Average daily census

I personally think you have all the data you need to know that for your system ~20 patients / day is too much for a 12 hour shift. Burnout is all too quickly followed by turnover and the problem just compounds on itself. Of course the challenge is less in recognizing the problem and identifying how to quickly respond to it. Surge  / back-up is only a temporary bandaid.

For our system we have separate rounders and admitters. Goal census for rounders is 15 alone or 20 when comanaging with an APP for a 9 hour shift. Personally seeing 15 is a manageable day and I can leave in a timely manner and feel that I have done everything I should as a hospitalist and not the bare minimum for patient care and safety. However, bump me to 18 patients in a day and I will not leave on time and will probably cut out key tasks that are associated with delayed patient benefits such as that extra family phone call or chasing down a timely discharge appointment. 

The attached paper published in 2014 supports the notion of a daily census of 15 representing a sweet spot for outcomes such as length of stay and cost. The attached abstract presented at HM 16 working from the same data set also found that with increased patient census there was increased utilization of specialist consults.

Prior to my current job I too worked in a small community hospital with an open ICU and it was almost exactly as you described.  We had 2 day rounders and we were each paired with a PA.  Admissions were done round robin style so frequently our census was anywhere from 10-18 (fairly high turnover) with upto 10 co-manages with PA ( which I felt was unsafe) and then 2-4 admissions daily.  These were 12 hour days and we worked 7on 7off and as you can imagine quite exhausting both physically and mentally.  After my one year contract I had to leave as I was feeling quite burnt out.

I brought up the idea of a day admitter shift but  the admin didn’t feel like we had the numbers for that, instead they thought of bringing in more PAs.  PA’s and NP’s are great but just like physicians it comes down to experience and comfort level, but to me felt unsafe.  

I really hope you have better support and are able to change the culture at your institution before it’s too late.  Sweet spot seems to be 12-15 for me as well, more than that and I always feel like I am forgetting something.

Michael,

Our hospital has two towers and around 349 beds.  The ICU is centralized and open as well.  The average daily census for the hospitalist is about 22 -- mixed inpatient with some observation, no NP's.  The census can surge to 25-29 in the winter.  Admissions from direct outreach or ER can be about 6-10 per 2 hour shift, 30+ overnight (15 hour shift).  Hospitalists carry follow-up and new admissions and they 'share' 2 hour ER on-c all shifts per day.  We divide the overnight admissions equally per Hospitalist.  We tend to pair those that want to carry slightly lower census with those that prefer higher census, we work 7 on 7 off -- helps keep stress/burnout in check.  All of our team members are independent contractors.

Nick C.

Hi, I work as a Hospitalist in a 573 bed county hospital with closed ICU. We see an average of 18-20 patients everyday but those are all rounding patients including consult patients, ICU transfers. If admitting physician gets overwhelmed, occasionally, rounding physician will admit 1 patient. With NP, average census is 22-25 patients. We work 7 on, 7 off schedule and started with equal number of patients everyday regardless of the number of discharges. Due to high acuity, I do feel it gets stressful. At times it's not possible to spend enough time with patients. We have had a lot of turn over in Physicians due to workload being unmanageable.

We have 2 hospitals in our town. The one I am working is a 212 bed hospital. Semi closed ICU except patients who are intubated and require titration of drips, all ICU patients are under hospitalists. We have resident backup on each team from Mon-Friday who typically sees anywhere between 2-8 patients. I end up in seeing 10patients on my own.Daily admissions per team are variable anywhere from 2 to 6 a day. High turnover, and low acuity. Winters are worse upto 20 patients per team Max was 24 patients. 

Across the street 700 bed hospital has 15 patient cap with 2 admissions before 2 pm. They have several admitters and night shift physicians. They can leave after 4 pm and be available on phone till 7pm.

My point is it's highly variable even in a same town.

 You’re looking at this all wrong it’s not about numbers it’s about many other factors I’ll gladly see 20 patients instead of 10 if it meant good support, efficient EMR, demographics etc. every hospital is different there is no one size fits all to this issue and many other issues that keep coming up 
 but if want an answer to this  no more than 10 patients encounters daily would be optimal in my opinion