frankly i don't see how one is able to do these 8 admits in 2-3hrs, unless 80% of ur patients are healthy 40 yr olds or something. where i am 4-5 admits a night is considered busy. (7 hr shifts). i get that the cases u listed are much simpler than my typical patient, but still some pneumonia or copd'er are likely to have at least a few other medical problems, a reasonably long list of home meds to go through, even if they are stable. we also need to do a full 10 point ros for billing purposes.
here's how a typical IM admit goes for me:
0. answer the ER call, discuss case with ER, decide if patient needs admission
1. review old records in the system(possibly multiple systems)
2. talk to the patient, which involves a full 10 point RoS, their CC, family hx, code status discussion etc etc
3. med rec, often done by the MD, going over a full list of 20 meds on an 80yr old patient who brings in conflicting med lists from different dates, along with a not so great memory.
4. rec above meds
5. review current results
6. formulate a plan
7. put in orders
8. dictate or write h&p
9. follow up labs before end of shift.
10. call consultants before end of shift and discuss case over the phone.
11. type my email signout, things to f/u etc.
3+4 alone can really take up to 15minutes and drain ur energy but if u want to do a good and thorough job, u kinda have to do it. trying to get ahold of consultants early AM or in the middle of the night is a literal nightmare too.
the above is a typical patient for me, and that isn't even some unstable ICU patient that requires minute to minute attention either.
ER triage/discharges also take longer due to having to arrange all their f/u at night, write prescriptions etc.
Well that's why I said that there is probably a great deal of variability and it certainly depends on what patients you are admitting.
I kid you not, my ED has a super low threshold to put patients for admission. I could hold my ground and either not accept the admission or admit and discharge both of which I have tried and I learned not to do (takes more of my time, usually the ED physician already told the patient that they are being admitted and start judging me and asking what's wrong with me, etc.) So yeah, I have been "stuck" admitting 40year old guys that have zero risks factors and and run 5miles/day for a chest-pain ACS rule out. I have been stuck admitting people for chronic pain, low risk PE, tiny kidney stones for which the pain was already controlled in the ED prior to me seeing the patient ("because they need urology consult") and so forth. Not to mention the alcoholics and psych patients that have no real medical reason (other than perhaps being intoxicated?) and they dont even talk to you because they either passed out (alcoholic) or ED sedated the crap out of them with haldol benadryl and ativan.
So yes, I could see how if you are admitting purely scleroderma renal crisis patients, ITP patients, lupus cerebritis, anca alveolar hemorrhage, etc it would take a million years.
for instance. My typical discussion with ER doc is about 3-5mins unless patient is super complicated (and often times when patient is that complicated it usually warrants ICU admission and in that case ICU does the orders/med-rec/etc)
2.- Talk to the patient, I spend the most time with this. It could be as short as 10mins on straightforward cases (kidney stone, appendicitis, relatively low risk ACS ruleout, HTN urgency, mild pneumonia)
3- Medrec is done by nursing staff. Offcourse it is always wrong so I confirm with patient but I don't usually have to put it in the computer, just make sure whatever is there is OK. On average, this does not take more than 2-3 mins. Yes it has happened that I get a 80year old on propafenone and digoxin and diltiazem DAPT and Eliquis and an EKG that looks like an EEG and I freak out and take like 20mins reviewing it twice, thrice, and then prior to going home yet again but this is perhaps once in a blue moon.
4.- as above.
5.- I am admitting. There are very few results I need to review. TYPICALLY, it is just a CBC, CMP, UA, CXR, EKG and one or two targeted tests for whatever complain they came (chest pain, CTA/troponins, headaches CT head, Stroke, CTA/CT/Carotid US, etc). Most tests are negative except those that are pertinent to their chief complain. Typically this takes me 5, maybe 10mins on complicated times and I tend to overlap this while talking to ED physician. Either I sit next to him/her while they show me during signout, or I am doing it while they talk on the phone.
5.5- what DOES takes me a long time, is sometimes when patients have been admitted a dozen times. I hated during recidency when the same guy came over and over and over with chest pain and always got an echocardiogram even though there are half a dozen echos done during the last 6 months in the system. So I do like checking previous admission. Also, I get a lot of recurrent nursing home semi-abandoned "AMS due to UTI" and there is nothing more disappointed that finding on the 3rd day of admission that ESBL grew and the patient was on cefepime all this time. I have a disgustingly low threshold for meropenem on admission.
6.- I formulate the plan as I talk to the patient 90% of the time. This does not take any additional time at all MOST of the times. In fact I don't know how to do a proper H&P if I am not thinking about the plan at the same time. Not to mention, in order to discuss with the patient "hey, I am going to give you ceftriaxone, it could give you diarrhea and in rare cases it could depress your bone marrow...." I kind of have to have the plan in my head as I talk to them.
Yes, sometimes I do need to talk to neuro IR to make sure they really don't want to do a thrombectomy and that can add time.
I do brush up on diagnosis that I have not seen in weeks or that are rare. So during a 12h shift maybe I spent 30mins in total reading 2-3 Uptodate pages on 2-3 diagnosis. But I do not have to do this, nor do I do it, for all of my admissions. Just the two or 3 that actually require it.
7.- orders is a 5mins deal and this goes for straightfoward patient as well as difficult ones. 1 admission order set + 5-10 individual orders depending on the actual reason for the admission.
8.- This, along with the H&P is what takes the longest. It could take me as little as 5mins for one of those alcoholic guys, it could take me 20 mins for a complex patient. On average, no more than 10mins I'd say.
9.- I don't necessarily follow up on all patients. I'll follow up on troponins, a CTA, or something that would require immediate action.
10.- No. Never done it, I have not met anyone else that does it. Maybe it has something to do with the very low threshold for admission that we have or something else. If the patient requires a time-sensitive consult, I'll give a call to the consultant when I admit the patient. Honestly, as I am writing this post I cannot think of any reason that is not urgent enough to require a call in the middle of the night but that I still should call at 6 in the morning when I am leaving home. If it is not urgent enough to be done at 3am, it can wait until 10 am.
11.- This is fairly short and straight to the point "this is what worries me, check on this and this prior to rounding" and that's it. If the morning doc needs anything else, very kindly I ask he reads my note which I wrote for a reason and not just for billing purposes.
