I spoke with an old medical school friend of mine the other day. They're having issues with throughput in their emergency department (ED). He's an emergency room doctor who works in a hospital where hospitalists cap their service at fifteen patients a day. He asked me whether I thought that was reasonable. No primary care physicians in his community come to the hospital anymore. They are also a large referral center for multiple Native American reservations. When the hospitalists cap their service, they often have to divert patients to other facilities or have them parked in the ED for hours or days. This severely interrupts their throughput of patients in their emergency room.
Do I think hospitalist programs should have caps? No I do not. I think capping the number of patients seen by a hospitalist on any given day is terrible policy. Caps are a disruption to patient flow and can create animosity between doctors. It can hinder the work flow of any number of system processes down stream from the ER. Many academic programs have instituted caps as a way of reducing work load for residents. I think that's a shame.
It's bad for patients to have them parked in the emergency room for hours when we all know that ED nurses and ED docs are not trained to manage floor activities well in a high volume department. Studies have shown that maximum hospitalist efficiency is achieved in the 15-17 patients per day range. Depending on how complicated my patients are, rounding can take me anywhere from five to eight hours with that workload.
If I cap my service to new admissions, am I doing the hospital, the patient or my relationship with other physicians any good? if I tell them I will not accept their patient sitting in their ED or wanting to be transferred directly from a small town because I feel I'm too busy, have I helped the situation instead of hurting it? No I have not. There are no winners when hospitalists cap their service.
The solution lies within the ability of administration to realize that a great hospitalist care model that provides top quality service and runs at maximum efficiency will be one in which the patient load does not exceed 15-17 total encounters per day. Administrations that realize the benefits of hospitalist programs are achieved when these standards are maintained also understand the value in continuing to support the growth of hospitalist programs with economic support. Avoiding the hospitalist capped model of care is paramount for long term success and for avoiding road blocks in emergency department throughput.
Administrations that choose not to subsidize and support their hospitalists are the ones who wonder why all their hospitalists leave after a year and why they show no benefit in resource utilization or length of stay. Just like everything else in this world, you get what you pay for. If you want to run a hospitalist program on the cheap, you will never realize the back end savings of your front end investment. If you ever have to consider implementing a cap in your hospitalist program, you know it's time to hire more doctors. It's as simple as that. Either that or work faster, as this original Happy ER doctor ecard explains.
This post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.