Harborview Medical Center

Night Float Service

Faculty Contact
Anneliese M. Schleyer, M.D., M.H.A.
Acting Instructor of Medicine
Attending Physician, HMC Inpatient Hospitalist Service
Division of General Internal Medicine
Phone: (206) 731-6868
Email: schleyer@uw.edu

Audrey Young, M.D.
Acting Instructor of Medicine
Attending Physician, HMC Inpatient Hospitalist Service
Division of General Internal Medicine
Phone: (206) 744-6868
Email: auyoung@uw.edu

Address
Harborview Medical Center
325 Ninth Avenue
Box 359780
Seattle, WA 98104

Overall Educational Purpose
1. Overnight workup and management of the acutely ill patient. Prioritizing complications as well as problems with particular attention to issues including, but not limited to:
· Hypotension
· Decreased urine output
· Chest pain
· Shortness of breath
· Fever
· Mental status changes

2. Management of inpatients in cardiac/pulmonary arrest using ACLS algorithms

3. Evaluate, triage, and manage patients presenting through the emergency department with acute inpatient needs. This includes, but is not limited to:
· Obtaining histories and physical exams
· Documentation of histories, physical exams, and treatment plans
· Competently performing basic procedures including:
o Venipuncture
o Arterial blood gas
o Central venous access
o Nasogastric tube placement
o Paracentesis
o Thoracentesis

Team Structure
2 Attendings
1 R2/R3
1 Intern

Principle Teaching Materials
Case discussion and review
The attendings on the hospitalist service discuss the patients that are admitted by the intern and resident.

Rounds
Bedside rounds take place every morning with the hospitalist attending and night float residents. Patients are presented and treatment plans discussed with the attending at which point the residents relinquish care of the patient to the attending

Didactics
At least three times per week the attending hospitalist will give formal case based didactics to the night float team after morning rounds. These usually consist of teaching related to the common admissions that are seen in our center.

Educational Content
Mix of Diseases
At Harborview, the majority of patients admitted have:
· Cellulitis and soft tissue infection
· Pneumonia
· Alcohol withdrawal
· Fever in an IV drug user
· End stage liver disease complications
· Chest pain
· Venous thromboembolism
· Tuberculosis
· HIV related opportunistic infections

Patient Characteristics
The patient population is a mix of races and comes from a broad range of socioeconomic backgrounds. About 1/3 of the population do not have insurance, 1/3 have Medicaid or Medicare, and the last 1/3 are private or self pay. Harborview serves a large homeless population, a significant intravenous drug using population, and operates as the regional care center for HIV infected individuals in the greater Seattle area.


Types of Clinical Encounters
Every patient seen by the residents on this service are inpatients. The night float team will not care for patients in the intensive care units, but when serving as the medical consultants they will often follow surgical patients with ICU needs. 100% of the patients that are admitted by the night float team come through the emergency department.

Procedures
Residents have the opportunity to perform the following procedures overnight while covering the existing inpatient medical services as well as those they admit directly.
o Venipuncture
o Arterial blood gas
o Central venous access
o Nasogastric tube placement
o Paracentesis
o Thoracentesis

Rotation Specific Schedule
Each intern and resident on the service will alternate between the medicine float service and the medicine consult service. Each intern/resident pair will rotate on a two-week basis.

* denotes activity not unique to consult or float service

Monday
7:30AM – 9AM – Night float R2/R3 and intern round with attending on patients admitted overnight. Attending gives AM didactic.
8AM – Intern relinquishes care for overnight patients and signs out to the daytime teams.
9AM - Intern and resident leave hospital
9PM – Intern and resident return to the hospital, accept sign-out from call team.

Tuesday
7:30AM – 9AM – Night float R2/R3 and intern round with attending on patients admitted overnight. Attending gives AM didactic.
8AM – Intern relinquishes care for overnight patients and signs out to the daytime teams.
9AM - Intern and resident leave hospital
9PM – Intern and resident return to the hospital, accept sign-out from call team.

Wednesday
7:30AM – 9AM – Night float R2/R3 and intern round with attending on patients admitted overnight. Attending gives AM didactic.
8AM – Intern relinquishes care for overnight patients and signs out to the daytime teams.
9AM - Intern and resident leave hospital
9PM – Intern and resident return to the hospital, accept sign-out from call team.

Thursday
7:30AM – 9AM – Night float R2/R3 and intern round with attending on patients admitted overnight. Attending gives AM didactic.
9AM – Intern relinquishes care for overnight patients and signs out to the daytime teams.
9AM - Intern and resident leave hospital
9PM – Intern and resident return to the hospital, accept sign-out from call team.

Friday
7:30AM – 9AM – Night float R2/R3 and intern round with attending on patients admitted overnight. Attending gives AM didactic.
8AM – Intern relinquishes care for overnight patients and signs out to the daytime teams.
9AM - Intern and resident leave hospital
9PM – Intern and resident return to the hospital, accept sign-out from call team.

Saturday/Sunday
8AM – 9AM – Night float R2/R3 and intern round with attending on patients admitted overnight. Attending gives AM didactic.
9AM – Intern relinquishes care for overnight patients and signs out to the daytime teams.
9AM - Intern and resident leave hospital
9PM – Intern and resident return to the hospital, accept sign-out from call team.

Call and Weekend Responsibilities
Call responsibilities are limited to the night float team who will sleep in house for seven days in a row prior to switching to the consult service, but will not exceed 12 hours for each of their overnight shifts.

Saturday is the day that the resident/intern pairs swap roles. The night float team will now assume the medicine consult role and the night float team assumes the consult role.

Principle Educational Materials Used
Recommended Readings
The consult attendings have assembled a notebook full of pertinent articles related to medicine consultation which is provided to each of the residents at the start of the rotation.

Pathologic materials
None

Methods used in Evaluating Resident and Program Performance
At the end of the rotation, the resident is evaluated in writing and their performance reviewed with them verbally by every attending and fellow he or she has interacted with for a significant amount of time. The evaluator rates the resident on a nine-point scale in each component of clinical competence (i.e. patient care, medical knowledge, practice based learning improvement, interpersonal and communication skills, professionalism, system based learning, educational attitudes, leadership, overall clinical competence).

The resident is given the opportunity to evaluate in writing the quality of the curriculum and the extent to which the educational goals and objectives of the rotation have been met. The resident also evaluates the teaching competence of each attending and fellow with whom s/he has interacted for a significant amount of time.

Explicit Lines of Responsibility for Care of Patients on this Service
Each patient seen on the float service is responsibility of the attending staff physician. That faculty physician sees, examines, and discusses all new patients with the resident or intern.

Ongoing care will be provided by the resident and intern with discussion with the attending on the consult service. The hospitalist/night float attendings will be responsible for the ongoing care of all patients admitted by the night float team. All major changes in status will have documented involvement by the attending faculty member.

Last Revised February 24, 2004 by Anneliese Schleyer, MD & Colin Cooke, MD