Impact of an internal medicine nocturnist service on care of patients with cancer at a large Canadian teaching hospital: a quality-improvement study

Abstract

N octurnists (overnight hospitalists) have been widely implemented in teaching hospitals in the United States in an effort to meet Accreditation Council for Graduate Medical Education workload standards, 1 improve overnight supervision and enhance the quality of patient care. [2][3][4][5][6][7][8] Recent data indicate that about 50% of US teaching hospitals have nocturnists. 9 Several single-centre surveys from the US suggest that nocturnist programs improve perceived quality of care, increase resident satisfaction with overnight supervision and may enhance efficiency. 3,7 However, studies have not shown reductions in hospital length of stay or rates of mortality or hospital readmission. 2 Canadian teaching hospitals have been slow to implement nocturnists. 10 Nocturnal coverage is typically provided by firstyear residents from multiple disciplines, with staff available by telephone. Nocturnists are rare, and typically all admissions are performed by residents, without caps on volumes of existing patients or new admissions. Moreover, many Canadian teaching hospitals rely on teams of residents to cover all admitted medical patients, with no caps on the number of patients per resident. In contrast, in US hospitals, first-year internal medicine residents can manage a maximum of 10 patients. 1 Limits on Canadian resident work hours are determined at the provincial level rather than nationally, as in the US. Only Quebec has stipulated a maximum shift length (16 h), with most provinces still allowing 24-hour shifts. In Europe, resident work hours are restricted to 48-hour work weeks, and 13-hour shift limits are common. 11

Surgical Outcomes in Canada and the United States: An Analysis of the ACS‐NSQIP Clinical Registry

“…[40] With respect to physician workload, the USA has imposed strict caps on the number of patients that resident physicians may look after, while Canada does not adhere to strict caps or work hour limits. [41, 42] It is also important to consider that the USA has invested heavily in important “enablers” of quality including health information technology and patient safety initiatives in ways that Canada has not. [43] For example, NSQIP was widely adopted across the USA in the late 1990s, but has only gained traction in Canada over the last 5‐years.…”