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Night Medicine Guide

Night Medicine Guide

Purpose

The Graduate Medical Education Night Medicine Guide provides a framework for GME faculty, residents, and other stakeholders to ensure an effective, safe and efficient learning environment in accordance with ACGME requirements.

Introduction

Night medicine offers residents a unique experience in patient care which involves safe transitions of care, admissions, and exposure to the management of emergent and urgent issues that may occur with patients admitted to teaching service.

In light of the fact that the transition to a teaching service has occurred before our residents becoming seasoned PGY3's the workflow will have to be determined by resident milestone expectations and competence keeping the safety of our patients as a priority.

  • Supervised admissions will prioritize clinic patients. Program will safely institute a progressive increase in volume, complexity and resident responsibility with regards to patients assigned as senior residents become more competent to the end of academic year.
  • If a non-faculty member works for teaching service on a Call day, expectation will be to staff morning and evening admissions and be available for urgent calls overnight.
  • Goal admissions or maximum encounters per night (for one PGY1 with one PGY 2 or 3 Team) is 6 patients. For only single PGY 2 or 3 on nights where schedule demands, maximum encounters is 3 patients. Clinic flex of additional 1-2 admissions will not apply to single resident on nights.

Team Structure

1 PGY2 or 1 PGY3 with PGY1

Procedure

  • I. Night Medicine team will attend sign-out which is protected time from 7-7.30am and 7-7.30p. Unstable patients will be prioritized.
  • II. Night Medicine Team will take floor calls and respond to all urgent bedside needs for Teaching Service patients.
  • III. Night Medicine Team will be provided with guidelines regarding timely communication with Supervising Attending.
  • IV. Night Medicine Attending will provide supervision for admissions, feedback, and relevant educational teaching points for learning.
  • V. Night medicine Team will be expected to attend all codes and rapids to enrich learning experience with the expectation of leading these scenarios when teaching service patients are involved.

Specific Roles and Responsibilities

Supervising Faculty (Night Medicine Attending)

Supervising Faculty is expected to:

  • Review all H&Ps and give feedback on improving documentation
  • Provide feedback to the night learners performing at least one history and physical per night and give feedback for improvement
  • Provide the Intern/resident with the opportunity to practice oral presentation skills and give appropriate feedback at Wednesday Morning reports scheduled for night team.
  • Supervise the resident in developing patient care plan for all admitted patients
  • Be available to resident at all times by phone to answer questions
  • It is the faculty member's responsibility to review goals and objectives, appropriate methods and when to call supervisor with the intern at the beginning of the rotation or shift change.
  • Verbal and written feedback is expected from the supervisor, evaluations will be sent through New Innovations system.

Learners

  • Residents are expected to contact their supervising Faculty after completion of review of their assigned patients to discuss their evaluation and plan of care.
  • Residents will be responsible for appropriate hand off of new and cross coverage patients to the ward teams in the morning.
  • Residents are expected to contact their supervising Faculty in the event of patient death.
  • Residents are expected to contact their supervising Faculty if patient signs out against medical advice.
  • Residents are expected to contact their supervising Faculty if patients Code Status changes.
  • Residents are expected to contact their supervising Faculty if patient is transferred to higher level of care.
  • Residents are expected to contact their supervising Faculty if patient is anticipated to become acutely unstable or in extremis or with acute decompensation.

Patient Distribution

  • Overnight admissions will be added to call Teams list till 7am.
  • If Call team is capped before 7am then admissions will go to Pre-Call Team.

Night Team Admission Requirements/Criteria

To help facilitate appropriate patient care and maintain safety standards these guidelines will assist night team / ED providers to determine patients appropriate for night admission.

  • Guidelines dictate the appropriate level of care for Night Team should be med/surg and step down (SDU) patients with great probability for improvement overnight with appropriate medical interventions.
  • Please ensure that all admissions have appropriate consult service required on call before accepting admission, especially in the case of Urology, ENT
  • Please ensure that complex patients do not need to transfer to Tertiary center before admission order placed.

Specific Examples of Appropriate Patients For Nighttime Admission

  • Acute MI /Acute Coronary Syndromes with appropriate consult established in the ED
  • Cardiac rhythm abnormalities requiring monitoring in SDU with stable hemodynamics
  • Hypertensive emergency patient requiring IV antihypertensive and monitoring in the SDU
  • Acute hypercapnic respiratory failure with clinical improvement displayed in the ED on BiPAP therapy and PH >7.2, PCO2 <70
  • Acute gastrointestinal bleeding but hemodynamically stable and needing frequent hemoglobin checks and monitoring for rebleeding
  • Severe Sepsis not requiring pressor support or fluid responsive
  • Congestive heart failure exacerbations with significant oxygen requirement without need for vasoactive drips (Dobutamine/ Milrinone)
  • *Diabetic Ketoacidosis (Exception to ICU level of care)

Specific Examples of Inappropriate Patients for Nighttime Admission

  • Requiring continuous hemodynamic monitoring / On vasoactive agents
  • Intubated on mechanical ventilation
  • Requiring invasive hemodynamic monitoring, including pulmonary artery catheters, arterial catheters, and circulatory assist devices such as Impella.
  • Temporary pacing
  • Sudden cardiac death s/p ROSC
  • Acute intracranial bleed requiring ICU monitoring, and Hypertonic Saline therapy
  • Septic Shock requiring pressor support
  • New Acute renal failure not amenable to medical management and likely to require renal replacement therapy
  • Pulmonary embolism with hemodynamic instability, and who may require thrombolytic therapy
Last update: April 12, 2026