Sumant R. Ranji, MD

Rapid response teams (RRTs) have been promoted by patient safety and quality‐improvement organizations as a strategy to reduce preventable in‐hospital deaths.[1] To date, critical analysis of RRTs has focused primarily on their impact on quality‐of‐care metrics.[2, 3, 4] Comparatively few studies have examined the cultural and educational impact of RRTs, particularly at academic medical centers, and those that do exist have focused almost exclusively on perceptions of nurses rather than resident physicians.[5, 6, 7, 8, 9, 10]

Although a prior study found that internal medicine and general surgery residents believed that RRTs improved patient safety, they were largely ambivalent about the RRT's impact on education and training.[11] To date, there has been no focused assessment of resident physician impressions of an RRT across years of training and medical specialty to inform the use of this multidisciplinary team as a component of their residency education.

We sought to determine whether resident physicians at a tertiary care academic medical center perceive educational benefit from collaboration with the RRT and whether they feel that the RRT adversely affects clinical autonomy.

METHODS

RESULTS

There were 246 responses to the survey of a possible 342, yielding a response rate of 72% (Table 2). Ten respondents stated that they had never cared for a patient where the RRT had been activated. Given their lack of exposure to the RRT, these respondents were excluded from the analysis, yielding a final sample size of 236. The demographic and clinical practice characteristics of respondents are shown in Table 1.

DISCUSSION

Most studies examining the educational and cultural impact of RRTs exist in the nursing literature. These studies demonstrate that medical and surgical nurses are often reluctant to call the RRT for fear of criticism by the patient's physician.[5, 8, 9, 10, 11, 12, 13] In contrast, our data demonstrate that resident physicians across all levels of training and specialties have a positive view of the RRT and its role in patient care. The data support our hypothesis that although most residents perceive educational benefit from their interactions with the RRT, this perception is greater for less‐experienced residents and for those residents who routinely provide care for critically ill patients and serve as code team leaders. In addition, a minority of residents, irrespective of years of training or medical specialty, felt that the RRT negatively impacted their clinical autonomy.

Our data have several important implications. First, although over half of the residents surveyed had not been exposed to RRTs during medical school, and despite having no formal training on the role of the RRT during residency, most residents identified their interactions with the RRT as potential learning opportunities. This finding differs from that of Benin and colleagues, who suggested that RRTs might negatively impact residents' educational development and decrease opportunities for high‐stakes clinical reasoning by allowing the clinical decision‐making process to be driven by the RRT staff rather than the resident.[5] One possible explanation for this discrepancy is the variable makeup of the RRT at different institutions. At our medical center, the RRT is comprised of a critical care nurse and respiratory therapist, whereas at other institutions, the RRT may be led by a resident, fellow, attending hospitalist, or intensivist, any of whom might supersede the primary resident once the RRT is engaged.

In our study, the perceived educational benefit of the RRT was most pronounced with interns. Interns likely derive incrementally greater benefit from each encounter with an acutely decompensating patient than do senior residents, whether the RRT is present or not. Observing the actions of seasoned nurses and respiratory therapists may demonstrate new tools for interns to use in their management of such situations; for example, the RRT may suggest different modes of oxygen delivery or new diagnostic tests. The RRT also likely helps interns navigate the hospital system by assisting with decisions around escalation of care and serving as a liaison to ICU staff.

Our data also have implications for resident perceptions of clinical autonomy. Interns, far less experienced caring for unstable patients than upper‐level residents, expressed more concern about the RRT stripping them of opportunities to do so and about feeling less prepared to handle clinically deteriorating patients. Part of this perception may be due to interns feeling less comfortable taking charge of a patient's care in the presence of an experienced critical care nurse and respiratory therapist, both for reasons related to clinical experience and to a cultural hierarchy that often places the intern at the bottom of the authority spectrum. In addition, when the RRT is called on an intern's patient, the senior resident may accompany the intern to the bedside and guide the intern on his or her approach to the situation; in some cases, the senior resident may take charge, leaving the intern feeling less autonomous.

If training sessions could be developed to address not only clinical decision making, but also multidisciplinary team interactions and roles in the acute care setting, this may mitigate interns' concerns. Such curricula could also enhance residents' experience in interprofessional care, an aspect of clinical training that has become increasingly important in the age of limited duty hours and higher volume, and higher acuity inpatient censuses. An RRT model, like a code blue model, could be used in simulation‐based training to increase both comfort with use of the RRT and efficiency of the RRTresidentnurse team. Although our study did not address specifically residents' perceptions of multidisciplinary teams, this could be a promising area for further study.

For surgical residents, additional factors are likely at play. Surgical residents spend significant time in the operating room, reducing time present at the bedside and hindering the ability to respond swiftly when an RRT is called on their patient. This could cause surgical residents to feel less involved in the care of that patientsupported by our finding that fewer surgical residents felt able to collaborate with the RRTand also to derive less educational benefit and clinical satisfaction from the experience. Differences between medical and surgical postgraduate training also likely play a role, manifest by varying clinical roles and duration of training, and as such it may not be appropriate to draw direct comparisons between respective postgraduate year levels. In addition, differences in patients' medical complexity, varying allegiance to the traditional hierarchy of medical providers, and degree of familiarity with the RRT itself may impact surgical residents' comfort with the RRT.

Limitations of our study include that it was conducted at a single site and addressed a specific population of residents at our tertiary academic center. Though we achieved an excellent response rate, our subspecialty sample sizes were too small to allow for individual comparisons among those groups. Conducting a larger study at multiple institutions where the makeup of the RRT differs could provide further insight into how different clinical environments and different RRT models impact resident perceptions. Finally, we allowed each respondent to interpret both educational benefit and clinical autonomy in the context of their own level of training and clinical practice rather than providing strict definitions of these terms. There is no standardized definition of autonomy in the context of resident clinical practice, and we did not measure direct educational outcomes. Our study design therefore allowed only for measurement of perceptions of these concepts. Measurement of actual educational value of the RRTfor example, through direct clinical observation or by incorporating the RRT experience into an entrustable professional activitywould provide more quantitative evidence of the RRT's utility for our resident population. Future study in this area would help to support the development and ongoing assessment of RRT‐based curricula moving forward.

CONCLUSION

Our data show that resident physicians have a strongly favorable opinion of the RRT at our institution. Future studies should aim to quantify the educational benefit of RRTs for residents and identify areas for curricular development to enhance resident education as RRTs become more pervasive.

Rapid response teams (RRTs) have been promoted by patient safety and quality‐improvement organizations as a strategy to reduce preventable in‐hospital deaths.[1] To date, critical analysis of RRTs has focused primarily on their impact on quality‐of‐care metrics.[2, 3, 4] Comparatively few studies have examined the cultural and educational impact of RRTs, particularly at academic medical centers, and those that do exist have focused almost exclusively on perceptions of nurses rather than resident physicians.[5, 6, 7, 8, 9, 10]

Although a prior study found that internal medicine and general surgery residents believed that RRTs improved patient safety, they were largely ambivalent about the RRT's impact on education and training.[11] To date, there has been no focused assessment of resident physician impressions of an RRT across years of training and medical specialty to inform the use of this multidisciplinary team as a component of their residency education.

We sought to determine whether resident physicians at a tertiary care academic medical center perceive educational benefit from collaboration with the RRT and whether they feel that the RRT adversely affects clinical autonomy.

METHODS

RESULTS

There were 246 responses to the survey of a possible 342, yielding a response rate of 72% (Table 2). Ten respondents stated that they had never cared for a patient where the RRT had been activated. Given their lack of exposure to the RRT, these respondents were excluded from the analysis, yielding a final sample size of 236. The demographic and clinical practice characteristics of respondents are shown in Table 1.

DISCUSSION

Most studies examining the educational and cultural impact of RRTs exist in the nursing literature. These studies demonstrate that medical and surgical nurses are often reluctant to call the RRT for fear of criticism by the patient's physician.[5, 8, 9, 10, 11, 12, 13] In contrast, our data demonstrate that resident physicians across all levels of training and specialties have a positive view of the RRT and its role in patient care. The data support our hypothesis that although most residents perceive educational benefit from their interactions with the RRT, this perception is greater for less‐experienced residents and for those residents who routinely provide care for critically ill patients and serve as code team leaders. In addition, a minority of residents, irrespective of years of training or medical specialty, felt that the RRT negatively impacted their clinical autonomy.

Our data have several important implications. First, although over half of the residents surveyed had not been exposed to RRTs during medical school, and despite having no formal training on the role of the RRT during residency, most residents identified their interactions with the RRT as potential learning opportunities. This finding differs from that of Benin and colleagues, who suggested that RRTs might negatively impact residents' educational development and decrease opportunities for high‐stakes clinical reasoning by allowing the clinical decision‐making process to be driven by the RRT staff rather than the resident.[5] One possible explanation for this discrepancy is the variable makeup of the RRT at different institutions. At our medical center, the RRT is comprised of a critical care nurse and respiratory therapist, whereas at other institutions, the RRT may be led by a resident, fellow, attending hospitalist, or intensivist, any of whom might supersede the primary resident once the RRT is engaged.

In our study, the perceived educational benefit of the RRT was most pronounced with interns. Interns likely derive incrementally greater benefit from each encounter with an acutely decompensating patient than do senior residents, whether the RRT is present or not. Observing the actions of seasoned nurses and respiratory therapists may demonstrate new tools for interns to use in their management of such situations; for example, the RRT may suggest different modes of oxygen delivery or new diagnostic tests. The RRT also likely helps interns navigate the hospital system by assisting with decisions around escalation of care and serving as a liaison to ICU staff.

Our data also have implications for resident perceptions of clinical autonomy. Interns, far less experienced caring for unstable patients than upper‐level residents, expressed more concern about the RRT stripping them of opportunities to do so and about feeling less prepared to handle clinically deteriorating patients. Part of this perception may be due to interns feeling less comfortable taking charge of a patient's care in the presence of an experienced critical care nurse and respiratory therapist, both for reasons related to clinical experience and to a cultural hierarchy that often places the intern at the bottom of the authority spectrum. In addition, when the RRT is called on an intern's patient, the senior resident may accompany the intern to the bedside and guide the intern on his or her approach to the situation; in some cases, the senior resident may take charge, leaving the intern feeling less autonomous.

If training sessions could be developed to address not only clinical decision making, but also multidisciplinary team interactions and roles in the acute care setting, this may mitigate interns' concerns. Such curricula could also enhance residents' experience in interprofessional care, an aspect of clinical training that has become increasingly important in the age of limited duty hours and higher volume, and higher acuity inpatient censuses. An RRT model, like a code blue model, could be used in simulation‐based training to increase both comfort with use of the RRT and efficiency of the RRTresidentnurse team. Although our study did not address specifically residents' perceptions of multidisciplinary teams, this could be a promising area for further study.

For surgical residents, additional factors are likely at play. Surgical residents spend significant time in the operating room, reducing time present at the bedside and hindering the ability to respond swiftly when an RRT is called on their patient. This could cause surgical residents to feel less involved in the care of that patientsupported by our finding that fewer surgical residents felt able to collaborate with the RRTand also to derive less educational benefit and clinical satisfaction from the experience. Differences between medical and surgical postgraduate training also likely play a role, manifest by varying clinical roles and duration of training, and as such it may not be appropriate to draw direct comparisons between respective postgraduate year levels. In addition, differences in patients' medical complexity, varying allegiance to the traditional hierarchy of medical providers, and degree of familiarity with the RRT itself may impact surgical residents' comfort with the RRT.

Limitations of our study include that it was conducted at a single site and addressed a specific population of residents at our tertiary academic center. Though we achieved an excellent response rate, our subspecialty sample sizes were too small to allow for individual comparisons among those groups. Conducting a larger study at multiple institutions where the makeup of the RRT differs could provide further insight into how different clinical environments and different RRT models impact resident perceptions. Finally, we allowed each respondent to interpret both educational benefit and clinical autonomy in the context of their own level of training and clinical practice rather than providing strict definitions of these terms. There is no standardized definition of autonomy in the context of resident clinical practice, and we did not measure direct educational outcomes. Our study design therefore allowed only for measurement of perceptions of these concepts. Measurement of actual educational value of the RRTfor example, through direct clinical observation or by incorporating the RRT experience into an entrustable professional activitywould provide more quantitative evidence of the RRT's utility for our resident population. Future study in this area would help to support the development and ongoing assessment of RRT‐based curricula moving forward.

CONCLUSION

Our data show that resident physicians have a strongly favorable opinion of the RRT at our institution. Future studies should aim to quantify the educational benefit of RRTs for residents and identify areas for curricular development to enhance resident education as RRTs become more pervasive.

Rapid response teams (RRTs) have been promoted by patient safety and quality‐improvement organizations as a strategy to reduce preventable in‐hospital deaths.[1] To date, critical analysis of RRTs has focused primarily on their impact on quality‐of‐care metrics.[2, 3, 4] Comparatively few studies have examined the cultural and educational impact of RRTs, particularly at academic medical centers, and those that do exist have focused almost exclusively on perceptions of nurses rather than resident physicians.[5, 6, 7, 8, 9, 10]

Although a prior study found that internal medicine and general surgery residents believed that RRTs improved patient safety, they were largely ambivalent about the RRT's impact on education and training.[11] To date, there has been no focused assessment of resident physician impressions of an RRT across years of training and medical specialty to inform the use of this multidisciplinary team as a component of their residency education.

We sought to determine whether resident physicians at a tertiary care academic medical center perceive educational benefit from collaboration with the RRT and whether they feel that the RRT adversely affects clinical autonomy.

METHODS

RESULTS

There were 246 responses to the survey of a possible 342, yielding a response rate of 72% (Table 2). Ten respondents stated that they had never cared for a patient where the RRT had been activated. Given their lack of exposure to the RRT, these respondents were excluded from the analysis, yielding a final sample size of 236. The demographic and clinical practice characteristics of respondents are shown in Table 1.

DISCUSSION

Most studies examining the educational and cultural impact of RRTs exist in the nursing literature. These studies demonstrate that medical and surgical nurses are often reluctant to call the RRT for fear of criticism by the patient's physician.[5, 8, 9, 10, 11, 12, 13] In contrast, our data demonstrate that resident physicians across all levels of training and specialties have a positive view of the RRT and its role in patient care. The data support our hypothesis that although most residents perceive educational benefit from their interactions with the RRT, this perception is greater for less‐experienced residents and for those residents who routinely provide care for critically ill patients and serve as code team leaders. In addition, a minority of residents, irrespective of years of training or medical specialty, felt that the RRT negatively impacted their clinical autonomy.

Our data have several important implications. First, although over half of the residents surveyed had not been exposed to RRTs during medical school, and despite having no formal training on the role of the RRT during residency, most residents identified their interactions with the RRT as potential learning opportunities. This finding differs from that of Benin and colleagues, who suggested that RRTs might negatively impact residents' educational development and decrease opportunities for high‐stakes clinical reasoning by allowing the clinical decision‐making process to be driven by the RRT staff rather than the resident.[5] One possible explanation for this discrepancy is the variable makeup of the RRT at different institutions. At our medical center, the RRT is comprised of a critical care nurse and respiratory therapist, whereas at other institutions, the RRT may be led by a resident, fellow, attending hospitalist, or intensivist, any of whom might supersede the primary resident once the RRT is engaged.

In our study, the perceived educational benefit of the RRT was most pronounced with interns. Interns likely derive incrementally greater benefit from each encounter with an acutely decompensating patient than do senior residents, whether the RRT is present or not. Observing the actions of seasoned nurses and respiratory therapists may demonstrate new tools for interns to use in their management of such situations; for example, the RRT may suggest different modes of oxygen delivery or new diagnostic tests. The RRT also likely helps interns navigate the hospital system by assisting with decisions around escalation of care and serving as a liaison to ICU staff.

Our data also have implications for resident perceptions of clinical autonomy. Interns, far less experienced caring for unstable patients than upper‐level residents, expressed more concern about the RRT stripping them of opportunities to do so and about feeling less prepared to handle clinically deteriorating patients. Part of this perception may be due to interns feeling less comfortable taking charge of a patient's care in the presence of an experienced critical care nurse and respiratory therapist, both for reasons related to clinical experience and to a cultural hierarchy that often places the intern at the bottom of the authority spectrum. In addition, when the RRT is called on an intern's patient, the senior resident may accompany the intern to the bedside and guide the intern on his or her approach to the situation; in some cases, the senior resident may take charge, leaving the intern feeling less autonomous.

If training sessions could be developed to address not only clinical decision making, but also multidisciplinary team interactions and roles in the acute care setting, this may mitigate interns' concerns. Such curricula could also enhance residents' experience in interprofessional care, an aspect of clinical training that has become increasingly important in the age of limited duty hours and higher volume, and higher acuity inpatient censuses. An RRT model, like a code blue model, could be used in simulation‐based training to increase both comfort with use of the RRT and efficiency of the RRTresidentnurse team. Although our study did not address specifically residents' perceptions of multidisciplinary teams, this could be a promising area for further study.

For surgical residents, additional factors are likely at play. Surgical residents spend significant time in the operating room, reducing time present at the bedside and hindering the ability to respond swiftly when an RRT is called on their patient. This could cause surgical residents to feel less involved in the care of that patientsupported by our finding that fewer surgical residents felt able to collaborate with the RRTand also to derive less educational benefit and clinical satisfaction from the experience. Differences between medical and surgical postgraduate training also likely play a role, manifest by varying clinical roles and duration of training, and as such it may not be appropriate to draw direct comparisons between respective postgraduate year levels. In addition, differences in patients' medical complexity, varying allegiance to the traditional hierarchy of medical providers, and degree of familiarity with the RRT itself may impact surgical residents' comfort with the RRT.

Limitations of our study include that it was conducted at a single site and addressed a specific population of residents at our tertiary academic center. Though we achieved an excellent response rate, our subspecialty sample sizes were too small to allow for individual comparisons among those groups. Conducting a larger study at multiple institutions where the makeup of the RRT differs could provide further insight into how different clinical environments and different RRT models impact resident perceptions. Finally, we allowed each respondent to interpret both educational benefit and clinical autonomy in the context of their own level of training and clinical practice rather than providing strict definitions of these terms. There is no standardized definition of autonomy in the context of resident clinical practice, and we did not measure direct educational outcomes. Our study design therefore allowed only for measurement of perceptions of these concepts. Measurement of actual educational value of the RRTfor example, through direct clinical observation or by incorporating the RRT experience into an entrustable professional activitywould provide more quantitative evidence of the RRT's utility for our resident population. Future study in this area would help to support the development and ongoing assessment of RRT‐based curricula moving forward.

CONCLUSION

Our data show that resident physicians have a strongly favorable opinion of the RRT at our institution. Future studies should aim to quantify the educational benefit of RRTs for residents and identify areas for curricular development to enhance resident education as RRTs become more pervasive.

Hospital readmissions, which account for a substantial proportion of healthcare expenditures, have increasingly become a focus for hospitals and health systems. Hospitals now assume greater responsibility for population health, and face financial penalties by federal and state agencies that consider readmissions a key measure of the quality of care provided during hospitalization. Consequently, there is broad interest in identifying approaches to reduce hospital reutilization, including emergency department (ED) revisits and hospital readmissions. In this issue of the Journal of Hospital Medicine, Auger et al.[1] report the results of a systematic review, which evaluates the effect of discharge interventions on hospital reutilization among children.

As Auger et al. note, the transition from hospital to home is a vulnerable time for children and their families, with 1 in 5 parents reporting major challenges with such transitions.[2] Auger and colleagues identified 14 studies spanning 3 pediatric disease processes that addressed this issue. The authors concluded that several interventions were potentially effective, but individual studies frequently used multifactorial interventions, precluding determination of discrete elements essential to success. The larger body of care transitions literature in adult populations provides insights for interventions that may benefit pediatric patients, as well as informs future research and quality improvement priorities.

The authors identified some distinct interventions that may successfully decrease hospital reutilization, which share common themes from the adult literature. The first is the use of a dedicated transition coordinator (eg, nurse) or coordinating center to assist with the patient's transition home after discharge. In adult studies, this bridging strategy[3, 4] (ie, use of a dedicated transition coordinator or provider) is initiated during the hospitalization and continues postdischarge in the form of phone calls or home visits. The second theme illustrated in both this pediatric review[1] and adult reviews[3, 4, 5] focuses on enhanced or individualized patient education. Most studies have used a combination of these strategies. For example, the Care Transitions Intervention (one of the best validated adult discharge approaches) uses a transition coach to aid the patient in medication self‐management, creation of a patient‐centered record, scheduling follow‐up appointments, and understanding signs and symptoms of a worsening condition.[6] In a randomized study, this intervention demonstrated a reduction in readmissions within 90 days to 16.7% in the intervention group, compared with 22.5% in the control group.[6] One of the pediatric studies highlighted in the review by Auger et al. achieved a decrease in 14‐day ED revisits from 8% prior to implementation of the program to 2.7% following implementation of the program.[7] This program was for patients discharged from the neonatal intensive care unit and involved a nurse coordinator (similar to a transition coach) who worked closely with families and ensured adequate resources prior to discharge as well as a home visitation program.[7]

Although Auger et al. identify some effective approaches to reducing hospital reutilization after discharge in children, their review and the complementary adult literature bring to light 4 main unresolved questions for hospitalists seeking to improve care transitions: (1) how to dissect diverse and heterogeneous interventions to determine the key driver of success, (2) how to interpret and generally apply interventions from single centers where they may have been tailored to a specific healthcare environment, (3) how to generalize the findings of many disease‐specific interventions to other populations, and (4) how to evaluate the cost and assess the costbenefit of implementing many of the more resource intensive interventions. An example of a heterogeneous intervention addressed in this pediatric systematic review was described by Ng et al.,[8] in which the intervention group received a combination of an enhanced discharge education session, disease‐specific nurse evaluation, an animated education booklet, and postdischarge telephone follow‐up, whereas the control group received a shorter discharge education session, a disease‐specific nurse evaluation only if referred by a physician, a written education booklet, and no telephone follow‐up. Investigators found that intervention patients were less likely to be readmitted or revisit the ED as compared with controls. A similarly multifaceted intervention introduced by Taggart et al.[9] was unable to detect a difference in readmissions or ED revisits. It is unclear whether or not the differences in outcomes were related to differences in the intervention bundle itself or institutional or local contextual factors, thus limiting application to other hospitals. Generalizability of interventions is similarly complicated in adults.

The studies presented in this pediatric review article are specific to 3 disease processes: cancer, asthma, and neonatal intensive care (ie, premature) populations. Beyond these populations, there were no other pediatric conditions that met inclusion criteria, thus limiting the generalizability of the findings. As described by Rennke et al.,[3] adult systematic reviews that have focused only on disease‐specific interventions to reduce hospital reutilization are also difficult to generalize to broader populations. Two of the 3 recent adult transition intervention systematic reviews excluded disease‐specific interventions in an attempt to find more broadly applicable interventions but struggled with the same heterogeneity discussed in this review by Auger et al.[3, 4] Although disease‐specific interventions were included in the third adult systematic review and the evaluation was restricted to randomized controlled trials, the authors still grappled with finding 1 or 2 common, successful intervention components.[5] The fourth unresolved question involves understanding the financial burden of implementing more resource‐intensive interventions such as postdischarge home nurse visits. For example, it may be difficult to justify the business case for hiring a transition coach or initiating home nurse visits when the cost and financial implications are unclear. Neither the pediatric nor adult literature describes this well.

Some of the challenges in identifying effective interventions differ between adult and pediatric populations. Adults tend to have multiple comorbid conditions, making them more medically complex and at greater risk for adverse outcomes, medication errors, and hospital utilization.[10] Although a small subset of the pediatric population with complex chronic medical conditions accounts for a majority of hospital reutilization and cost,[11] most hospitalized pediatric patients are otherwise healthy with acute illnesses.[12] Additionally, pediatric patients have lower overall hospital reutilization rates when compared with adults. Adult 30‐day readmission rates are approximately 20%[13] compared with pediatric patients whose mean 30‐day readmission rate is 6.5%.[14] With readmission being an outcome upon which studies are basing intervention success or failure, the relatively low readmission rates in the pediatric population make shifting that outcome more challenging.

There is also controversy about whether policymakers should be focusing on decreasing 30‐day readmission rates as a measure of success. We believe that efforts should focus on identifying more meaningful outcomes, especially outcomes important to patients and their families. No single metric is likely to be an adequate measure of the quality of care transitions, but a combination of outcome measures could potentially be more informative both for patients and clinicians. Patient satisfaction with the discharge process is measured as part of standard patient experience surveys, and the 3‐question Care Transitions Measure[15] has been validated and endorsed as a measure of patient perception of discharge safety in adult populations. There is a growing consensus that 30‐day readmission rates are lacking as a measure of discharge quality, and therefore, measuring shorter‐term7‐ or 14‐dayreadmission rates along with short‐term ED utilization after discharge would likely be more helpful for identifying care transitions problems. Attention should also be paid to measuring rates of specific adverse events in the postdischarge period, such as adverse drug events or failure to follow up on pending test results, as these failures are often implicated in reutilization.

In reflecting upon the published data on adult and pediatric transitions of care interventions and the lingering unanswered questions, we propose a few considerations for future direction of the field. First, engagement of the primary care provider may be beneficial. In many interventions describing a care transition coordinator, nursing fulfilled this role; however, there are opportunities for the primary care provider to play a greater role in this arena. Second, the use of factorial design in future studies may help elucidate which specific parts of each intervention may be the most crucial.[16] Finally, readmission rates are a controversial quality measure in adults. Pediatric readmissions are relatively uncommon, making it difficult to track measurements and show improvement. Clinicians, patients, and policymakers should prioritize outcome measures that are most meaningful to patients and their families that occur at a much higher rate than that of readmissions.

Hospital readmissions, which account for a substantial proportion of healthcare expenditures, have increasingly become a focus for hospitals and health systems. Hospitals now assume greater responsibility for population health, and face financial penalties by federal and state agencies that consider readmissions a key measure of the quality of care provided during hospitalization. Consequently, there is broad interest in identifying approaches to reduce hospital reutilization, including emergency department (ED) revisits and hospital readmissions. In this issue of the Journal of Hospital Medicine, Auger et al.[1] report the results of a systematic review, which evaluates the effect of discharge interventions on hospital reutilization among children.

As Auger et al. note, the transition from hospital to home is a vulnerable time for children and their families, with 1 in 5 parents reporting major challenges with such transitions.[2] Auger and colleagues identified 14 studies spanning 3 pediatric disease processes that addressed this issue. The authors concluded that several interventions were potentially effective, but individual studies frequently used multifactorial interventions, precluding determination of discrete elements essential to success. The larger body of care transitions literature in adult populations provides insights for interventions that may benefit pediatric patients, as well as informs future research and quality improvement priorities.

The authors identified some distinct interventions that may successfully decrease hospital reutilization, which share common themes from the adult literature. The first is the use of a dedicated transition coordinator (eg, nurse) or coordinating center to assist with the patient's transition home after discharge. In adult studies, this bridging strategy[3, 4] (ie, use of a dedicated transition coordinator or provider) is initiated during the hospitalization and continues postdischarge in the form of phone calls or home visits. The second theme illustrated in both this pediatric review[1] and adult reviews[3, 4, 5] focuses on enhanced or individualized patient education. Most studies have used a combination of these strategies. For example, the Care Transitions Intervention (one of the best validated adult discharge approaches) uses a transition coach to aid the patient in medication self‐management, creation of a patient‐centered record, scheduling follow‐up appointments, and understanding signs and symptoms of a worsening condition.[6] In a randomized study, this intervention demonstrated a reduction in readmissions within 90 days to 16.7% in the intervention group, compared with 22.5% in the control group.[6] One of the pediatric studies highlighted in the review by Auger et al. achieved a decrease in 14‐day ED revisits from 8% prior to implementation of the program to 2.7% following implementation of the program.[7] This program was for patients discharged from the neonatal intensive care unit and involved a nurse coordinator (similar to a transition coach) who worked closely with families and ensured adequate resources prior to discharge as well as a home visitation program.[7]

Although Auger et al. identify some effective approaches to reducing hospital reutilization after discharge in children, their review and the complementary adult literature bring to light 4 main unresolved questions for hospitalists seeking to improve care transitions: (1) how to dissect diverse and heterogeneous interventions to determine the key driver of success, (2) how to interpret and generally apply interventions from single centers where they may have been tailored to a specific healthcare environment, (3) how to generalize the findings of many disease‐specific interventions to other populations, and (4) how to evaluate the cost and assess the costbenefit of implementing many of the more resource intensive interventions. An example of a heterogeneous intervention addressed in this pediatric systematic review was described by Ng et al.,[8] in which the intervention group received a combination of an enhanced discharge education session, disease‐specific nurse evaluation, an animated education booklet, and postdischarge telephone follow‐up, whereas the control group received a shorter discharge education session, a disease‐specific nurse evaluation only if referred by a physician, a written education booklet, and no telephone follow‐up. Investigators found that intervention patients were less likely to be readmitted or revisit the ED as compared with controls. A similarly multifaceted intervention introduced by Taggart et al.[9] was unable to detect a difference in readmissions or ED revisits. It is unclear whether or not the differences in outcomes were related to differences in the intervention bundle itself or institutional or local contextual factors, thus limiting application to other hospitals. Generalizability of interventions is similarly complicated in adults.

The studies presented in this pediatric review article are specific to 3 disease processes: cancer, asthma, and neonatal intensive care (ie, premature) populations. Beyond these populations, there were no other pediatric conditions that met inclusion criteria, thus limiting the generalizability of the findings. As described by Rennke et al.,[3] adult systematic reviews that have focused only on disease‐specific interventions to reduce hospital reutilization are also difficult to generalize to broader populations. Two of the 3 recent adult transition intervention systematic reviews excluded disease‐specific interventions in an attempt to find more broadly applicable interventions but struggled with the same heterogeneity discussed in this review by Auger et al.[3, 4] Although disease‐specific interventions were included in the third adult systematic review and the evaluation was restricted to randomized controlled trials, the authors still grappled with finding 1 or 2 common, successful intervention components.[5] The fourth unresolved question involves understanding the financial burden of implementing more resource‐intensive interventions such as postdischarge home nurse visits. For example, it may be difficult to justify the business case for hiring a transition coach or initiating home nurse visits when the cost and financial implications are unclear. Neither the pediatric nor adult literature describes this well.

Some of the challenges in identifying effective interventions differ between adult and pediatric populations. Adults tend to have multiple comorbid conditions, making them more medically complex and at greater risk for adverse outcomes, medication errors, and hospital utilization.[10] Although a small subset of the pediatric population with complex chronic medical conditions accounts for a majority of hospital reutilization and cost,[11] most hospitalized pediatric patients are otherwise healthy with acute illnesses.[12] Additionally, pediatric patients have lower overall hospital reutilization rates when compared with adults. Adult 30‐day readmission rates are approximately 20%[13] compared with pediatric patients whose mean 30‐day readmission rate is 6.5%.[14] With readmission being an outcome upon which studies are basing intervention success or failure, the relatively low readmission rates in the pediatric population make shifting that outcome more challenging.

There is also controversy about whether policymakers should be focusing on decreasing 30‐day readmission rates as a measure of success. We believe that efforts should focus on identifying more meaningful outcomes, especially outcomes important to patients and their families. No single metric is likely to be an adequate measure of the quality of care transitions, but a combination of outcome measures could potentially be more informative both for patients and clinicians. Patient satisfaction with the discharge process is measured as part of standard patient experience surveys, and the 3‐question Care Transitions Measure[15] has been validated and endorsed as a measure of patient perception of discharge safety in adult populations. There is a growing consensus that 30‐day readmission rates are lacking as a measure of discharge quality, and therefore, measuring shorter‐term7‐ or 14‐dayreadmission rates along with short‐term ED utilization after discharge would likely be more helpful for identifying care transitions problems. Attention should also be paid to measuring rates of specific adverse events in the postdischarge period, such as adverse drug events or failure to follow up on pending test results, as these failures are often implicated in reutilization.

In reflecting upon the published data on adult and pediatric transitions of care interventions and the lingering unanswered questions, we propose a few considerations for future direction of the field. First, engagement of the primary care provider may be beneficial. In many interventions describing a care transition coordinator, nursing fulfilled this role; however, there are opportunities for the primary care provider to play a greater role in this arena. Second, the use of factorial design in future studies may help elucidate which specific parts of each intervention may be the most crucial.[16] Finally, readmission rates are a controversial quality measure in adults. Pediatric readmissions are relatively uncommon, making it difficult to track measurements and show improvement. Clinicians, patients, and policymakers should prioritize outcome measures that are most meaningful to patients and their families that occur at a much higher rate than that of readmissions.

Hospital readmissions, which account for a substantial proportion of healthcare expenditures, have increasingly become a focus for hospitals and health systems. Hospitals now assume greater responsibility for population health, and face financial penalties by federal and state agencies that consider readmissions a key measure of the quality of care provided during hospitalization. Consequently, there is broad interest in identifying approaches to reduce hospital reutilization, including emergency department (ED) revisits and hospital readmissions. In this issue of the Journal of Hospital Medicine, Auger et al.[1] report the results of a systematic review, which evaluates the effect of discharge interventions on hospital reutilization among children.

As Auger et al. note, the transition from hospital to home is a vulnerable time for children and their families, with 1 in 5 parents reporting major challenges with such transitions.[2] Auger and colleagues identified 14 studies spanning 3 pediatric disease processes that addressed this issue. The authors concluded that several interventions were potentially effective, but individual studies frequently used multifactorial interventions, precluding determination of discrete elements essential to success. The larger body of care transitions literature in adult populations provides insights for interventions that may benefit pediatric patients, as well as informs future research and quality improvement priorities.

The authors identified some distinct interventions that may successfully decrease hospital reutilization, which share common themes from the adult literature. The first is the use of a dedicated transition coordinator (eg, nurse) or coordinating center to assist with the patient's transition home after discharge. In adult studies, this bridging strategy[3, 4] (ie, use of a dedicated transition coordinator or provider) is initiated during the hospitalization and continues postdischarge in the form of phone calls or home visits. The second theme illustrated in both this pediatric review[1] and adult reviews[3, 4, 5] focuses on enhanced or individualized patient education. Most studies have used a combination of these strategies. For example, the Care Transitions Intervention (one of the best validated adult discharge approaches) uses a transition coach to aid the patient in medication self‐management, creation of a patient‐centered record, scheduling follow‐up appointments, and understanding signs and symptoms of a worsening condition.[6] In a randomized study, this intervention demonstrated a reduction in readmissions within 90 days to 16.7% in the intervention group, compared with 22.5% in the control group.[6] One of the pediatric studies highlighted in the review by Auger et al. achieved a decrease in 14‐day ED revisits from 8% prior to implementation of the program to 2.7% following implementation of the program.[7] This program was for patients discharged from the neonatal intensive care unit and involved a nurse coordinator (similar to a transition coach) who worked closely with families and ensured adequate resources prior to discharge as well as a home visitation program.[7]

Although Auger et al. identify some effective approaches to reducing hospital reutilization after discharge in children, their review and the complementary adult literature bring to light 4 main unresolved questions for hospitalists seeking to improve care transitions: (1) how to dissect diverse and heterogeneous interventions to determine the key driver of success, (2) how to interpret and generally apply interventions from single centers where they may have been tailored to a specific healthcare environment, (3) how to generalize the findings of many disease‐specific interventions to other populations, and (4) how to evaluate the cost and assess the costbenefit of implementing many of the more resource intensive interventions. An example of a heterogeneous intervention addressed in this pediatric systematic review was described by Ng et al.,[8] in which the intervention group received a combination of an enhanced discharge education session, disease‐specific nurse evaluation, an animated education booklet, and postdischarge telephone follow‐up, whereas the control group received a shorter discharge education session, a disease‐specific nurse evaluation only if referred by a physician, a written education booklet, and no telephone follow‐up. Investigators found that intervention patients were less likely to be readmitted or revisit the ED as compared with controls. A similarly multifaceted intervention introduced by Taggart et al.[9] was unable to detect a difference in readmissions or ED revisits. It is unclear whether or not the differences in outcomes were related to differences in the intervention bundle itself or institutional or local contextual factors, thus limiting application to other hospitals. Generalizability of interventions is similarly complicated in adults.

The studies presented in this pediatric review article are specific to 3 disease processes: cancer, asthma, and neonatal intensive care (ie, premature) populations. Beyond these populations, there were no other pediatric conditions that met inclusion criteria, thus limiting the generalizability of the findings. As described by Rennke et al.,[3] adult systematic reviews that have focused only on disease‐specific interventions to reduce hospital reutilization are also difficult to generalize to broader populations. Two of the 3 recent adult transition intervention systematic reviews excluded disease‐specific interventions in an attempt to find more broadly applicable interventions but struggled with the same heterogeneity discussed in this review by Auger et al.[3, 4] Although disease‐specific interventions were included in the third adult systematic review and the evaluation was restricted to randomized controlled trials, the authors still grappled with finding 1 or 2 common, successful intervention components.[5] The fourth unresolved question involves understanding the financial burden of implementing more resource‐intensive interventions such as postdischarge home nurse visits. For example, it may be difficult to justify the business case for hiring a transition coach or initiating home nurse visits when the cost and financial implications are unclear. Neither the pediatric nor adult literature describes this well.

Some of the challenges in identifying effective interventions differ between adult and pediatric populations. Adults tend to have multiple comorbid conditions, making them more medically complex and at greater risk for adverse outcomes, medication errors, and hospital utilization.[10] Although a small subset of the pediatric population with complex chronic medical conditions accounts for a majority of hospital reutilization and cost,[11] most hospitalized pediatric patients are otherwise healthy with acute illnesses.[12] Additionally, pediatric patients have lower overall hospital reutilization rates when compared with adults. Adult 30‐day readmission rates are approximately 20%[13] compared with pediatric patients whose mean 30‐day readmission rate is 6.5%.[14] With readmission being an outcome upon which studies are basing intervention success or failure, the relatively low readmission rates in the pediatric population make shifting that outcome more challenging.

There is also controversy about whether policymakers should be focusing on decreasing 30‐day readmission rates as a measure of success. We believe that efforts should focus on identifying more meaningful outcomes, especially outcomes important to patients and their families. No single metric is likely to be an adequate measure of the quality of care transitions, but a combination of outcome measures could potentially be more informative both for patients and clinicians. Patient satisfaction with the discharge process is measured as part of standard patient experience surveys, and the 3‐question Care Transitions Measure[15] has been validated and endorsed as a measure of patient perception of discharge safety in adult populations. There is a growing consensus that 30‐day readmission rates are lacking as a measure of discharge quality, and therefore, measuring shorter‐term7‐ or 14‐dayreadmission rates along with short‐term ED utilization after discharge would likely be more helpful for identifying care transitions problems. Attention should also be paid to measuring rates of specific adverse events in the postdischarge period, such as adverse drug events or failure to follow up on pending test results, as these failures are often implicated in reutilization.

In reflecting upon the published data on adult and pediatric transitions of care interventions and the lingering unanswered questions, we propose a few considerations for future direction of the field. First, engagement of the primary care provider may be beneficial. In many interventions describing a care transition coordinator, nursing fulfilled this role; however, there are opportunities for the primary care provider to play a greater role in this arena. Second, the use of factorial design in future studies may help elucidate which specific parts of each intervention may be the most crucial.[16] Finally, readmission rates are a controversial quality measure in adults. Pediatric readmissions are relatively uncommon, making it difficult to track measurements and show improvement. Clinicians, patients, and policymakers should prioritize outcome measures that are most meaningful to patients and their families that occur at a much higher rate than that of readmissions.

Postgraduate medical education has traditionally relied on a training model of progressive independence, where housestaff learn patient care through increasing autonomy and decreasing levels of supervision.1 While this framework has little empirical backing, it is grounded in sound educational theory from similar disciplines and endorsed by medical associations.1, 2 The Accreditation Council for Graduate Medical Education (ACGME) recently implemented regulations requiring that first‐year residents have a qualified supervisor physically present or immediately available at all times.3 Previously, oversight by an offsite supervisor (for example, an attending physician at home) was considered adequate. These new regulations, although motivated by patient safety imperatives,4 have elicited concerns that increased supervision may lead to decreased housestaff autonomy and an increased reliance on supervisors for clinical guidance.5 Such changes could ultimately produce less qualified practitioners by the completion of training.

Critics of the current training model point to a patient safety mechanism where housestaff must take responsibility for requesting attending‐level help when situations arise that surpass their skill level.5 For resident physicians, however, the decision to request support is often complex and dependent not only on the clinical question, but also on unique and variable trainee and supervisor factors.6 Survey data from 1999, prior to the current training regulations, showed that increased faculty presence improved resident reports of educational value, quality of patient care, and autonomy.7 A recent survey, performed after the initiation of overnight attending supervision at an academic medical center, demonstrated perceived improvements in educational value and patient‐level outcomes by both faculty and housestaff.8 Whether increased supervision and resident autonomy can coexist remains undetermined.

Overnight rotations for residents (commonly referred to as night float) are often times of little direct or indirect supervision. A recent systematic review of clinical supervision practices for housestaff in all fields found scarce literature on overnight supervision practices.9 There remains limited and conflicting data regarding the quality of patient care provided by the resident night float,10 as well as evidence revealing a low perceived educational value of night rotations when compared with non‐night float rotations.11 Yet in 2006, more than three‐quarters of all internal medicine programs employed night float rotations.12 In response to ACGME guidelines mandating decreased shift lengths with continued restrictions on overall duty hours, it appears likely even more training programs will implement night float systems.

The presence of overnight hospitalists (also known as nocturnists) is growing within the academic setting, yet their role in relation to trainees is either poorly defined13 or independent of housestaff.14 To better understand the impact of increasing levels of supervision on residency training, we investigated housestaff perceptions of education, autonomy, and clinical decision‐making before and after implementation of an in‐hospital, overnight attending physician (nocturnist).

METHODS

The study was conducted at a 570‐bed academic, tertiary care medical center affiliated with an internal medicine residency program of 170 housestaff. At our institution, all first year residents perform a week of intern night float consisting of overnight cross‐coverage of general medicine patients on the floor, step‐down, and intensive care units (ICUs). Second and third year residents each complete 4 to 6 days of resident night float each year at this hospital. They are responsible for assisting the intern night float with cross‐coverage, in addition to admitting general medicine patients to the floor, step‐down unit, and intensive care units. Every night at our medical center, 1 intern night float and 1 resident night float are on duty in the hospital; this is in addition to a resident from the on‐call medicine team and a resident working in the ICU. Prior to July 2010, no internal medicine attending physicians were physically present in the hospital at night. Oversight for the intern and resident night float was provided by the attending physician for the on‐call resident ward team, who was at home and available by pager. The night float housestaff were instructed to contact the responsible attending physician only when a major change in clinical status occurred for hospitalized or newly admitted patients, though this expectation was neither standardized nor monitored.

We established a nocturnist program at the start of the 2010 academic year. The position was staffed by hospitalists from within the Division of Hospital Medicine without the use of moonlighters. Two‐thirds of shifts were filled by 3 dedicated nocturnists with remaining staffing provided by junior hospitalist faculty. The dedicated nocturnists had recently completed their internal medicine residency at our institution. Shift length was 12 hours and dedicated nocturnists worked, on average, 10 shifts per month. The nocturnist filled a critical overnight safety role through mandatory bedside staffing of newly admitted ICU patients within 2 hours of admission, discussion in person or via telephone of newly admitted step‐down unit patients within 6 hours of admission, and direct or indirect supervision of the care of any patients undergoing a major change in clinical status. The overnight hospitalist was also available for clinical questions and to assist housestaff with triaging of overnight admissions. After nocturnist implementation, overnight housestaff received direct supervision or had immediate access to direct supervision, while prior to the nocturnist, residents had access only to indirect supervision.

In addition, the nocturnist admitted medicine patients after 1 _AM in a 1:1 ratio with the admitting night float resident, performed medical consults, and provided coverage of non‐teaching medicine services. While actual volume numbers were not obtained, the estimated average of resident admissions per night was 2 to 3, and the number of nocturnist admissions was 1 to 2. The nocturnist also met nightly with night float housestaff for half‐hour didactics focusing on the management of common overnight clinical scenarios. The role of the new nocturnist was described to all housestaff in orientation materials given prior to their night float rotation and their general medicine ward rotation.

We administered pre‐rolling surveys and post‐rolling surveys of internal medicine intern and resident physicians who underwent the night float rotation at our hospital during the 2010 to 2011 academic year. Surveys examined housestaff perceptions of the night float rotation with regard to supervisory roles, educational and clinical value, and clinical decision‐making prior to and after implementation of the nocturnist. Surveys were designed by the study investigators based on prior literature,1, 510 personal experience, and housestaff suggestion, and were refined during works‐in‐progress meetings. Surveys were composed of Likert‐style questions asking housestaff to rate their level of agreement (15, strongly disagree to strongly agree) with statements regarding the supervisory and educational experience of the night float rotation, and to judge their frequency of contact (15, never to always/nightly) with an attending physician for specific clinical scenarios. The clinical scenarios described situations dealing with attendingresident communication around transfers of care, diagnostic evaluation, therapeutic interventions, and adverse events. Scenarios were taken from previous literature describing supervision preferences of faculty and residents during times of critical clinical decision‐making.15

One week prior to the beginning their night float rotation for the 20102011 academic year, housestaff were sent an e‐mail request to complete an online survey asking about their night float rotation during the prior academic year, when no nocturnist was present. One week after completion of their night float rotation for the 20102011 academic year, housestaff received an e‐mail with a link to a post‐survey asking about their recently completed, nocturnist‐supervised, night float rotation. First year residents received only a post‐survey at the completion of their night float rotation, as they would be unable to reflect on prior experience.

Informed consent was imbedded within the e‐mail survey request. Survey requests were sent by a fellow within the Division of Hospital Medicine with a brief message cosigned by an associate program director of the residency program. We did not collect unique identifiers from respondents in order to offer additional assurances to the participants that the survey was anonymous. There was no incentive offered for completion of the survey. Survey data were anonymous and downloaded to a database by a third party. Data were analyzed using Microsoft Excel, and pre‐responses and post‐responses compared using a Student t test. The study was approved by the medical center's Institutional Review Board.

RESULTS

Rates of response for pre‐surveys and post‐surveys were 57% (43 respondents) and 51% (53 respondents), respectively. Due to response rates and in order to convey accurately the perceptions of the training program as a whole, we collapsed responses of the pre‐surveys and post‐surveys based on level of training. After implementation of the overnight attending, we observed a significant increase in the perceived clinical value of the night float rotation (3.95 vs 4.27, P = 0.01) as well as in the adequacy of overnight supervision (3.65 vs 4.30, P < 0.0001; Table 1). There was no reported change in housestaff decision‐making autonomy (4.35 vs 4.45, P = 0.44). In addition, we noted a nonsignificant trend towards an increased perception of the night float rotation as a valuable educational experience (3.83 vs 4.04, P = 0.24). After implementation of the nocturnist, more resident physicians agreed that overnight supervision by an attending positively impacted patient outcomes (3.79 vs 4.30, P = 0.002).

After implementation of the nocturnist, night float providers demonstrated increased rates of contacting an attending physician overnight (Table 2). There were significantly greater rates of attending contact for transfers from outside facilities (2.00 vs 3.20, P = 0.006) and during times of adverse events (2.51 vs 3.25, P = 0.04). We observed a reported increase in attending contact prior to ordering invasive diagnostic procedures (1.75 vs 2.76, P = 0.004) and noninvasive diagnostic procedures (1.09 vs 1.31, P = 0.03), as well as prior to initiation of intravenous antibiotics (1.11 vs 1.47, P = 0.007) and vasopressors (1.52 vs 2.40, P = 0.004).

After initiating the program, the nocturnist became the most commonly contacted overnight provider by the night float housestaff (Table 3). We observed a decrease in peer to peer contact between the night float housestaff and the on‐call overnight resident after implementation of the nocturnist (2.67 vs 2.04, P = 0.006).

Attending presence led to increased agreement that there was a defined overnight attending to contact (2.97 vs 1.96, P < 0.0001) and a decreased fear of waking an attending overnight for assistance (3.26 vs 2.72, P = 0.03). Increased attending availability, however, did not change resident physician's fear of revealing knowledge gaps, their desire to make decisions independently, or their belief that contacting an attending would not change a patient's outcome (Table 4).

DISCUSSION

The ACGME's new duty hour regulations require that supervision for first‐year residents be provided by a qualified physician (advanced resident, fellow, or attending physician) who is physically present at the hospital. Our study demonstrates that increased direct overnight supervision provided by an in‐house nocturnist enhanced the clinical value of the night float rotation and the perceived quality of patient care. In our study, increased attending supervision did not reduce perceived decision‐making autonomy, and in fact led to increased rates of attending contact during times of critical clinical decision‐making. Such results may help assuage fears that recent regulations mandating enhanced attending supervision will produce less capable practitioners, and offers reassurance that such changes are positively impacting patient care.

Many academic institutions are implementing nocturnists, although their precise roles and responsibilities are still being defined. Our nocturnist program was explicitly designed with housestaff supervision as a core responsibility, with the goal of improving patient safety and housestaff education overnight. We found that availability barriers to attending contact were logically decreased with in‐house faculty presence. Potentially harmful attitudes, however, around requesting support (such as fear of revealing knowledge gaps or the desire to make decisions independently) remained. Furthermore, despite statistically significant increases in contact between faculty and residents at times of critical decision‐making, overall rates of attending contact for diagnostic and therapeutic interventions remained low. It is unknown from our study or previous research, however, what level of contact is appropriate or ideal for many clinical scenarios.

Additionally, we described a novel role of an academic nocturnist at a tertiary care teaching hospital and offered a potential template for the development of academic nocturnists at similar institutions seeking to increase direct overnight supervision. Such roles have not been previously well defined in the literature. Based on our experience, the nocturnist's role was manageable and well utilized by housestaff, particularly for assistance with critically ill patients and overnight triaging. We believe there are a number of factors associated with the success of this role. First, clear guidelines were presented to housestaff and nocturnists regarding expectations for supervision (for example, staffing ICU admissions within 2 hours). These guidelines likely contributed to the increased attending contact observed during critical clinical decision‐making, as well as the perceived improved patient outcomes by our housestaff. Second, the nocturnists were expected to be an integral part of the overnight care team. In many systems, the nocturnists act completely independently of the housestaff teams, creating an additional barrier to contact and communication. In our system, because of clear guidelines and their integral role in staffing overnight admissions, the nocturnists were an essential partner in care for the housestaff. Third, most of the nocturnists had recently completed their residency training at this institution. Although our survey does not directly address this, we believe their knowledge of the hospital, appreciation of the role of the intern and the resident within our system, and understanding of the need to preserve housestaff autonomy were essential to building a successful nocturnist role. Lastly, the nocturnists were not only expected to supervise and staff new admissions, but were also given a teaching expectation. We believe they were viewed by housestaff as qualified teaching attendings, similar to the daytime hospitalist. These findings may provide guidelines for other institutions seeking to balance overnight hospitalist supervision with preserving resident's ability to make autonomous decisions.

There are several limitations to our study. The findings represent the experience of internal medicine housestaff at a single academic, tertiary care medical center and may not be reflective of other institutions or specialties. We asked housestaff to recall night float experiences from the prior year, which may have introduced recall bias, though responses were obtained before participants underwent the new curriculum. Maturation of housestaff over time could have led to changes in perceived autonomy, value of the night float rotation, and rates of attending contact independent of nocturnist implementation. In addition, there may have been unaccounted changes to other elements of the residency program, hospital, or patient volume between rotations. The implementation of the nocturnist, however, was the only major change to our training program that academic year, and there were no significant changes in patient volume, structure of the teaching or non‐resident services, or other policies around resident supervision.

It is possible that the nocturnist may have contributed to reports of increased clinical value and perceived quality of patient care simply by decreasing overnight workload for housestaff, and enhanced supervision and teaching may have played a lesser role. Even if this were true, optimizing resident workload is in itself an important goal for teaching hospitals and residency programs alike in order to maximize patient safety. Inclusion of intern post‐rotation surveys may have influenced data; though, we had no reason to suspect the surveyed interns would respond in a different manner than prior resident groups. The responses of both junior and senior housestaff were pooled; while this potentially weighted the results in favor of higher responding groups, we felt that it conveyed the residents' accurate sentiments on the program. Finally, while we compared two models of overnight supervision, we reported only housestaff perceptions of education, autonomy, patient outcomes, and supervisory contact, and not direct measures of knowledge or patient care. Further research will be required to define the relationship between supervision practices and patient‐level clinical outcomes.

The new ACGME regulations around resident supervision, as well as the broader movement to improve the safety and quality of care, require residency programs to negotiate a delicate balance between providing high‐quality patient care while preserving graduated independence in clinical training. Our study demonstrates that increased overnight supervision by nocturnists with well‐defined supervisory and teaching roles can preserve housestaff autonomy, improve the clinical experience for trainees, increase access to support during times of critical decision‐making, and potentially lead to improved patient outcomes.

Postgraduate medical education has traditionally relied on a training model of progressive independence, where housestaff learn patient care through increasing autonomy and decreasing levels of supervision.1 While this framework has little empirical backing, it is grounded in sound educational theory from similar disciplines and endorsed by medical associations.1, 2 The Accreditation Council for Graduate Medical Education (ACGME) recently implemented regulations requiring that first‐year residents have a qualified supervisor physically present or immediately available at all times.3 Previously, oversight by an offsite supervisor (for example, an attending physician at home) was considered adequate. These new regulations, although motivated by patient safety imperatives,4 have elicited concerns that increased supervision may lead to decreased housestaff autonomy and an increased reliance on supervisors for clinical guidance.5 Such changes could ultimately produce less qualified practitioners by the completion of training.

Critics of the current training model point to a patient safety mechanism where housestaff must take responsibility for requesting attending‐level help when situations arise that surpass their skill level.5 For resident physicians, however, the decision to request support is often complex and dependent not only on the clinical question, but also on unique and variable trainee and supervisor factors.6 Survey data from 1999, prior to the current training regulations, showed that increased faculty presence improved resident reports of educational value, quality of patient care, and autonomy.7 A recent survey, performed after the initiation of overnight attending supervision at an academic medical center, demonstrated perceived improvements in educational value and patient‐level outcomes by both faculty and housestaff.8 Whether increased supervision and resident autonomy can coexist remains undetermined.

Overnight rotations for residents (commonly referred to as night float) are often times of little direct or indirect supervision. A recent systematic review of clinical supervision practices for housestaff in all fields found scarce literature on overnight supervision practices.9 There remains limited and conflicting data regarding the quality of patient care provided by the resident night float,10 as well as evidence revealing a low perceived educational value of night rotations when compared with non‐night float rotations.11 Yet in 2006, more than three‐quarters of all internal medicine programs employed night float rotations.12 In response to ACGME guidelines mandating decreased shift lengths with continued restrictions on overall duty hours, it appears likely even more training programs will implement night float systems.

The presence of overnight hospitalists (also known as nocturnists) is growing within the academic setting, yet their role in relation to trainees is either poorly defined13 or independent of housestaff.14 To better understand the impact of increasing levels of supervision on residency training, we investigated housestaff perceptions of education, autonomy, and clinical decision‐making before and after implementation of an in‐hospital, overnight attending physician (nocturnist).

METHODS

The study was conducted at a 570‐bed academic, tertiary care medical center affiliated with an internal medicine residency program of 170 housestaff. At our institution, all first year residents perform a week of intern night float consisting of overnight cross‐coverage of general medicine patients on the floor, step‐down, and intensive care units (ICUs). Second and third year residents each complete 4 to 6 days of resident night float each year at this hospital. They are responsible for assisting the intern night float with cross‐coverage, in addition to admitting general medicine patients to the floor, step‐down unit, and intensive care units. Every night at our medical center, 1 intern night float and 1 resident night float are on duty in the hospital; this is in addition to a resident from the on‐call medicine team and a resident working in the ICU. Prior to July 2010, no internal medicine attending physicians were physically present in the hospital at night. Oversight for the intern and resident night float was provided by the attending physician for the on‐call resident ward team, who was at home and available by pager. The night float housestaff were instructed to contact the responsible attending physician only when a major change in clinical status occurred for hospitalized or newly admitted patients, though this expectation was neither standardized nor monitored.

We established a nocturnist program at the start of the 2010 academic year. The position was staffed by hospitalists from within the Division of Hospital Medicine without the use of moonlighters. Two‐thirds of shifts were filled by 3 dedicated nocturnists with remaining staffing provided by junior hospitalist faculty. The dedicated nocturnists had recently completed their internal medicine residency at our institution. Shift length was 12 hours and dedicated nocturnists worked, on average, 10 shifts per month. The nocturnist filled a critical overnight safety role through mandatory bedside staffing of newly admitted ICU patients within 2 hours of admission, discussion in person or via telephone of newly admitted step‐down unit patients within 6 hours of admission, and direct or indirect supervision of the care of any patients undergoing a major change in clinical status. The overnight hospitalist was also available for clinical questions and to assist housestaff with triaging of overnight admissions. After nocturnist implementation, overnight housestaff received direct supervision or had immediate access to direct supervision, while prior to the nocturnist, residents had access only to indirect supervision.

In addition, the nocturnist admitted medicine patients after 1 _AM in a 1:1 ratio with the admitting night float resident, performed medical consults, and provided coverage of non‐teaching medicine services. While actual volume numbers were not obtained, the estimated average of resident admissions per night was 2 to 3, and the number of nocturnist admissions was 1 to 2. The nocturnist also met nightly with night float housestaff for half‐hour didactics focusing on the management of common overnight clinical scenarios. The role of the new nocturnist was described to all housestaff in orientation materials given prior to their night float rotation and their general medicine ward rotation.

We administered pre‐rolling surveys and post‐rolling surveys of internal medicine intern and resident physicians who underwent the night float rotation at our hospital during the 2010 to 2011 academic year. Surveys examined housestaff perceptions of the night float rotation with regard to supervisory roles, educational and clinical value, and clinical decision‐making prior to and after implementation of the nocturnist. Surveys were designed by the study investigators based on prior literature,1, 510 personal experience, and housestaff suggestion, and were refined during works‐in‐progress meetings. Surveys were composed of Likert‐style questions asking housestaff to rate their level of agreement (15, strongly disagree to strongly agree) with statements regarding the supervisory and educational experience of the night float rotation, and to judge their frequency of contact (15, never to always/nightly) with an attending physician for specific clinical scenarios. The clinical scenarios described situations dealing with attendingresident communication around transfers of care, diagnostic evaluation, therapeutic interventions, and adverse events. Scenarios were taken from previous literature describing supervision preferences of faculty and residents during times of critical clinical decision‐making.15

One week prior to the beginning their night float rotation for the 20102011 academic year, housestaff were sent an e‐mail request to complete an online survey asking about their night float rotation during the prior academic year, when no nocturnist was present. One week after completion of their night float rotation for the 20102011 academic year, housestaff received an e‐mail with a link to a post‐survey asking about their recently completed, nocturnist‐supervised, night float rotation. First year residents received only a post‐survey at the completion of their night float rotation, as they would be unable to reflect on prior experience.

Informed consent was imbedded within the e‐mail survey request. Survey requests were sent by a fellow within the Division of Hospital Medicine with a brief message cosigned by an associate program director of the residency program. We did not collect unique identifiers from respondents in order to offer additional assurances to the participants that the survey was anonymous. There was no incentive offered for completion of the survey. Survey data were anonymous and downloaded to a database by a third party. Data were analyzed using Microsoft Excel, and pre‐responses and post‐responses compared using a Student t test. The study was approved by the medical center's Institutional Review Board.

RESULTS

Rates of response for pre‐surveys and post‐surveys were 57% (43 respondents) and 51% (53 respondents), respectively. Due to response rates and in order to convey accurately the perceptions of the training program as a whole, we collapsed responses of the pre‐surveys and post‐surveys based on level of training. After implementation of the overnight attending, we observed a significant increase in the perceived clinical value of the night float rotation (3.95 vs 4.27, P = 0.01) as well as in the adequacy of overnight supervision (3.65 vs 4.30, P < 0.0001; Table 1). There was no reported change in housestaff decision‐making autonomy (4.35 vs 4.45, P = 0.44). In addition, we noted a nonsignificant trend towards an increased perception of the night float rotation as a valuable educational experience (3.83 vs 4.04, P = 0.24). After implementation of the nocturnist, more resident physicians agreed that overnight supervision by an attending positively impacted patient outcomes (3.79 vs 4.30, P = 0.002).

After implementation of the nocturnist, night float providers demonstrated increased rates of contacting an attending physician overnight (Table 2). There were significantly greater rates of attending contact for transfers from outside facilities (2.00 vs 3.20, P = 0.006) and during times of adverse events (2.51 vs 3.25, P = 0.04). We observed a reported increase in attending contact prior to ordering invasive diagnostic procedures (1.75 vs 2.76, P = 0.004) and noninvasive diagnostic procedures (1.09 vs 1.31, P = 0.03), as well as prior to initiation of intravenous antibiotics (1.11 vs 1.47, P = 0.007) and vasopressors (1.52 vs 2.40, P = 0.004).

After initiating the program, the nocturnist became the most commonly contacted overnight provider by the night float housestaff (Table 3). We observed a decrease in peer to peer contact between the night float housestaff and the on‐call overnight resident after implementation of the nocturnist (2.67 vs 2.04, P = 0.006).

Attending presence led to increased agreement that there was a defined overnight attending to contact (2.97 vs 1.96, P < 0.0001) and a decreased fear of waking an attending overnight for assistance (3.26 vs 2.72, P = 0.03). Increased attending availability, however, did not change resident physician's fear of revealing knowledge gaps, their desire to make decisions independently, or their belief that contacting an attending would not change a patient's outcome (Table 4).

DISCUSSION

The ACGME's new duty hour regulations require that supervision for first‐year residents be provided by a qualified physician (advanced resident, fellow, or attending physician) who is physically present at the hospital. Our study demonstrates that increased direct overnight supervision provided by an in‐house nocturnist enhanced the clinical value of the night float rotation and the perceived quality of patient care. In our study, increased attending supervision did not reduce perceived decision‐making autonomy, and in fact led to increased rates of attending contact during times of critical clinical decision‐making. Such results may help assuage fears that recent regulations mandating enhanced attending supervision will produce less capable practitioners, and offers reassurance that such changes are positively impacting patient care.

Many academic institutions are implementing nocturnists, although their precise roles and responsibilities are still being defined. Our nocturnist program was explicitly designed with housestaff supervision as a core responsibility, with the goal of improving patient safety and housestaff education overnight. We found that availability barriers to attending contact were logically decreased with in‐house faculty presence. Potentially harmful attitudes, however, around requesting support (such as fear of revealing knowledge gaps or the desire to make decisions independently) remained. Furthermore, despite statistically significant increases in contact between faculty and residents at times of critical decision‐making, overall rates of attending contact for diagnostic and therapeutic interventions remained low. It is unknown from our study or previous research, however, what level of contact is appropriate or ideal for many clinical scenarios.

Additionally, we described a novel role of an academic nocturnist at a tertiary care teaching hospital and offered a potential template for the development of academic nocturnists at similar institutions seeking to increase direct overnight supervision. Such roles have not been previously well defined in the literature. Based on our experience, the nocturnist's role was manageable and well utilized by housestaff, particularly for assistance with critically ill patients and overnight triaging. We believe there are a number of factors associated with the success of this role. First, clear guidelines were presented to housestaff and nocturnists regarding expectations for supervision (for example, staffing ICU admissions within 2 hours). These guidelines likely contributed to the increased attending contact observed during critical clinical decision‐making, as well as the perceived improved patient outcomes by our housestaff. Second, the nocturnists were expected to be an integral part of the overnight care team. In many systems, the nocturnists act completely independently of the housestaff teams, creating an additional barrier to contact and communication. In our system, because of clear guidelines and their integral role in staffing overnight admissions, the nocturnists were an essential partner in care for the housestaff. Third, most of the nocturnists had recently completed their residency training at this institution. Although our survey does not directly address this, we believe their knowledge of the hospital, appreciation of the role of the intern and the resident within our system, and understanding of the need to preserve housestaff autonomy were essential to building a successful nocturnist role. Lastly, the nocturnists were not only expected to supervise and staff new admissions, but were also given a teaching expectation. We believe they were viewed by housestaff as qualified teaching attendings, similar to the daytime hospitalist. These findings may provide guidelines for other institutions seeking to balance overnight hospitalist supervision with preserving resident's ability to make autonomous decisions.

There are several limitations to our study. The findings represent the experience of internal medicine housestaff at a single academic, tertiary care medical center and may not be reflective of other institutions or specialties. We asked housestaff to recall night float experiences from the prior year, which may have introduced recall bias, though responses were obtained before participants underwent the new curriculum. Maturation of housestaff over time could have led to changes in perceived autonomy, value of the night float rotation, and rates of attending contact independent of nocturnist implementation. In addition, there may have been unaccounted changes to other elements of the residency program, hospital, or patient volume between rotations. The implementation of the nocturnist, however, was the only major change to our training program that academic year, and there were no significant changes in patient volume, structure of the teaching or non‐resident services, or other policies around resident supervision.

It is possible that the nocturnist may have contributed to reports of increased clinical value and perceived quality of patient care simply by decreasing overnight workload for housestaff, and enhanced supervision and teaching may have played a lesser role. Even if this were true, optimizing resident workload is in itself an important goal for teaching hospitals and residency programs alike in order to maximize patient safety. Inclusion of intern post‐rotation surveys may have influenced data; though, we had no reason to suspect the surveyed interns would respond in a different manner than prior resident groups. The responses of both junior and senior housestaff were pooled; while this potentially weighted the results in favor of higher responding groups, we felt that it conveyed the residents' accurate sentiments on the program. Finally, while we compared two models of overnight supervision, we reported only housestaff perceptions of education, autonomy, patient outcomes, and supervisory contact, and not direct measures of knowledge or patient care. Further research will be required to define the relationship between supervision practices and patient‐level clinical outcomes.

The new ACGME regulations around resident supervision, as well as the broader movement to improve the safety and quality of care, require residency programs to negotiate a delicate balance between providing high‐quality patient care while preserving graduated independence in clinical training. Our study demonstrates that increased overnight supervision by nocturnists with well‐defined supervisory and teaching roles can preserve housestaff autonomy, improve the clinical experience for trainees, increase access to support during times of critical decision‐making, and potentially lead to improved patient outcomes.

Postgraduate medical education has traditionally relied on a training model of progressive independence, where housestaff learn patient care through increasing autonomy and decreasing levels of supervision.1 While this framework has little empirical backing, it is grounded in sound educational theory from similar disciplines and endorsed by medical associations.1, 2 The Accreditation Council for Graduate Medical Education (ACGME) recently implemented regulations requiring that first‐year residents have a qualified supervisor physically present or immediately available at all times.3 Previously, oversight by an offsite supervisor (for example, an attending physician at home) was considered adequate. These new regulations, although motivated by patient safety imperatives,4 have elicited concerns that increased supervision may lead to decreased housestaff autonomy and an increased reliance on supervisors for clinical guidance.5 Such changes could ultimately produce less qualified practitioners by the completion of training.

Critics of the current training model point to a patient safety mechanism where housestaff must take responsibility for requesting attending‐level help when situations arise that surpass their skill level.5 For resident physicians, however, the decision to request support is often complex and dependent not only on the clinical question, but also on unique and variable trainee and supervisor factors.6 Survey data from 1999, prior to the current training regulations, showed that increased faculty presence improved resident reports of educational value, quality of patient care, and autonomy.7 A recent survey, performed after the initiation of overnight attending supervision at an academic medical center, demonstrated perceived improvements in educational value and patient‐level outcomes by both faculty and housestaff.8 Whether increased supervision and resident autonomy can coexist remains undetermined.

Overnight rotations for residents (commonly referred to as night float) are often times of little direct or indirect supervision. A recent systematic review of clinical supervision practices for housestaff in all fields found scarce literature on overnight supervision practices.9 There remains limited and conflicting data regarding the quality of patient care provided by the resident night float,10 as well as evidence revealing a low perceived educational value of night rotations when compared with non‐night float rotations.11 Yet in 2006, more than three‐quarters of all internal medicine programs employed night float rotations.12 In response to ACGME guidelines mandating decreased shift lengths with continued restrictions on overall duty hours, it appears likely even more training programs will implement night float systems.

The presence of overnight hospitalists (also known as nocturnists) is growing within the academic setting, yet their role in relation to trainees is either poorly defined13 or independent of housestaff.14 To better understand the impact of increasing levels of supervision on residency training, we investigated housestaff perceptions of education, autonomy, and clinical decision‐making before and after implementation of an in‐hospital, overnight attending physician (nocturnist).

METHODS

The study was conducted at a 570‐bed academic, tertiary care medical center affiliated with an internal medicine residency program of 170 housestaff. At our institution, all first year residents perform a week of intern night float consisting of overnight cross‐coverage of general medicine patients on the floor, step‐down, and intensive care units (ICUs). Second and third year residents each complete 4 to 6 days of resident night float each year at this hospital. They are responsible for assisting the intern night float with cross‐coverage, in addition to admitting general medicine patients to the floor, step‐down unit, and intensive care units. Every night at our medical center, 1 intern night float and 1 resident night float are on duty in the hospital; this is in addition to a resident from the on‐call medicine team and a resident working in the ICU. Prior to July 2010, no internal medicine attending physicians were physically present in the hospital at night. Oversight for the intern and resident night float was provided by the attending physician for the on‐call resident ward team, who was at home and available by pager. The night float housestaff were instructed to contact the responsible attending physician only when a major change in clinical status occurred for hospitalized or newly admitted patients, though this expectation was neither standardized nor monitored.

We established a nocturnist program at the start of the 2010 academic year. The position was staffed by hospitalists from within the Division of Hospital Medicine without the use of moonlighters. Two‐thirds of shifts were filled by 3 dedicated nocturnists with remaining staffing provided by junior hospitalist faculty. The dedicated nocturnists had recently completed their internal medicine residency at our institution. Shift length was 12 hours and dedicated nocturnists worked, on average, 10 shifts per month. The nocturnist filled a critical overnight safety role through mandatory bedside staffing of newly admitted ICU patients within 2 hours of admission, discussion in person or via telephone of newly admitted step‐down unit patients within 6 hours of admission, and direct or indirect supervision of the care of any patients undergoing a major change in clinical status. The overnight hospitalist was also available for clinical questions and to assist housestaff with triaging of overnight admissions. After nocturnist implementation, overnight housestaff received direct supervision or had immediate access to direct supervision, while prior to the nocturnist, residents had access only to indirect supervision.

In addition, the nocturnist admitted medicine patients after 1 _AM in a 1:1 ratio with the admitting night float resident, performed medical consults, and provided coverage of non‐teaching medicine services. While actual volume numbers were not obtained, the estimated average of resident admissions per night was 2 to 3, and the number of nocturnist admissions was 1 to 2. The nocturnist also met nightly with night float housestaff for half‐hour didactics focusing on the management of common overnight clinical scenarios. The role of the new nocturnist was described to all housestaff in orientation materials given prior to their night float rotation and their general medicine ward rotation.

We administered pre‐rolling surveys and post‐rolling surveys of internal medicine intern and resident physicians who underwent the night float rotation at our hospital during the 2010 to 2011 academic year. Surveys examined housestaff perceptions of the night float rotation with regard to supervisory roles, educational and clinical value, and clinical decision‐making prior to and after implementation of the nocturnist. Surveys were designed by the study investigators based on prior literature,1, 510 personal experience, and housestaff suggestion, and were refined during works‐in‐progress meetings. Surveys were composed of Likert‐style questions asking housestaff to rate their level of agreement (15, strongly disagree to strongly agree) with statements regarding the supervisory and educational experience of the night float rotation, and to judge their frequency of contact (15, never to always/nightly) with an attending physician for specific clinical scenarios. The clinical scenarios described situations dealing with attendingresident communication around transfers of care, diagnostic evaluation, therapeutic interventions, and adverse events. Scenarios were taken from previous literature describing supervision preferences of faculty and residents during times of critical clinical decision‐making.15

One week prior to the beginning their night float rotation for the 20102011 academic year, housestaff were sent an e‐mail request to complete an online survey asking about their night float rotation during the prior academic year, when no nocturnist was present. One week after completion of their night float rotation for the 20102011 academic year, housestaff received an e‐mail with a link to a post‐survey asking about their recently completed, nocturnist‐supervised, night float rotation. First year residents received only a post‐survey at the completion of their night float rotation, as they would be unable to reflect on prior experience.

Informed consent was imbedded within the e‐mail survey request. Survey requests were sent by a fellow within the Division of Hospital Medicine with a brief message cosigned by an associate program director of the residency program. We did not collect unique identifiers from respondents in order to offer additional assurances to the participants that the survey was anonymous. There was no incentive offered for completion of the survey. Survey data were anonymous and downloaded to a database by a third party. Data were analyzed using Microsoft Excel, and pre‐responses and post‐responses compared using a Student t test. The study was approved by the medical center's Institutional Review Board.

RESULTS

Rates of response for pre‐surveys and post‐surveys were 57% (43 respondents) and 51% (53 respondents), respectively. Due to response rates and in order to convey accurately the perceptions of the training program as a whole, we collapsed responses of the pre‐surveys and post‐surveys based on level of training. After implementation of the overnight attending, we observed a significant increase in the perceived clinical value of the night float rotation (3.95 vs 4.27, P = 0.01) as well as in the adequacy of overnight supervision (3.65 vs 4.30, P < 0.0001; Table 1). There was no reported change in housestaff decision‐making autonomy (4.35 vs 4.45, P = 0.44). In addition, we noted a nonsignificant trend towards an increased perception of the night float rotation as a valuable educational experience (3.83 vs 4.04, P = 0.24). After implementation of the nocturnist, more resident physicians agreed that overnight supervision by an attending positively impacted patient outcomes (3.79 vs 4.30, P = 0.002).

After implementation of the nocturnist, night float providers demonstrated increased rates of contacting an attending physician overnight (Table 2). There were significantly greater rates of attending contact for transfers from outside facilities (2.00 vs 3.20, P = 0.006) and during times of adverse events (2.51 vs 3.25, P = 0.04). We observed a reported increase in attending contact prior to ordering invasive diagnostic procedures (1.75 vs 2.76, P = 0.004) and noninvasive diagnostic procedures (1.09 vs 1.31, P = 0.03), as well as prior to initiation of intravenous antibiotics (1.11 vs 1.47, P = 0.007) and vasopressors (1.52 vs 2.40, P = 0.004).

After initiating the program, the nocturnist became the most commonly contacted overnight provider by the night float housestaff (Table 3). We observed a decrease in peer to peer contact between the night float housestaff and the on‐call overnight resident after implementation of the nocturnist (2.67 vs 2.04, P = 0.006).

Attending presence led to increased agreement that there was a defined overnight attending to contact (2.97 vs 1.96, P < 0.0001) and a decreased fear of waking an attending overnight for assistance (3.26 vs 2.72, P = 0.03). Increased attending availability, however, did not change resident physician's fear of revealing knowledge gaps, their desire to make decisions independently, or their belief that contacting an attending would not change a patient's outcome (Table 4).

DISCUSSION

The ACGME's new duty hour regulations require that supervision for first‐year residents be provided by a qualified physician (advanced resident, fellow, or attending physician) who is physically present at the hospital. Our study demonstrates that increased direct overnight supervision provided by an in‐house nocturnist enhanced the clinical value of the night float rotation and the perceived quality of patient care. In our study, increased attending supervision did not reduce perceived decision‐making autonomy, and in fact led to increased rates of attending contact during times of critical clinical decision‐making. Such results may help assuage fears that recent regulations mandating enhanced attending supervision will produce less capable practitioners, and offers reassurance that such changes are positively impacting patient care.

Many academic institutions are implementing nocturnists, although their precise roles and responsibilities are still being defined. Our nocturnist program was explicitly designed with housestaff supervision as a core responsibility, with the goal of improving patient safety and housestaff education overnight. We found that availability barriers to attending contact were logically decreased with in‐house faculty presence. Potentially harmful attitudes, however, around requesting support (such as fear of revealing knowledge gaps or the desire to make decisions independently) remained. Furthermore, despite statistically significant increases in contact between faculty and residents at times of critical decision‐making, overall rates of attending contact for diagnostic and therapeutic interventions remained low. It is unknown from our study or previous research, however, what level of contact is appropriate or ideal for many clinical scenarios.

Additionally, we described a novel role of an academic nocturnist at a tertiary care teaching hospital and offered a potential template for the development of academic nocturnists at similar institutions seeking to increase direct overnight supervision. Such roles have not been previously well defined in the literature. Based on our experience, the nocturnist's role was manageable and well utilized by housestaff, particularly for assistance with critically ill patients and overnight triaging. We believe there are a number of factors associated with the success of this role. First, clear guidelines were presented to housestaff and nocturnists regarding expectations for supervision (for example, staffing ICU admissions within 2 hours). These guidelines likely contributed to the increased attending contact observed during critical clinical decision‐making, as well as the perceived improved patient outcomes by our housestaff. Second, the nocturnists were expected to be an integral part of the overnight care team. In many systems, the nocturnists act completely independently of the housestaff teams, creating an additional barrier to contact and communication. In our system, because of clear guidelines and their integral role in staffing overnight admissions, the nocturnists were an essential partner in care for the housestaff. Third, most of the nocturnists had recently completed their residency training at this institution. Although our survey does not directly address this, we believe their knowledge of the hospital, appreciation of the role of the intern and the resident within our system, and understanding of the need to preserve housestaff autonomy were essential to building a successful nocturnist role. Lastly, the nocturnists were not only expected to supervise and staff new admissions, but were also given a teaching expectation. We believe they were viewed by housestaff as qualified teaching attendings, similar to the daytime hospitalist. These findings may provide guidelines for other institutions seeking to balance overnight hospitalist supervision with preserving resident's ability to make autonomous decisions.

There are several limitations to our study. The findings represent the experience of internal medicine housestaff at a single academic, tertiary care medical center and may not be reflective of other institutions or specialties. We asked housestaff to recall night float experiences from the prior year, which may have introduced recall bias, though responses were obtained before participants underwent the new curriculum. Maturation of housestaff over time could have led to changes in perceived autonomy, value of the night float rotation, and rates of attending contact independent of nocturnist implementation. In addition, there may have been unaccounted changes to other elements of the residency program, hospital, or patient volume between rotations. The implementation of the nocturnist, however, was the only major change to our training program that academic year, and there were no significant changes in patient volume, structure of the teaching or non‐resident services, or other policies around resident supervision.

It is possible that the nocturnist may have contributed to reports of increased clinical value and perceived quality of patient care simply by decreasing overnight workload for housestaff, and enhanced supervision and teaching may have played a lesser role. Even if this were true, optimizing resident workload is in itself an important goal for teaching hospitals and residency programs alike in order to maximize patient safety. Inclusion of intern post‐rotation surveys may have influenced data; though, we had no reason to suspect the surveyed interns would respond in a different manner than prior resident groups. The responses of both junior and senior housestaff were pooled; while this potentially weighted the results in favor of higher responding groups, we felt that it conveyed the residents' accurate sentiments on the program. Finally, while we compared two models of overnight supervision, we reported only housestaff perceptions of education, autonomy, patient outcomes, and supervisory contact, and not direct measures of knowledge or patient care. Further research will be required to define the relationship between supervision practices and patient‐level clinical outcomes.

The new ACGME regulations around resident supervision, as well as the broader movement to improve the safety and quality of care, require residency programs to negotiate a delicate balance between providing high‐quality patient care while preserving graduated independence in clinical training. Our study demonstrates that increased overnight supervision by nocturnists with well‐defined supervisory and teaching roles can preserve housestaff autonomy, improve the clinical experience for trainees, increase access to support during times of critical decision‐making, and potentially lead to improved patient outcomes.

Wachter and Goldman1 described the hospitalist model for inpatient care more than a decade ago. The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.2 This care delivery model has enjoyed exponential growth, with approximately 20,000 hospitalists in the United States, and an estimated 30,000 by the end of the decade.35 Currently, 29% of hospitals, including 55% with at least 200 beds, employ hospitalists to coordinate inpatient care.6 Data suggests that hospitalists promote cost containment and decrease length of stay without negatively affecting rates of death, readmission, or patient satisfaction.715

In academic settings, hospitalists also provide a substantial amount of teaching to trainees,1618 and the hospitalist model represents a fundamental change in inpatient education delivery. Traditional ward attendings typically consisted of a heterogeneous group of subspecialists, laboratory‐based clinician scientists, and general internists, many of whom attended and taught relatively infrequently. By virtue of focusing purely on inpatient care, hospitalists are more intimately involved with inpatient care systems, as well as teaching challenges (and opportunities) in the inpatient setting. The theoretical educational benefits of hospitalists include greater availability, more expertise in hospital medicine, and more emphasis on cost‐effective care.7, 18, 19 Concerns that trainees would have diminished autonomy and less exposure to subspecialist care have not been borne out.16, 20, 21

The purpose of this study was to examine the role of hospitalists on inpatient trainee education. We systematically reviewed the literature to determine the impact of hospitalists compared to nonhospitalist attendings on medical students' and residents' education.

MATERIALS AND METHODS

RESULTS

Search Results

The database searches yielded 711 articles (Figure 1). Based on review of titles and abstracts, 32 articles were retrieved for full‐text review. During full‐text review, we eliminated 26 studies because they had no nonhospitalist control group,7, 16, 18, 2427 were opinion or review articles,19, 21, 2834 examined hospitalists' roles without trainee outcomes,17, 3540 surveyed program administration,41 or did not involve hospitalists.42, 43 Ultimately, 6 citations published between 2002 and 2007 met all inclusion criteria (Table 1).4449 The updated literature search through October 1, 2008 did not yield any additional relevant studies.

Figure 1

Table 1.Summary of Studies

Location, yearreference	Learners (n)	Number of Attendings	Attending Ward Responsibilities (weeks per year)	Attending Experience (mean years postgraduation)	Attending Gender (% female)	Survey Response Rate (%)	Data Strength
* Meeting abstracts. Brigham & Women's Hospital, University of California San Francisco, University of Chicago, University of Washington, University of Illinois, University of New Mexico. Data strength: 1 (no clear conclusions can be drawn), 2 (results ambiguous, but appears to be a trend), 3 (conclusions can probably be based on results), 4 (results are clear and very likely to be true), 5 (results are unequivocal).
University of Chicago, 200244	PGY‐unspecified (86)	2‐4 hospitalists; unknown nonhospitalists	12‐24 hospitalists; 4‐8 nonhospitalists			58	2
Children's Hospital, Boston, 200245	PGY‐1, PGY‐3 (unknown)	8 hospitalists; 75 nonhospitalists	12‐16 hospitalists; 2‐4 nonhospitalists			63	2
Oregon Health & Sciences, 200446	MS3 (138)	6 hospitalists; 11 nonhospitalists	22.8 hospitalists; 6.4 nonhospitalists	4.2 hospitalists; 10.9 nonhospitalists	2/6 (33%) hospitalists; 4/11 (36%) nonhospitalists	72	3
University of California, San Francisco, 200447	MS3‐4, PGY1‐3 (917)	17 hospitalists; 39 general internists; 13 subspecialists	12 hospitalists; 3.24 nonhospitalists		6/17 (35%) hospitalists; 17/52 (33%) nonhospitalists	91	4
Grady Memorial, 200448	MS3‐4, PGY1‐3 (unknown)	12 hospitalists; 27 general internists; 51 subspecialists	24 hospitalists; 6 nonhospitalists	6.1 hospitalists; 9.7 general internists; 21.6 subspecialists	6/12 (50%) hospitalists; 16/51 (31%) nonhospitalists	81	3
Penn State Children's Hospital, 200749	MS3 (67)	2 hospitalists; 8 nonhospitalists	2 MDs covered 32 hospitalists; 8 MDs covered 28 nonhospitalists		1/2 (50%) hospitalists; 2/8 (25%) nonhospitalists	100	3
Multiple sites, 200550*	MS3 (294)					54	2
California Pacific Medical Center, 200651*	PGY‐unspecified (unknown)						1

Examination of meeting abstracts yielded a total of 7,062 abstracts (Figure 2), of which 9 abstracts were retrieved for full‐text review. Two abstracts met inclusion criteria (Table 1).50, 51 Excluded meeting abstracts included published studies that were already abstracted as manuscripts,52, 53 had no nonhospitalist control group,54, 55 did not involve hospitalists,56 surveyed program administrators,57 or examined hospitalists' roles without trainee outcomes.58 Our communications with abstract authors did not yield any relevant additional information.

Figure 2

DISCUSSION

This systematic review of the literature describing hospitalists as educators shows that trainees are generally more satisfied with hospitalists than nonhospitalists on their inpatient rotations. Hospitalists were rated more highly than traditional ward attendings overall, and for teaching effectiveness44, 47, 49, 50 and feedback delivery.45, 47 Limited data (3 studies each) indicates that trainees perceive hospitalists as being at least as knowledgeable as traditional attendings, and encouraging similar levels of trainee involvement in patient care decisions. Trainees may be more satisfied with hospitalists than with general internists or subspecialists, although some comparisons have shown that general internists may be preferred. No studies have evaluated the impact of hospitalists on trainee outcomes beyond satisfaction, such as knowledge acquisition, rotation grades, or clinical performance.

Our review suggests that, with increased time spent on the wards, hospitalists exhibit attributes consistent with specialization in inpatient care.1, 14 Hospitalists were noted to emphasize cost‐effectiveness47 and evidence‐based medicine48 and to conduct higher‐quality ward rounds.44, 49 Hospitalists are uniquely qualified to teach about inpatient goals and processes such as decreasing length of stay in the hospital and cost‐effective care.1, 3, 7, 12, 15 Trainees see hospitalists as role models,45, 47 and the site‐defined nature of hospital medicine promotes trainees' access to hospitalist attendings. Such accessibility has been described as an independent attribute of excellent physician role models,59, 60, 62 Our findings from our methodologically rigorous systematic review of the literature extend the conclusions of a narrative review of the literature on hospitalists as educators that also identified favorable ratings of hospitalists, with some unresolved concerns about resident autonomy and the role of subspecialist teachers in hospitalist systems.63

Diminished trainee autonomy was an early concern about hospitalists in academic medical centers.16, 20, 21 In the earliest study we identified that assessed autonomy, trainees perceived similar amounts of autonomy with hospitalists compared to nonhospitalists.44 Interestingly, house staff in more experienced hospitalist models even described experiencing increased involvement in patient care when supervised by hospitalist attendings in both the pediatric and internal medicine settings.45, 47 Hospitalists might also generate more clinical diversity for house staff by reducing length of stay and thereby enhancing opportunities for learning with newly admitted patients.13, 14, 64

The studies that did not demonstrate increased satisfaction with hospitalists may be instructive as well. One negative study46 reported results from a program that instituted the hospitalist model in response to declining trainee satisfaction. With an emphasis on improving the educational experience, nonhospitalist physicians who were already rated highly as teachers were also selected to attend on the wards. Nonetheless, trainees still were more satisfied with hospitalists overall. One study showed that hospitalists were rated more highly than subspecialists when delivering feedback but less so than general internists.47 The authors suggest that their general internists may have been at a more optimum demographic by being a few more years out of training; such correlations of age and rank to evaluations have not been previously described.60, 61

The disadvantages of hospitalists in trainee education identified by this systematic review include the quality of bedside teaching in one study45 and interest in psychosocial aspects of care in another48 compared to general internists. The decline in satisfaction with bedside teaching is a concern but the comparison was noncontemporaneous and the authors explained that the team size increased and resulted in an overall decrease in time at the bedside.45 The concern that decreased patient length of stays may translate to less time spent with patients and less bedside teaching is not new.18 Although hospitalists have shown particular educational advantages, the balance of clinical efficiency and education remains challenging. Trainees' perception that hospitalists were less interested in the psychosocial aspects of care compared to general internists48 was also anticipated when inpatient attending models began to shift, because hospitalization may now be viewed by trainees as discontinuous from a patient's outpatient care and social situation.18 Nevertheless, hospitalists have been able to achieve such quality measures as decreased length of stay without decreasing patient satisfaction.10, 12

Our study has several limitations. First, all attendings were rated highly in all studies. These high ratings are commonly seen with educational evaluations,65 and this phenomenon creates a ceiling effect that limits variability within the group. Nevertheless, trainees rated hospitalists significantly higher than nonhospitalists overall in all of the included studies. The impact of these small but significant differences on trainees' learning and future clinical performance is unknown. Additionally, the distinction between hospitalists and nonhospitalists was not universal. Initially, it was proposed that academic hospitalists work as hospitalists 3 to 6 months each year.1 This definition is sustained through almost all included studies that reported attending time on the wards, with hospitalists working 3 to 7 months and nonhospitalists working less than 3 months, but observed variability does not permit a universal hospitalist definition. It is possible that publication bias influenced our findings toward positive ratings of hospitalists; we reviewed and included meeting abstracts to minimize this bias. We did not review family medicine meeting abstracts.

The included studies had some methodologic strengths, including quasirandom assignment of trainees and use of a contemporaneous control group in almost all studies. However, the overall methodologic strength was fair given limitations in response rates and reporting of cointerventions; we thus considered most studies to represent trends rather than definitive results. Finally, all of the studies meeting our inclusion criteria to date only evaluated trainees' attitudes and beliefs. Because knowledge and skills were not objectively assessed, it is unclear how increased trainee satisfaction translates to knowledge and skill acquisition on the wards. However, Miller's pyramid and its proposed modification, the Cambridge model, suggest that targeting attitudes precedes knowledge acquisition,66 and our study suggests the need for a research agenda examining the impact of hospitalists on trainees' future performance. Griffith et al.67 demonstrated an association between increased satisfaction with teaching and medical students' performance on clerkship examinations and the U.S. Medical Licensing Examination (USMLE) Step 2.

Overall, trainees were more satisfied with hospitalists' teaching and feedback delivery. Our literature search shows that, although there are a limited number of studies of varying level of quality that cannot be compared using meta‐analytic techniques, the currently available data suggests that hospitalists lead to improved learner satisfaction. More studies to delineate the differences between hospitalists and nonhospitalist general internists are needed. Continued exploration of the effects of attending age and rank on trainee learning may help determine whether this effect is reproducible, and what facets of attendings' teaching actually impact trainees' knowledge, skill acquisition, and behaviors. Since all studies only evaluated attitudes, studies analyzing knowledge and skills are required to more fully understand the educational outcomes of the hospitalist model.

Wachter and Goldman1 described the hospitalist model for inpatient care more than a decade ago. The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.2 This care delivery model has enjoyed exponential growth, with approximately 20,000 hospitalists in the United States, and an estimated 30,000 by the end of the decade.35 Currently, 29% of hospitals, including 55% with at least 200 beds, employ hospitalists to coordinate inpatient care.6 Data suggests that hospitalists promote cost containment and decrease length of stay without negatively affecting rates of death, readmission, or patient satisfaction.715

In academic settings, hospitalists also provide a substantial amount of teaching to trainees,1618 and the hospitalist model represents a fundamental change in inpatient education delivery. Traditional ward attendings typically consisted of a heterogeneous group of subspecialists, laboratory‐based clinician scientists, and general internists, many of whom attended and taught relatively infrequently. By virtue of focusing purely on inpatient care, hospitalists are more intimately involved with inpatient care systems, as well as teaching challenges (and opportunities) in the inpatient setting. The theoretical educational benefits of hospitalists include greater availability, more expertise in hospital medicine, and more emphasis on cost‐effective care.7, 18, 19 Concerns that trainees would have diminished autonomy and less exposure to subspecialist care have not been borne out.16, 20, 21

The purpose of this study was to examine the role of hospitalists on inpatient trainee education. We systematically reviewed the literature to determine the impact of hospitalists compared to nonhospitalist attendings on medical students' and residents' education.

MATERIALS AND METHODS

RESULTS

Search Results

The database searches yielded 711 articles (Figure 1). Based on review of titles and abstracts, 32 articles were retrieved for full‐text review. During full‐text review, we eliminated 26 studies because they had no nonhospitalist control group,7, 16, 18, 2427 were opinion or review articles,19, 21, 2834 examined hospitalists' roles without trainee outcomes,17, 3540 surveyed program administration,41 or did not involve hospitalists.42, 43 Ultimately, 6 citations published between 2002 and 2007 met all inclusion criteria (Table 1).4449 The updated literature search through October 1, 2008 did not yield any additional relevant studies.

Figure 1

Table 1.Summary of Studies

Location, yearreference	Learners (n)	Number of Attendings	Attending Ward Responsibilities (weeks per year)	Attending Experience (mean years postgraduation)	Attending Gender (% female)	Survey Response Rate (%)	Data Strength
* Meeting abstracts. Brigham & Women's Hospital, University of California San Francisco, University of Chicago, University of Washington, University of Illinois, University of New Mexico. Data strength: 1 (no clear conclusions can be drawn), 2 (results ambiguous, but appears to be a trend), 3 (conclusions can probably be based on results), 4 (results are clear and very likely to be true), 5 (results are unequivocal).
University of Chicago, 200244	PGY‐unspecified (86)	2‐4 hospitalists; unknown nonhospitalists	12‐24 hospitalists; 4‐8 nonhospitalists			58	2
Children's Hospital, Boston, 200245	PGY‐1, PGY‐3 (unknown)	8 hospitalists; 75 nonhospitalists	12‐16 hospitalists; 2‐4 nonhospitalists			63	2
Oregon Health & Sciences, 200446	MS3 (138)	6 hospitalists; 11 nonhospitalists	22.8 hospitalists; 6.4 nonhospitalists	4.2 hospitalists; 10.9 nonhospitalists	2/6 (33%) hospitalists; 4/11 (36%) nonhospitalists	72	3
University of California, San Francisco, 200447	MS3‐4, PGY1‐3 (917)	17 hospitalists; 39 general internists; 13 subspecialists	12 hospitalists; 3.24 nonhospitalists		6/17 (35%) hospitalists; 17/52 (33%) nonhospitalists	91	4
Grady Memorial, 200448	MS3‐4, PGY1‐3 (unknown)	12 hospitalists; 27 general internists; 51 subspecialists	24 hospitalists; 6 nonhospitalists	6.1 hospitalists; 9.7 general internists; 21.6 subspecialists	6/12 (50%) hospitalists; 16/51 (31%) nonhospitalists	81	3
Penn State Children's Hospital, 200749	MS3 (67)	2 hospitalists; 8 nonhospitalists	2 MDs covered 32 hospitalists; 8 MDs covered 28 nonhospitalists		1/2 (50%) hospitalists; 2/8 (25%) nonhospitalists	100	3
Multiple sites, 200550*	MS3 (294)					54	2
California Pacific Medical Center, 200651*	PGY‐unspecified (unknown)						1

Examination of meeting abstracts yielded a total of 7,062 abstracts (Figure 2), of which 9 abstracts were retrieved for full‐text review. Two abstracts met inclusion criteria (Table 1).50, 51 Excluded meeting abstracts included published studies that were already abstracted as manuscripts,52, 53 had no nonhospitalist control group,54, 55 did not involve hospitalists,56 surveyed program administrators,57 or examined hospitalists' roles without trainee outcomes.58 Our communications with abstract authors did not yield any relevant additional information.

Figure 2