Monday, January 08, 2007

Pediatric Check-Up: Sleep, Rounding, and Sign Outs

I've often been asked how much sleep I get as an intern; it's an understandable question because on certain rotations I work 30 hour shifts. What really bothers me, though, is not necessarily how much sleep I get, but when I have to get up. Generally, when I was on the inpatient service in August, I hit the floors around 7AM. However, now that it's the wintertime, I'm really facing a wake-up time of around 5:30AM and an arrival of around 6AM to get the work done in time to present patients to the team for the morning's planning session, generally known as "rounds". It sounds very, very painful to me. I used to be a night owl and still relish staying up as long as I want when I can. Furthermore, Sunny's a night owl too and likes to go to bed around 1AM. I can't do that with a 5:30 alarm bell.

What makes tonight even more interesting is that each team is switching personnel. All of the interns are coming from other rotations to pick up the current team load. Furthermore, the team I am switching to is admitting patients tonight, resulting in uncertainty of how many patients I'll need to see by 8AM tomorrow morning, which is when rounds start. I don't like it, but there's nothing I can do but try to make it in by 6AM, a feat I've never accomplished unless I was already in the hospital.

Pre-rounding, that is getting the data for rounds, is always an adrenalin-laced experience for me, and I don't really like it. For pre-rounds, I record a summary of all my patients' vitals, lab values, and general events from the 24 hours since we rounded last. This includes a bedside visit and exam. For new patients I am generally slow, hopefully due to me being thorough vs. some kind of intrinsic inefficiency.

Generally, though I know my patients and know exactly what to look for to see if they are getting worse or better. On a switch day, though, the quality of the information from the departing intern tries to fill in for that familiarity. The passage of information is called sign out, and it's a process that desperately needs some troubleshooting.

In an effort to decrease medical errors, residents across the nation have had their work hours limited to an average of 80hr/wk each month. This is similar to work hour limits in fields such as aviation (pilots) and other crucial errors. However, preliminary data suggests that the increased mental rest residents are getting is being offset by errors made by cross-cover teams due to sketchy sign out. I'm still in the process of reading up on this, and I hope that further studies continue not only to track the numbers, but to also test ways of making sign out more efficient and information-laden.

Occasionally, I am irked, as today, with the quality and thoroughness of sign out. One person just left and didn't bother to sign out to me. Another describes a 3 week hospital stay that included an ICU stay as "simple". Such things suggest to me that there is a systems issue that needs to be addressed by a policy statement to clarify things. My current personal policy is that whenever I leave a hospitalized patient for another rotation, I tend to leave a summary of their stay under my care, so that the next person doesn't have to flip through a whole book of notes to try to figure out what happened. I also intend that when I am team leader to clearly verbalize criteria I expect for this kind of major sign out, and make sure all of the team members understand what I am expecting. It might just be easier and less bossy to get the whole caboodle in writing, or find out where it is written, and just email it out.

  • Editorial: Is 80 the cost of saving lives? Reduced duty hours, errors, and cost.

  • Residency work-hours reform. A cost analysis including preventable adverse events.

  • Disclaimer: I'm still reading the literature on this.
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