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Tonight, I am completing my first two week stint as the Neurology night shift resident at my hospital. For better or worse, I did not have any night float experience as a Medicine intern (plenty of long and painful on-call shifts, but no long consecutive stretches of nights), so these two weeks have been an interesting, exploratory experience for me. I have a total of two months of the night float rotation during my residency, so I have plenty more time to perfect my strategies for both maintaining the best possible patient care and making the best use of the time. I have picked up a few pearls that might help other residents who also will be filling this role:

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[1] The Plan and Pickup

As detailed in my last post, signout is an extremely important process and is the initial and primary means of high-yield information gathering for the night shift resident. Day residents are often tired and worn out by signout time, making it difficult to execute an effective delivery of all of the important details that a night shift resident covering all of the patients requires. Accordingly, it is the night shift resident’s job to ask the important questions when important information is left unsaid.

Of the many details that are valuable, I find that there is special significance in the day team’s plan of action for the patient. The night shift resident’s job is sometimes viewed as a “float” position where one simply tides the patients over until the next morning when active patient care can continue; the job in that case is very passive and only activated in reaction to new developments. Sometimes the team’s plan for the patient is glossed over during a signout process or even omitted. However, the night shift resident covers half of the twenty-four hour day, and much can be done during that time (albeit in smaller, discrete measures, given that the night shift resident is covering a much larger patient census). Sometimes medication titrations started during the day (e.g. for blood pressure control or diuresis) can be continued during the night. Sometimes a new therapy or plan started during the day shift might result in a less desirable outcome, requiring that it be reverted back to the original regimen during the night shift.

Inevitably, small details of care are omitted from signouts, whether intentionally or unintentionally. Nonetheless, the night shift resident can assess the team’s plan and pick up where they left off by following up on ordered studies, touching base with collaborating services or nurses, etc.

[2] The Preemptive Measures

Anticipation is a valuable skill. Being able to predict needs and requests can save valuable time. For example, at my current hospital, the order set for cardiac telemetry does not include a system to indicate whether or not the patient can leave the hospital floor without telemetry when being transferred to another part of the hospital for testing (e.g. Radiology). Residents have to manually type in a text order to give the nurses permission to release patients to the transport team. Accordingly, whenever I start my night shift, I look to see which patients are scheduled for overnight tests, determine whether it is reasonable for them to be off cardiac telemetry monitoring for a period of time, and then indicate such in the ordering system. Placing a few orders and touching base with nurses early in the shift helps prevent the potential slowing down of care delivery when one is dealing with multiple consults, admissions, codes and triggers, and other unpredictable developments.

[3] The PM Rounds

For me, there is great value in laying eyes on each patient. Unfortunately, the 8PM start time for my night shift is past the bedtime for many patients, so they are hidden behind curtains in dark rooms. Nonetheless, I make a concerted effort to locate all patients and mentally store an image of where patients are and what they look like (if I can see them). That way if something happens later requiring me to rush to the bedside, I know exactly where to find each patient. I try to lay eyes on the patients whose clinical statuses are more likely to change, and I examine the patients who are quite sick and are already changing in stability. With regards to examinations, I find that it is important to think about the patient’s pathology, their baseline examination, and the likely changes that one might see with the most likely complications. For example, a patient with a large cerebellar hemorrhage might develop brainstem abnormalities or depressed level of consciousness on examination, so that’s what I would look for as an indicator of worsening clinical status and a trigger for intervention.

[4] The Face Time

The geography of my night is unfortunately split between three locations: three floors in three different buildings, separated by a series of bridges and elevators. Furthermore, the Neurology floor is on the top floor of one building and the Emergency Department is on the bottom floor of another. Accordingly, I find it useful to split up my night into segments where I can minimize my migration from one section to another. Generally, I spend the first four to five hours of my twelve hour shift on the floor where most of my department’s patients are located. This is the start of the nursing shift as well, so there is more activity, more requests, and fresh pairs of eyes reviewing the orders and the patients themselves. The night shift is the best time to get to know the nurses in a hospital with regional admissions: there’s only one doctor on the floor, and that’s me! During those first few hours, I can be a useful resource to the nurses, both by providing some insight conveyed by the physician teams and by helping to facilitate the care ideas generated by the night nurses. Putting in this face time early in the rotation is quite valuable, too, because one develops relationships of trust with the nurses and can better triage requests and nurse assessments when brought to one’s attention later. After the floor patients quiet down, I usually migrate down to the call room which is closer to the Emergency Department where I can more easily set up camp, eat and drink, write notes, and run to either the floor or the ED as needed.

[5] The Quiet Place

Although the hospital is quieter at night (literally), there is still a cacophony of telemetry beeps, yelling and moaning patients, and chatter. A large part of a physician’s job is documentation, and writing well requires mental focus. For me, I can generate clinical documents much faster if I can find a quiet place, be this the call room, a quiet hallway, or an empty conference room. Finding a quiet space and making it a frequent stop during the night shift can help improve efficiency when the admission and consult notes start piling up. Some people prefer to work to music, so finding a room with a computer where one can play Pandora or an iPhone/Android on speaker can help facilitate the written work that needs to be done.

[6] The Energy Food

Shifting to the night schedule can screw up one’s gastrointestinal clock. I eat breakfast and dinner at the usual times, but I have switched lunch to a post-midnight meal so that I don’t have to wake up in the middle of my daytime nap to maintain my calorie intake. However, despite changing over to the night schedule with my meals, my stomach continues to growl constantly and loudly between 4AM and 7AM, or until whenever I can next eat.

The most important thing with regards to food and drink is to keep up one’s energy levels and hydration. As an on-call intern, I spent my on-call budget on a cache of Life Waters; I would keep four or five bottles in one of the physician conference rooms, and then I would down one bottle at a time to stay hydrated throughout the night. Now, as a night shift Neurology resident wandering between different floors and buildings, I keep close tabs on the water machines and on my supply of food (whether in my bag, locker, or the conference room fridge) so that I can snack throughout the night and stave off hunger and dehydration. Everyone has different preferences for on-call food: make it tasty and energizing!

[7] The Rally

Inevitably, fatigue ensues. With fatigue comes a loss of willpower and the onset of complacency. When the hours wear on and one is nearing the end of the shift (particularly in the 4-8 AM hours), it is important to buckle down and push through. Stretch, snack, or take a quick power nap to reenergize and refocus. The end is near: race to the finish!

Hopefully, these tips will be useful to those who will be doing the night shift, which is to say, virtually all residents now that the 16 hour work day restrictions have come into effect for interns. However, don’t be a night float and just muddle through through the night. Be a night rider!

Do you have other tips or strategies for surviving and adapting to the night shift? Please post your comments and suggestions below.

With the advent and evolution of work-hour restrictions, the importance of the signout as a learned skill and a necessary aspect of patient care has grown considerably. The signout or “pass off” is viewed by some senior physicians as a necessary evil (with the emphasis on “evil”), but as work shifts for residents become shorter and the population of hospitalists expands, it becomes ever more important to learn how to do a signout right.

What is a signout or pass off?

By its nature, it is:
[1] A temporary yielding of responsibility for a patient’s care to another physician.
[2] A process by which one prepares the covering physician to perform at maximum capacity as if he or she were the primary physician directing the care of one’s patient.

These two aspects of the signout are essential and intertwined; one cannot exist without the other. Some residents eagerly throw the responsibility for their patients at a fellow resident without adequately preparing them for anticipated or potential overnight complications. On the other hand, some residents overprepare their night shift colleagues, poring over every lab value and detail, while also signing in from their home computers to update electronic signouts and notes. The best strategy is to find the right balance of information transfer and a secure handing over of patient care responsibility.

Granted, it takes two to tango: signout requires both an effective transmitter of information and an actively engaged recipient. The person receiving the signout needs to know what questions to ask and needs to know when to jump in regarding a clarification or to keep things on track when the other resident starts to lose steam and digress.

What are the essential elements of the signout?

While some residency programs and hospitals are trying to standardize signout processes and even study their efficacy, the current process lacks standardization across programs and hospitals. Nonetheless, a few key details form the backbone of a solid signout. Signout can take a long time and is often interrupted by pages and requests, so the most important information that requires verbal transmission must be shared first.

[1] The Red Highlighter – “Which patients are the sickest? Which patients are changing in condition?”

Identifying the sickest patients alerts the on-call resident to the patients who need to be re-evaluated more frequently or who are most likely to have complications or changes in condition overnight. This helps the resident prioritize his or her time and also potentially evaluate these patients early during the shift so that reevaluations later can be compared to a baseline examination.

[2] The Code Status – “Which patients are DNR/DNI? Are any patients CMO?”

Night shifts in particular can be chaotic, and nothing is more chaotic than a Code. Accordingly, the algorithms underlying Codes are meant to provide order and structure for a situation where interventions must be rapidly delivered. However, not all of these interventions are desired by the patient, and so the Code Status must be the hand that stays the trigger finger in these cases.

Identifying patients who are “comfort measures only” and may likely pass during the shift helps the on-call resident prepare, particularly if he or she has questions regarding the cause of death (which will have to be documented and can be an ardurous process).

[3] The One-Liner – “Mr. T is a 43 year old man with a history of hypertension, coronary artery disease, and diabetes presenting with intermittent substernal chest pain for one day, most likely representing acid reflux.”

This skill is learned by medical students, but it still requires honing and perfection throughout residency and beyond. It is important to be able to convey key details of information in a compact amout of time and space. This includes age, pertinent past medical history, the presenting complaint, and the suspected diagnosis.

This is also a common area which can balloon in size and detail: the entire past medical history does not need to be conveyed, only the important aspects. Nonetheless, these details can be important, and it helps to provide some detail in a written version of the signout. For example, it helps to know the left ventricular ejection fraction for a patient with Congestive Heart Failure, that a patient with chronic renal insufficiency has a baseline creatinine of 1.6, that a patient with CAD has coronary stents, and that a patient with a prior left MCA stroke has residual right arm and face weakness.

[4] The Plan – “He is being ruled out for myocardial infarction and evaluated for other causes of chest pain.”

The “second line” following the one-liner should indicate what is being done for the patient. In particular, night shift residents are often called to the bedside to update patients and their families regarding the medical team’s plan of action because that is the time when family members are off work and can visit their loves ones in the hospital. This information also helps the night shift resident think about the direction of the patient’s care and potentially offer contributions in the form of suggested investigatory testing, additional history taking from the patient, or collecting collateral information from visiting family members. This can empower night shift residents to continue the work of the day time.

[5] The To-Do’s – “He has cardiac enzymes pending at 2000 and 0400.”

This part is a no-brainer. If there are specific tests to follow up or re-evaluations that must be done at a particular time, this should be communicated clearly and concisely. A plan of how to react to potential data points is also important here. For example, what should be done if the patient’s lungs have more crackles than before? What should be done if the patient’s blood pressure drops below a desired range?

[6] The Contingencies – “If he has recurrent chest pain, reassess, check his telemetry, and consider a repeat ECG. If his cardiac enzymes turn positive, call the Cardiology fellow and consider Heparin.”

Part of the day resident’s job is to anticipate potential problems or complications that might occur based on his or her current knowledge of the patient and the suspected disease process. This should accordingly be communicated to the night resident, and they should plan together how to react to these situations. In some places, these are called “disaster rounds” where the residents discuss worst-case scenarios and develop plans on how to deal with them.

This how-to guide should provide some structure and tips on how to make signouts systematic and effective. Signouts will continue to be a part of practicing medicine, wherever and whenever one is involved in patient care. Are there other aspects of the signout process not listed here that you believe are important to include? Has your program developed signout strategies that are particularly helpful or effective?

[ Introduction and Background ]
Tablet computing has grown at an incredible rate over the past year. Surprisingly, even physicians and hospitals have adopted this technology in relatively large numbers, considering that many hospitals and clinics continue to rely on paper-based charts, fax machines, and ledger-style appointment tracking. Some hospitals transmit blood draw orders by having them placed in a computer by a physician, printed out by a nurse, and dropped in a paper slot for a phlebotomist to collect. In spite of this archaic backdrop, the iPad in particular has blazed a trail to the bedside of the patient. A number of medical schools and residency programs are actually buying iPads for their students and residents, sometimes with and at other times without a clear idea as to how the tablets would be used. One thing is certain: that tablet computing has made its inroads into the medical community, and it is here to stay.

While tablet computers have a variety of uses for consumption by medical trainees such as reading textbooks (whether through the Kindle or iBook stores, individual apps developed by big publishers, or through interactive textbooks that are being developed) and watching instructional videos (e.g. how to perform an arterial blood gas), production of new content has major barriers. In particular, most people do not find the glass keyboard of the iPad comfortable enough to type anything longer than a short e-mail. Even for me, someone who has used computers since an early age with good manual dexterity, I find that even the iPad 2 with its faster processing speeds and reduced typing-key-to-screen delay is too cumbersome and can be a hindrance to efficiency, an achievement so rarely acquired in health care delivery settings. I have tried using text expansion and templates to speed up the process, but writing an admission or consultation note remains a chore.

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[ Hypothesis ]
Accordingly, I was very excited to discover the ClamCase, a keyboard case for the iPad and iPad 2. Unlike other keyboard cases, it has a hard shell and seamless method of connecting the Bluetooth device to the iPad. I suspected that this device might succeed where others might not: in facilitating a rapid means of text input in the medical setting into a device that is built for speed and convenience.

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[ Results ]
The ClamCase, as one might expect from the name, has two halves like the shell of a clam. The iPad snaps into place in the top half: two lips hold the iPad tightly into place. The top half has indentations to allow for head phones and the charger to be plugged in; recesses for the power, orientation, and volume buttons to be accessed; and a cutout for the rear camera to take pictures and video. Unlike with some other cases, the alignment is perfect. The bottom half houses the recessed keyboard, two indicator lights, and rubber bumpers on the top and on the bottom to protect the iPad screen and provide friction on the bottom to prevent sliding. The bottom half has a small USB port for charging with the cable provided (which can be plugged into the same AC adaptor as that used by the iPad). The two halves are connected by a tight hinge which feels very sturdy.

The case itself has a spectrum of orientations. When completely closed, it provides full back, front, and edge protection for the iPad as though it were a laptop. It can then be pulled opened and angled in the same way (90 to 120 degrees) as a laptop. However, it doesn’t stop there: the hinge rotates a full 180 degrees, allowing you to use the keyboard face of the bottom half as the support/stand for the device, allowing for easy access to the screen when reading at a table or watching a video. Finally, the case can be fully folded back and used as a tablet held in one hand and directed with the other.

The case does have some weight and nearly doubles the weight of the iPad. Of note, much of the weight is in the top half of the case, meaning that tilting the screen too far back while it rests on a slanted surface that the rubber grips can’t hold as well (like a lap) can cause it to topple over if one isn’t careful.

The case comes in three colors: white, black, and a limited edition aluminum/brushed metal finish.

Typing on the keyboard is surprisingly pleasing. The keyboard is notably smaller than a full-sized keyboard, but this is the same trade off one would find with a netbook of a similar size. After a few minutes, I found that I could easily touch-type the way I would with a full-sized keyboard.

The Bluetooth connection between the keyboard and iPad is one of the best features. After the initial setup, the keyboard connects to the iPad 2 automatically. Like other magnet cases, the iPad 2 activates the lock screen or turns on when the case is opened. After clicking any key on the keyboard, the keyboard emerges from its “sleep” or “suspend” mode and immediately connects to the iPad as indicated by the flashing Bluetooth symbol at the top right of the iPad screen. After a couple of seconds, the synchronization is complete, and one can start typing. As expected, the keyboard returns to a sleep mode when it has not been used for some period of time. It is possible to turn on and off the keyboard as well when one does not want to accidentally press the keys (for example, when using the case in tablet mode wherein the keys would be resting against a surface such as one’s forearm).

Lastly, the keyboard offers a number of features that would be missing from a non-keyboard case: keyboard commands (such as copying, pasting, cutting), arrow keys, easy access to numbers and letters and punctuation on the same spread, and finally special characters (such as accents).

[ Discussion and Conclusions ]
While all keyboard cases would add much needed ease of use and additional functionality to the iPad, the ClamCase appears to stand ahead of the crowd. After inserting the iPad into the case, the device and case truly feel unified. One does not need to keep plugging and unplugging the iPad from the keyboard. Many other cases have a “pasted-on” feel to the keyboard which might add extra bulk but very little form factor or protection, but the ClamCase makes one forget that this isn’t actually a traditional laptop. The landscape orientation feels much more natural for word processing than does the portrait orientation used by some other keyboards, an orientation that is better suited for stylus writing on the screen.

The convenience, utility, and form factor do come at a price, though: $150 for the iPad and iPad 2 versions. Most keyboard cases come at a price ranging in the $50 to $150 range. Nonetheless, while some balk at the idea of spending more money on an already expensive device, the money could be very well spent if the added functionality is worth it. For me, my impression thus far is that the added value of a solid keyboard for generating medical notes (in the setting of a medical record system that lacks text expansion, a medical team structure that suffers from long rounding times and frequent activities that removes one from the ward computers, and a service that has a high admission and consultation rate) is well worth this price.

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