Overnight Attending Supervision Didn’t Improve Hospital Care

HERSHEY, PA – It might seem obvious that having an attending-level physician on site to supervise overnight medical residents would appreciably improve hospital care.

Yet that’s not what happened at the Penn State Hershey Medical Center, according to a report in the Journal of General Internal Medicine. A study found no significant impact on important clinical outcomes.

"Over the past 10 to 15 years, academic hospitals have utilized hospitalists during the day," said lead author Jed Gonzalo, MD, Penn State’s associate dean for health systems education and assistant professor of medicine and public health sciences. "Ours is the first study to look at the impact of an overnight academic hospitalist program."

Background information in the article notes that many teaching hospitals have implemented an overnight academic hospitalist (OAH) program in response to concerns for patient safety and quality of care.

To determine what effect that might have, Gonzalo and colleagues evaluated an OAH program implemented in September 2012 at the Hershey Medical Center, focusing on the following outcomes:

· in-hospital mortality rates

· 30-day readmission rates

· lengths of stay and

· transfers to the intensive care unit both on the night of admission and later during the hospital stay

Researchers reviewed medical records of all patients admitted to the internal medicine department at the medical center between April 1, 2011, and May 31, 2014. Overall, more than 6,000 patients were admitted during the overnight shift – from 7 p.m. to 6:59 a.m. – during the study period, with 42% admitted before the intervention and 58% afterward.

Prior to the intervention, the in-hospital mortality rate was 1.1%, dropping to 0.9% afterward. Slightly fewer patients, 3.5%, were upgraded to the ICU during their hospital stay before the program implementation than after, 4.2%.

No significant differences were detected in level of care, even when researchers dug deeper, looking at age, gender or race of patients admitted to the hospital before and after implementation of the program.

"Given that regulatory bodies are pushing toward on-site house staff supervision, the medical education community needs to think about how to continue to allow autonomy for residents," Gonzalo said. "For years, residents were on their own at night – they had to make decisions on their feet, because the buck stopped with them. Newer models of care at night have the potential to strip away residency autonomy because they can lean on the attending now. However, the other view is 'the more eyes, the better.' So it's a challenge we need to think more about to balance education and ideal patient outcomes."