Appropriate Patient Census: Hospital Medicine's Holy Grail

An additive effect

Michael N. Huber, MD, president and CEO of Inpatient Medical Services Inc. in Fairlawn, Ohio, says the day-to-day unpredictability of HM can thwart even the best-laid plans. “You just don’t know day to day when you’re going to have a day where the average is exceeded or it’s far under the average,” he says.

Dr. Huber says the company tries to keep its physicians’ average census at 18, where metrics suggest they’re at their most efficient and productive. Experience consistently shows that once the daily census exceeds 20, it will likely keep climbing. “It’s because the discharge process gets delayed, the throughput gets delayed,” he says. “And then if we add a physician to that mix, either temporarily or permanently, then we see the number drastically go down.”

At one of the company’s 13 practices, patient volume increased so much that the daily staff grew from three to four hospitalists last March to at least five to six by December, requiring both flexible, short-term solutions and long-term planning. One Monday in December, for example, the five hospitalists on duty called for help after unexpectedly dealing with 117 patient encounters. The company intervened by bringing in a regional administrator the next morning, part of the “fireman team” that can step in temporarily put out fires. By that Thursday, total patient encounters had fallen to less than 100, dropping the daily census from more than 23 to less than 17.

“I can be reasonably certain that if we were to leave this practice for a length of time at five physicians, we would be at 120 encounters a day, and our report cards would start to suffer,” Dr. Huber says. Conversely, the added help has had a cumulative effect, making the whole team more efficient.