Ellis Knight, MD, MBA, FHM, senior vice president for physician and clinical integration at Palmetto Health in Columbia, S.C., recalls conducting root cause analyses after every serious adverse event when he was vice president for medical affairs at a large teaching hospital. “For every one of them—it was just like a broken record—every one of them, the nursing staff or the physicians involved would start the recount by saying, ‘It was a very, very busy day; we had a very high census,’” Dr. Knight says. “When that happens, when you get those, what I call tsunami waves of patients coming into a unit or being admitted at one time, it can really wreak havoc and it can make even the best clinicians get rushed, take shortcuts, and make mistakes.”
Researchers have long studied the consequences of temporary and longer-term workload imbalances for other healthcare providers; a recent in-depth study of one hospital found that the risk of inpatient patient mortality increased during shifts with below-target nurse staffing or higher patient turnover.1
Few studies, however, have specifically examined the repercussions of a patient census that is either too high or too low for a hospitalist service. At many facilities, that census can be influenced by an increasing threshold for hospitalization, meaning that the average inpatient is becoming sicker and more complicated, requiring more time during a hospitalist’s daily rounds. HM providers might report having better or worse electronic health records, support staff, and other ancillary services; different schedules; and mixes of clinical, administrative, and teaching responsibilities.
Even then, David M. Mitchell, MD, PhD, a hospitalist at Sibley Memorial Hospital in Washington, D.C., and a member of the SHM Performance Standards Committee, cautions that the ability of a doctor to churn through a higher patient count in no way ensures quality. “You don’t want to confuse efficiency with sloppiness,” he says.
In the absence of clear precedents and solid guidelines, hospitalist groups are struggling to come up with their own formulas for ensuring that workloads balance high productivity with sustainable quality—no easy feat. Nonetheless, first-hand accounts and survey data suggest that more providers are identifying common warning signs and devising tailored solutions to help the rapidly maturing field stay on track.
Henry Michtalik, MD, MPH, assistant professor of medicine at Johns Hopkins University School of Medicine, led one of the only surveys that has directly asked hospitalists how they perceive their own workloads. The survey, conducted through an online community of hospitalists and first presented at HM11, revealed several intriguing findings.2
On average, hospitalists reported seeing about 15 patients per shift or day, not including nights, weekends, or holidays. Apart from a few outliers, the range extended from the low teens to the mid-20s, Dr. Michtalik says. According to the survey, 40% of physicians said that more than once a month, their typical inpatient census exceeded the level that they deemed safe and appropriate for specific work settings; 36.1% of physicians reported that was true more than once per week.