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4 in 10 Hospitalists Report Unsafe Patient Workloads

 |  By cclark@healthleadersmedia.com  
   January 30, 2013

Four in 10 hospitalists responding to a survey from Johns Hopkins University say their workloads exceeded safe levels at least once a month.

In a research letter published in JAMA Internal Medicine this week, authors Henry J. Michtalik, MD, Peter Pronovost, MD, and others also said that 36% of the 506 hospitalist respondents reported excessive workload assignments exceeding safe levels at least once per week.

"We weren't surprised that there is an issue with workload, and that providers believed it fluctuated to points that exceeded safe levels," Michtalik says. "But we were surprised at the frequency with which we were seeing this across all different kinds of institutions and practice settings, and with different providers."

Respondents said that time constraints prevented them from discussing treatment options, delayed patient admissions and discharges, and worsened patient experience scores. They acknowledged that their workload "likely contributed to patient transfers, morbidity, or even mortality."

Michtalik adds that failure of top hospital leadership to acknowledge excess workloads among hospitalists and attending physicians, who manage some of the sickest, most complex patients, could be "pound foolish."

"The typical response to reductions in payments and reimbursement (now impacting acute care revenue) is to increase patient flow and try to decrease length of stay, but what this would suggest is that while we're being penny wise in increasing flow and decreasing stay, we might be pound foolish by paradoxically increasing costs," Michtalik says.

 

The excessive workloads reportedly decreased the time spent on inpatient discussions, and may lead to the ordering of unnecessary test procedures and consultations, Michtalik says.

The authors note that the issue of burnout and high patient workloads leading to errors and adverse outcomes is well known in nursing and in academic residency programs. But they said this research paper is the first to address the issue among hospitalists.

The responses to the survey, administered to 890 self-identified hospitalists who were members of the online physician community QuantiaMD.com, came during four weeks in November, 2010. The researchers said that 57%, or 506, responded. Responses were sought dealing only with daytime shifts.

Michtalik said the survey is the first to "to assess perception of unsafe workload by a direct question, to compare self-reported safe and actual census numbers, and to evaluate the potential impact of inpatient attending physician workload on patient outcomes." He added that several other workforce reports are in the works.

John Nelson, MD, co-founder and past president of the Society of Hospital Medicine, called the Johns Hopkins findings "important," but cautioned that it indicates certified hospitalists "continue to be in short supply throughout much of the country," which may contribute to the negative responses.

He adds that as a practicing hospitalist who visits many hospitals and talks with hospitalists throughout the year, he is aware that many are very overworked.

In a phone conversation Tuesday, however, he cautioned that many hospitalists schedule their own work shifts, and may have only themselves to blame if their workload is too hectic.

"While some organizations (that employ or contract with hospitalists for their services) may have unreasonable expectations of what they can do, and that may lead to performance suffering, hospitalists may be complaining about some conditions they bring on themselves."

Hospitals that use hospitalists to manage care for admitting community physicians has been a dramatically expanding trend, with more than 34,000 hospitalists now practicing in more than 3,300 hospitals, according to the Society for Hospital Medicine. It conservatively projects the number to grow to 40,000 this year. In the late 1980s, Nelson notes, there were only about 200.

Of acute care facilities with more than 200 beds, four in five employ or contract with hospitalists.


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