Nightfloat pictures from my phone

From a few weeks ago when I was working nightfloat...

From top to bottom:
the hospital at night
hallways
and a sign put outside the rooms of patients on fall precautions.

Advance by day, maintain by night

If hospitals finally designed truly rational production processes and became 24 hour enterprises, care might work better and be safer--but where would the romance of the night shift be?

I'm quoted today in White Coat Notes, a brief quote in which I say that in the hospital "We maintain by night and advance by day", which might be worth explaining a bit more.

The hospital is a constant production process. But it's in transition: it inherits many of the features of its pre-industrial roots. A truly efficient production process never stops, but the hospital slows down considerably at night. I think there would be a lot to be said for a truly 24-hour hospital. But that would require more health care workers, more money to pay people extra to work overnight, and a completely different way of arranging care.

Hospital care moves in fits and starts. We try to help people with the hospital's resources and then move them out of the hospital before they begin accumulating too many of the hospital's risks, like hospital infections, or unnecessary procedures stemming from results of unnecessary tests.

The five-day-a-week, 10-hours-a-day schedule of much of the healthcare system means that the discharge that could happen on Saturday waits until Monday because there's no skilled nursing facility screener who can come on a weekend to accept the patient. A CT scan that could take place overnight waits until the next day because there are only enough radiology technicians and radiologists to staff emergencies at night.

Meanwhile, there are things we do to advance care at night. For instance, we might start an infusion of medicine overnight. But most of what we do is planned and started in the daytime. We make our plans by day, do most of our testing and procedures and imaging by day, and make most of our clinical assessments by day.

A hospital would be more efficient, and care would happen more quickly and probably yield more clinical benefit if we operated hospitals on a 24 hour schedule. Care would probably be better if it took place at a constant pace rather than a stop-and-start pace.

The argument against the 24 hour hospital is obvious: it's nice that for a while, we can just let our patients sleep. On the other hand, most people don't sleep well in the hospital. If we could get them out 50% faster, they'd get more sleep where they're going than the hospital where they're staying. And at least from the house staff point of view, it's frightening to cover patients on a hospital floor where nurses and other staff don't regularly come in to rooms to take vitals and check on how they're doing.

On the other hand, maybe this is all self-justifying fantasizing from a pre-call intern, the root idea of which is: We're awake. Maybe the rest of the hospital should be too.