A Prospective Trial of an In-house Overnight Fellow Rotation in the Intensive Care Unit.

Although previous studies in academic intensive care units (ICUs) have found no improvement in patient care outcomes with in-house overnight attending physician coverage compared with home call coverage, the effect of in-house supervision on trainee education and well-being is less clear. In addition, no studies have examined the effect of in-house coverage by fellow physicians overnight. What is the impact of an in-house overnight critical care fellow on resident, fellow, and attending perception of patient safety, house staff education, and house staff well-being? A prospective trial alternating 2-week periods of in-house overnight critical care fellow coverage with 2-week periods of home call coverage was performed in our tertiary medical ICU. Residents, fellows, and attendings were surveyed to evaluate perceptions of the night fellows' impact on patient care, communication, supervision, educational experience, autonomy, well-being, and job satisfaction. Over the 6-month study period, surveys were sent to 83 residents, 22 fellows, and 23 attendings, with completion by 56 (67%), 22 (100%), and 16 (70%), respectively. Overall, 89% of residents, 68% of fellows, and 81% of attendings reported perceived improvements in patient care with an in-house fellow. The in-house fellow was also associated with improved well-being in 79% of residents and 73% of fellows, and 82% of residents felt that it positively impacted education. As compared with the traditional home call system, an in-house night critical care fellow can improve the perception of patient care, trainee well-being, and education in a tertiary ICU at an academic hospital.

Schwab Jensen K ，Sherman AE ，Wang T ，Melamed K ... -  《-》

Perceptions of 24/7 In-house Attending Coverage on Fellow Education and Autonomy in a Pediatric Cardiothoracic Intensive Care Unit.

The 24/7 in-house attending coverage is emerging as the standard of care in intensive care units. Implementation costs, workforce feasibility, and patient outcomes resulting from changes in physician staffing are widely debated topics. Understanding the impact of staffing models on the learning environment for medical trainees and faculty is equally warranted, particularly with respect to trainee education and autonomy. This study aims to elicit the perceptions of pediatric cardiology fellows and attendings toward 24/7 in-house attending coverage and its effect on fellow education and autonomy. We surveyed pediatric cardiology fellows and attendings practicing in the pediatric cardiothoracic intensive care unit (PCTU) of a large, university-affiliated medical center, using structured Likert response items and open-ended questions, prior to and following the transition to 24/7 in-house attending coverage. All (100%) trainees and faculty completed all surveys. Both prior to and following transition to 24/7 in-house attending coverage, all fellows, and the majority of attendings agreed that the overnight call experience benefited fellow education. At baseline, trainees identified limited circumstances in which on-site attending coverage would be critical. Preimplementation concerns that 24/7 in-house attending coverage would negatively affect the education of fellows were not reflected following actual implementation of the new staffing policy. However, based upon open-ended questions, fellow autonomy was affected by the new paradigm, with fellows and attendings reporting decreased "appropriateness" of autonomy after implementation. Our prospective study, showing initial concerns about limiting the learning environment in transitioning to 24/7 in-house attending coverage did not result in diminished perceptions of the educational experience for our fellows but revealed an expected decrease in fellow autonomy. The study indirectly facilitated open discussions about methods to preserve fellow education and warranted autonomy in our PCTU; however, continued efforts are needed to achieve the optimal balance between supervised training and the transition to autonomous practice.

Owens ST ，Owens GE ，Rajput SH ，Charpie JR ，Kidwell KM ，Mullan PB ... -  《-》

Transition to an In-House Night Float System for Critical Care Fellows: Resident Experience, Morbidity, and Mortality in a Rural Academic Hospital.

Background In-house night call systems for ICUs are frequently implemented to enable hands-on patient care and provide direct supervision of resident physicians at night. Previous studies have highlighted the benefits of an in-house night float (NF) such as minimized time to intervention but failed to consistently demonstrate an improvement in patient outcomes. This study aimed to evaluate the impact of an in-house critical care fellow at night on the resident experience and assess for impact on patient morbidity and mortality. Methods An in-house overnight critical care fellow shift was implemented at West Virginia University Hospital in 2018. Resident physicians rotating overnight in the medical ICU (MICU) for six-month periods before and after the intervention were anonymously surveyed. A retrospective chart review of 300 patients admitted overnight to the MICU was performed. Multiple patient outcomes from the pre (2017) and post (2018) intervention periods were collected and compared using a two-sample t-test. Results In the post-intervention survey, nearly every element of resident experience improved (availability of support, comfort in performing invasive procedures, and input in treatment plans), and far fewer residents felt overwhelmed relative to the pre-intervention survey. The resident experience markedly improved with the addition of an in-house critical care fellow. For the retrospective chart review, both groups had similar severity of illness and there was no change in ICU or hospital length of stay. No difference in mortality was found, though the study was underpowered for this outcome. For secondary measures, there was no difference in mechanical ventilation or use days, though more procedures performed were overnight compared to the former staffing model. Conclusions Implementation of an in-house overnight critical care fellow shift in the MICU positively impacted resident experience without worsening patient outcomes. The intervention did not worsen measures of morbidity or mortality but did lead to an increased number of procedures performed overnight. The model of in-house NF coverage continues to be preferred by clinicians.

Chapman KD ，Badami V ，Stawovy L ，Ali S ，Abdelfattah M ... -  《Cureus》

24/7/365 Neuroradiologist Coverage Improves Resident Perception of Educational Experience, Referring Physician Satisfaction, and Turnaround Time.

To quantitatively and qualitatively assess the impact of attending neuroradiology coverage on radiology resident perceptions of the on-call experience, referring physician satisfaction, and final report turnaround times. 24/7/365 attending neuroradiologist coverage began in October 2016 at our institution. In March 2017, an online survey of referring physicians, (emergency medicine, neurosurgery, and stroke neurology) and radiology residents was administered at a large academic medical center. Referring physicians were queried regarding their perceptions of patient care, report accuracy, timeliness, and availability of attending radiologists before and after the implementation of overnight neuroradiology coverage. Radiology residents were asked about their level of independence, workload, and education while on-call. Turnaround time (TAT) was measured over a 5-month period before and after the implementation of overnight neuroradiology coverage. A total of 28 of 64 referring physicians surveyed responded, for a response rate of 67%. Specifically, 19 of 23 second (junior resident on-call) and third year radiology residents (senior resident on-call) replied, 4 of 4 stroke neurology fellows replied, 8 of 21 neurosurgery residents, and 16 of 39 emergency medicine residents replied. Ninety-five percent of radiology residents stated they had adequate independence on call, 100% felt they have enough faculty support while on call, and 84% reported that overnight attending coverage has improved the educational value of their on-call experience. Residents who were present both before and after the implementation of TAT metrics thought their education, and independence had been positively affected. After overnight neuroradiology coverage, 85% of emergency physicians perceived improved accuracy of reports, 69% noted improved timeliness, and 77% found that attending radiologists were more accessible for consultation. The surveyed stroke neurology fellows and neurosurgery residents reported positive perception of the TAT, report quality, and availability of accessibility of attending radiologist. In concordance with prior results, overnight attending coverage significantly reduced turnaround time. As expected, referring physicians report increased satisfaction with overnight attending coverage, particularly with respect to patient care and report accuracy. In contrast to some prior studies, radiology residents reported both improved educational value of the on-call shifts and preserved independence. This may be due to the tasking the overnight neuroradiology attending with dual goals of optimized TAT, and trainee growth. Unique implementation including subspecialty trained attendings may facilitate radiology resident independence and educational experience with improved finalized report turnaround.

Spitler K ，Vijayasarathi A ，Salehi B ，Dua S ，Azizyan A ，Cekic M ，Yaghmai N ，Homer R ，Salamon N ... -  《-》

Effect of 24/7 attending coverage in the neonatal intensive care unit on fellow education.

Sahni M ，Mowes A 《BMC Medical Education》