When the census soars

Creative scheduling and on-call systems prevent surges from spiraling out of control.

Like many large hospitals, Mayo Clinic Hospital's Saint Mary's Campus in Rochester, Minn., has a system to deal with unexpected fluctuations in inpatient volume. But in 2014 its average medical inpatient census hovered about 10% higher than in 2013, pushing hospitalists to regularly work longer and longer hours.

“Our surge policy primarily allows us to temporarily increase the census caps on some of our services and also to document that we don't have the capacity to accept elective transfers from other hospitals,” said A. Scott Keller, MD, FACP, a Mayo Clinic hospitalist. “Our highest surge stage is activated when the census approaches 150, but for the past few months our census has frequently been above 150 and at times as high as the 190s.”

Illustration by Sarah Ferone
Illustration by Sarah Ferone

Dr. Keller worries about the potential downstream effects of a consistently high census. For example, a May 2014 JAMA Internal Medicine study showed an association between increased hospitalist workload and reduced efficiency and higher costs. The retrospective study looked at more than 20,000 admissions at a large academic community hospital system and found that length of stay increased by as much as 2 days, at a cost of between $5,000 and $7,500, as hospitalist workload increased.

Inpatient surges happen periodically at most hospitals but may persist, especially if not managed quickly. “Every month we kept saying the surge was temporary, but it's stayed persistent all year,” said Dr. Keller. “It's caused us to look at revamping what we're doing.”

Just over 40% of hospitals have no back-up system for surges, according to the Society of Hospital Medicine's (SHM) 2014 State of Hospital Medicine Report. Of those that do have systems, only 18% make it mandatory for most clinicians to serve a backup shift.

“Every hospitalist practice should be thinking about how they're going to handle unpredictable fluctuations in volume,” said Leslie Flores, MHS, partner in La Quinta, Calif.-based Nelson Flores Hospital Medicine Consultants. “That might mean creating a formal backup system or just staffing for an average workload that's low enough to allow for additional resources on busy days.”

Putting a plan in place

Many surge systems use a pre-determined cap on the number of patients each physician can safely manage per shift. When it is exceeded, help is called in. Hospitalists may take turns being on call as part of their regular schedule or volunteer to cover extra shifts when needed.

It's important to establish a cap or other triggering mechanism for calling in reinforcements because sudden surges tend to happen every few weeks for no obvious reason, said Erik C. Summers, MD, chief of hospital medicine and associate chief medical officer at Wake Forest Baptist Medical Center in Winston-Salem, N.C. Otherwise, sudden surges in volume can spiral out of control.

“Waiting and hoping the rising census will go down on its own doesn't work,” said Dr. Summers, who uses a voluntary, paid call system that's triggered when physicians' average patient load goes above 16. “If we took a ‘wait and see’ approach, we probably would see a surge broaden over 5-6 days as physicians get busier and discharges get delayed. But we've been able to get them under control in about 3 days.”

Just knowing that a plan is in place has a positive impact on physicians' ability to deal with a rising census, said Henry J. Michtalik, MD, MPH, assistant professor of medicine and hospitalist at Johns Hopkins Hospital in Baltimore and lead author of a study focusing on the impact of physician workload on patient care, published in JAMA Internal Medicine in March 2013.

“The most frequent reporters of unsafe census or workloads in our study were those who didn't have any systems in place to accommodate fluctuations,” said Dr. Michtalik. “Not establishing volume caps or having an additional call-in system to handle fluctuations significantly increases hospitalists' perceptions of having an unsafe workload.”

At Virginia Mason Medical Center in Seattle, the hospitalist division recently established volume caps after realizing that physicians needed guidance on when to call for reinforcements, said Therese Franco, MD, ACP Member, hospitalist and innovation specialist. The suggested caps are now set at 16 for teaching services and 13 for non-teaching services.

“We used to let physicians admit and round until they felt they couldn't do it safely anymore, but that system was very ambiguous and people tended to work over their functional cap,” said Dr. Franco. “If one doctor calls for help at 12 patients and another calls at 16 patients, what does it say about the 2 providers? There tended to be a stigma about calling for help.”

Under Virginia Mason's current system, the hospitalist in charge assesses the census at 7 a.m. and again at 2 p.m. and calls in the physician on surge call if the numbers are too high. The on-call physician might be asked to come in right away or at 5 p.m. to help with late-afternoon admissions. A text message is sent out after the 2 p.m. assessment if no backup is needed that day.

In addition to monitoring volume caps, the hospital is planning to institute a system to use data on past admissions to help gauge whether backup is needed on a particular day, said Dr. Franco.

“We have data going back more than 2 years showing the rolling average for admissions per day,” she said. “We will chart that data and if it looks like the slope of the line for the day is steeper than the slope over the past 2 years, we'll call in surge.”

Many hospitals also have a “jeopardy” on-call system but use it mainly as an emergency backup for sickness or family emergencies. While it is sometimes employed as a second backup during surges, it's preferable to keep it in reserve for true emergencies, said Daniel J. Brotman, MD, FACP, director of the hospitalist program and professor of medicine at Johns Hopkins.

“To minimize use of that system in our division, if a clinician calls on jeopardy [to work his or her shift], they have to pay back the group with a moonlight shift and the jeopardy person gets paid for that shift,” he said. “It works as a disincentive and encourages people to figure out other coverage in non-emergency situations.”

Balancing cost and safety

Hospital administrators often struggle with the best way to handle surges without incurring excessive cost, said Ms. Flores. They want to have enough staff on hand to handle fluctuations in volume but also want to avoid having to pay for too many extra shifts.

Changes to routine scheduling can help with that dilemma, she said. For example, staffing at a slightly higher level every day ensures that the existing staff can handle most surges without bringing in more expensive locum tenens or emergency backup. Alternatively, administrators might allow hospitalists to adjust their hours based on workload.

“It's not reasonable to expect hospitalists to work 13 to 14 hours on busy days unless there are other days when they can leave after 8 to 9 hours,” said Ms. Flores. “Administrators need to adopt a mindset of paying professionals for the work that needs to be done; some days that's going to be a long day and sometimes a short day.”

Scheduling part-time staff or bringing in locum tenens during high-volume periods can help manage surges, but it can also slow things down if the person is not familiar with the normal workflow, noted Dr. Summers.

“We're looking for someone who can come in and work at the same level as the other hospitalists,” he said. “Clinicians who are being paid extra for working during a high census may not be as motivated to discharge as the rest of the team. Some part-timers can be great, but it won't work if it's all about the money.”

Mayo Clinic has added a new medicine service as of Jan. 5 that is primarily a “rounding service,” where a clinician sees patients admitted the previous night and will have limited daytime admissions, said Dr. Keller. Also, they now have an on-call physician and a contingency physician who can come in to help out when the census is extremely high.

Overlapping shifts during peak times can also help minimize the need for extra backup, said Dr. Michtalik. For example, morning and afternoon shifts could overlap to maintain the flow of admissions during peak admitting times in the late afternoon.

“We try to have a system that's robust enough to handle surges rather than rely on a backup system to do it,” he said. “We try to be anticipatory rather than reactionary so that we are deciding how to best distribute our resources during a surge rather than looking for backup after it happens.”

Issues to consider

Some surge control strategies can solve a short-term problem but create other issues downstream, hospitalists said. For example, adding extra staff may boost efficiency during surges but it can also have a negative impact on continuity of care.

“If you have an extra physician coming in and following 8 to 10 patients, do you have that physician come back the next day and handle the patients they know or do you hand them off?” said Dr. Franco. “The census might have returned to normal the next morning, but there are those 10 patients who know the surge physician so you have to make a decision about how to handle that.”

Assigning the surge physician to admissions that are expected to be low-acuity or short stays, such as syncope or chest pain rule-outs, is one potential way to minimize handoffs, said Dr. Franco. For patients who aren't discharged by the end of the shift, the surge physician might be asked to come in the next day for a few hours to round only on those patients.

Payment is another issue to think through carefully. Some hospitals offer additional compensation for being on backup or for being called into work during surges, while others build surge call into the regular schedule.

According to the SHM survey, only 11% of hospitalist groups that have a formal backup plan in place offered compensation for both being on the backup schedule and being called into work, while 28% paid for neither. The majority (59%) offered some payment or stipend for being on the backup schedule but no additional payment for doing the extra shift.

The opportunity to earn extra money for a backup shift can be a good incentive, said Dr. Brotman, but having a predictable schedule is even more important to many hospitalists. That can be achieved by building surge call into the regular schedule and accounting for it in the hospitalist's overall compensation package.

“The job description is fundamentally important to hospitalists because they are uniquely vulnerable to people calling on them to fill in gaps,” said Dr. Brotman. “It's very nerve-wracking to have their schedule change week to week, and it can lead to burnout.”

However, paying for backup to handle a high census often makes financial sense in the long run, said Dr. Franco.

“People can't work as efficiently with a high census and that drives up length of stay,” she said. “If you look at it in terms of cost per discharge, there may actually be cost savings in bringing in an extra physician to handle the volume appropriately.”

Ultimately, patient safety and profitability are intertwined, agreed Dr. Summers. “Many hospitals tend to absorb more patients with the same staff but that can be shortsighted,” he said. “A provider may be able to see more patients, but at some point efficiency and patient safety will go down.”