One crucial reason for having dedicated nocturnal APPs is to ensure that critically ill patients, especially those who are unstable, receive prompt and focused attention during the night. For example, if a patient needs ventilator weaning, there might not be someone available during nighttime hours to oversee this process, as the focus often shifts towards managing urgent cases like a patient in cardiac arrest. Having a dedicated Nocturnal APP allows for continuous care and treatment plan execution, thereby facilitating patient progress even during nighttime hours.
It's worth noting that all the APPs, including the Nocturnal APPs, collaborate with the hospitalists during their respective shifts. Currently, the hospitalists handle patient admissions, while the APPs take charge of stabilizing the patients' conditions. There are eight hospitalists and eight APPs on staff, following a 7/7 schedule from 7 pm to 7 am.
One of the challenges faced in this setting is the absence of a step-down unit, except for a mild cardiac care unit. There are two ICUs, one with 14 rooms and the other 12, making 26 ICU beds. The ICUs are located on the same floor, connected by a hallway, and are sometimes both open simultaneously, depending on the patient load.
Dr. Bullard, one of the Nocturnists, is primarily responsible for procedures like intubations, lumbar punctures, central lines, and other critical interventions. This focus on the ICU is essential because, at present, one of the hospitalists is responsible for ICU calls, even though they cannot always be physically present in the ICU due to the demands of the busy admission service.
On average, there is a daily ICU census of 10-12 admitted patients with responsibility for 6-7 patients per day. Admission to the ICU can also involve cardiothoracic surgeons, depending on the severity of the trauma. Importantly, there are no on-call duties for the Nocturnal APPs.
The most common pathologies encountered in this medical setting include sepsis, pneumonia, exacerbation of congestive heart failure, non-ST elevation myocardial infarction (NSTEMI), pulmonary embolism, and acute kidney injury (AKI).
Regarding the electronic medical records (EMR) system, the hospital currently uses Paragon, but there are plans to transition to a more user-friendly system like Meditech in the future.
Dr. Bullard mentioned that one of the reasons individuals choose to work at this hospital is the culture. The sense of making a meaningful impact on patients' health and well-being is a driving force. The sense of community and the relationships built over time are highly valued. The unique aspect of this medical practice is the focus on caring for very ill patients in the hospital, with the potential for patients to recover and go home within a few days. The welcoming culture, comfortable working environment, and friendly administration contribute to the overall positive atmosphere. Additionally, the presence of specialty groups like cardiology and nephrology facilitates communication and collaboration. This culture