comprised of one resident and one intern provides care to hospitalized internal medicine patients on general medical ward. Resident service patients are primarily located on 4W per our geographic rounding policy. All resident care of patients is indirectly supervised by hospitalist attending physicians.

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, medical subspecialists, surgeons, psychiatrists, podiatrists, gynecologists, and radiologists
  • Handoff to and from the day-team

Principal Resources

  • On-line databases including UptoDate, Dynamed
  • Textbooks of internal medicine including MGH handbook of internal medicine
  • Consultation with hospitalist attendings and consultants

Schedule and Expectations

Work hours and nightly schedule

The night resident and the night intern work Sunday through Thursday nights, from 6 p.m. to 8 a.m. On Friday and Saturday nights, a float night resident and intern comprise the ward night team and work from 6 p.m. to 8 a.m. 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 6 p.m., the ward night team will take sign out from the day teams. Bedside rounds are recommended for any complex or unstable patients.
  • At 7 p.m,. the night team meet with the night hospitalist 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. Night team should meet with nurses at start of their shift to communicate this plan, as this can susbtantially cut down on interruptions for non-urgent questions.

Work assignment and caps

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 Resident team or Gold team 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 6pm 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 hospitalist attending. Night intern does a full presentation to the night hospitalist and gets feedback on their plan. On busy nights the staffing can be altered so some patients are staffed by resident, at resident's discretion. Night hospitalist sees every patient, regardless of who staffs. Night intern and resident still work independent from the night hospitalist, apart from staffing patients and other questions the night team have for the hospitalist.

Morning Handoff

Towards end of their shift the night team executes a careful handoff for the overnight admissions and events. This is done in the resident work room and requires preparation from day- and night- teams to occur efficiently and effectively. See Handoff template and expectations.

  • At 6 am, the night team sends out an email to day teams (and chief residents) with list of new admissions, team assignments and one-liner. See example.
  • 6:30 - 7:30 a.m., day interns arrive, get signout on old patients from overnight team
  • 7:30 - 8 a.m., day residents arrive and get handoff on new patients admitted by night team

Representative week for ward night rotation (interns and residents

Night Team

Sun

Mon

Tue

Wed

Thu

Fri

Sat

Total

6 p.m. - 8 a.m.

6 p.m. - 8 a.m.

6 p.m. - 8 a.m.

6 p.m. - 8 a.m.

6 p.m. - 8 a.m.

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. Cases are formally discussed by the teams with overnight hospitalist attending. Night hospitalist will provide teaching to the intern and resident related to each case, either guided by the night team's specific questions or by what they think are interesting take-aways from the case.

In addition to patient care skills, interns also use night rotation to hone their presentation skills. They should practice 'staffing' with night hosptialist and 'handoff' with day teams and 'one-liner' in 6am email. Residents can model, coach and give feedback to interns for these communication skills.

Night resident and intern are excused from all educational conferences, including Tuesday school and DOM Grand rounds.

Evaluation

Resident Evaluation

Evaluation of resident (and intern) performance during the night rotation is done by night hospitalist.
Evaluation of intern handoff skill is done by night resident.
End of rotation evaluations: Ward ICU - PGY1, Ward ICU - PGY2/3, Ward ICU Nights - PGY1, Ward ICU Nights - PGY2/3,

Rotation Evaluation

Interns and residents are expected to complete an online evaluation form of the rotation. These evaluations are reviewed quarterly.
Urgent clarification or concerns should be reported to chief residents or rotation director.