Patient Care Volumes

The workload for taking care of patients in the electronic era is significant and ever-increasing. Awkward and voracious documentation demands, rapid patient turnover, complex and frequent handoffs, untoward complexity navigating and finding data in EHR’s, demands from payors and reviewing agencies, time needed to search for information on unfamiliar patients, and ever-increasing patient acuity all lead into the same sinkhole. It takes much more time to care for each patient and do it right. Because of time constraints and financial pressures, this produces the temptation of adapting to these pressures inadequately. One problem that has emanated from this time transformation is seeking providers having too large a census, reducing their financial pressures but at the cost of longer (too long) hours, or cutting corners on quality of care

Here are some of the issues:

  1. High patient volumes have produced problems in dealing effectively and thoroughly with inpatient care needs, including timely review of information, appropriate communication with primary care physician at admission and discharge, addressing advance directives and opportunities for palliative or less aggressive care, managing length of stay effectively, timely assessment of patients, prompt and appropriate discharge, medicine reconciliation, and high-quality discussions with patient and family.
  2. Too high patient volumes can also lead to excess physician hours contributing to inefficiency, burnout, and the potential for errors and omissions.
  3. Current hospitalist literature recognizes these issues and has no rigid guidelines but consistently suggests that a maximum patient load for a full-time hospitalist is between 12 and 15 patients as an average daily census.
  4. Given the complexity of the patients and the large gap in training and knowledge, it is reasonable to assume that optimal capacity for non-physician providers (PA or NP) will be 1/3 to 1/2 that of a fulltime board-certified internal medicine hospitalist. This would calculate out to 15-21 patients as a maximal average census for a combination of 1 full-time physician with 1 full-time NPP.
  5. Failure to contact the PCP on admission as well as discharge and during important developments, not discussing the case with the PCP, and not documenting these discussions in the medical record – when these are not occurring that is both a quality issue that provides substandard care to patient but it is an indicator patient census is too high since necessary work for good patient care is being ignored/bypassed.

 

Suggestions to improve patient care impacted by high patient census:

  1. Monitor patient volumes and workflows with respect to making sure that patient volumes are not routinely higher than optimal. Use national guidelines with respect to census size and provider capacity not as rigid guidelines but as a benchmark so you can monitor and compare your work.
  2. Expand provider pool or collaborate with colleagues to deal with higher patient volumes.
  3. If using NPP’s on your inpatient service, make sure that deliberate and well-planned workflows are established that provide for timely dealing with all patient care issues and that each member of the team is practicing to the top of their license.
  4. Discharge patients more quickly (shorter length of stay) which reduces census and decreases likelihood of mistakes from too high a census
  5. Call for consultations more sparingly to avoid the problems of excess testing or delays that can sometimes be created with inefficient or ineffective requests for consultations. Consultants routinely complain that many consultation requests they receive are completely unnecessary. Every such consult can not only delay discharge (while waiting), lead to more testing (and delay discharge), but it also means your consultants are stretched too thin and may not be as timely available for when you really need them.
  6. Complex testing (MRI, CT scan, EEG, echocardiography) should be critically evaluated before ordering such during a hospital stay. Whenever such testing is indicated but does not need to be done right now, it may be more appropriate to do in the ambulatory setting. That should be part of the regular discussion with the PCP so such testing is seamlessly integrated into the Care Transition. When such testing is done needlessly on an inpatient basis it prolongs the hospital stay unnecessarily, increases costs inappropriately and ties up critical hospital personnel and resources and makes them less available to seriously ill patients who truly need these services on a prompt basis.