Curious on the limits of patients per day of inpatient.

[Faebinder]

I am curious if anyone knows if there is an ACGME limit to the total number of patients you can see per day as a resident in the inpatient units? I know there are some locally imposed limits.. but is there an ACGME limit like Internal Medicine has for example that the first years can't carry more than 10 patients per day.

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[ssrnh]

In my program the cap was 6 patients during inpatient service

 

[Suedehead]

In my program the cap was 6 patients during inpatient service

You're KIDDING!!
My goodness. I've been consistently holding loads of 9-12 on inpt units. Aarg. I've nobody to strangle, I guess I'll just go spend some money on something superfluous.

I'm curious to know about any other pt caps at any other programs. If there is seeming consensus, maybe we'll be able to push for a cap ourselves.

 

[Faebinder]

My program has two branches. One branch caps at 6. The other has no caps and usually holds 12-16.

 

[masterofmonkeys]

Theoretically 6 at my program. But depending on how things play out, who your attending is, and how 'protected' you are by them, it can go much higher. I've seen and had to write notes/do discharges/admit up to 12. Even on our 'half days' (clinic and/or didactic days).

 

[whopper]

Caveat: I've been out of the ACGME game for over a year so anything I write you should double check.
There are caps, and from what I remember the caps are the same as Internal Medicine which I believe is 12 a day.

This site may help you.
http://www.acgme.org/acwebsite/rrc_400/400_prindex.asp

I remember that being odd becuase psychiatry patients often times require less maintenance than regular patients. In IM we had a cap of 12, and we had to cover the floor. Covering the floor took about 5-6 hrs a day, leaving with only a few hours to see your usual 7-12 patients. In psychiatry, covering the floor (responding to beeps and concerns that didn't have to do with the patients that were specifically yours) was less than 1/2 an hour a day on most days.

The stress of being beeped in IM even while seeing your patients was enormous. I remember being beeped on something of the order of 30x a day in IM. It was like have a bomb strapped on my back. At any moment it could go off. You rarely get beeped in psychiatry (at least at our place) because you're on the unit most of the time, and 1/2 of the patients you cover, while the other half the other resident covers.

However despite that cap, if we occasionally went over 12 (which when I was at the program was rare-happened maybe once 2-3 days a month), I didn't really mind covering, reason being is that if you look at the maximum cap, yes there's 12 pts max, but they could make you work 80 hrs a week too in addition to doing a lot of other things that could've been uncomfortable. The program never did that. We often times got out in less than 40 (minus calls). For that reason, I didn't decide to fire back because that can lead to the trap of a trench warfare mentality against people who are your superiors. (The juice has to be worth the squeeze).

I did mind other things. E.g. we had a time where one of the attendings just showed up, signed his stuff, and left--which put him on the unit for only about 1 hr a day. If you called him up, he didn't call back sometimes for 1/2 an hour, and when he was on the line you could barely hear him because his cell phone carrier blew. If the resident didn't know what to do, and it was an acute situation--SOTL, and the staff would try to blame the situation on the resident. That from my understanding violated his contractual and legal responsibilities with covering a unit. Blaming a resident when there should've been an attending present to handle the situation a resident can't handle? That was over the line. I was chief then, I felt I had to bring it up, and the then new dept chair fixed the problem.

So with the situation where a resident had over 12, and the attending wasn't there---that added the straw to the camel's back. I was not enforcing the cap which is fine by me so long as everything else was cool, but everything else wasn't cool. The guy wasn't doing his bare minimum responsibilities.

Any resident should be aware of the ACGME guidelines because they detail several of your rights and responsibilities as a resident.

 

[Faebinder]

Caveat: I've been out of the ACGME game for over a year so anything I write you should double check.
There are caps, and from what I remember the caps are the same as Internal Medicine which I believe is 12 a day.

This site may help you.
http://www.acgme.org/acwebsite/rrc_400/400_prindex.asp

I remember that being odd becuase psychiatry patients often times require less maintenance than regular patients. In IM we had a cap of 12, and we had to cover the floor. Covering the floor took about 5-6 hrs a day, leaving with only a few hours to see your usual 7-12 patients. In psychiatry, covering the floor (responding to beeps and concerns that didn't have to do with the patients that were specifically yours) was less than 1/2 an hour a day on most days.

The stress of being beeped in IM even while seeing your patients was enormous. I remember being beeped on something of the order of 30x a day in IM. It was like have a bomb strapped on my back. At any moment it could go off. You rarely get beeped in psychiatry (at least at our place) because you're on the unit most of the time, and 1/2 of the patients you cover, while the other half the other resident covers.

However despite that cap, if we occasionally went over 12 (which when I was at the program was rare-happened maybe once 2-3 days a month), I didn't really mind covering, reason being is that if you look at the maximum cap, yes there's 12 pts max, but they could make you work 80 hrs a week too in addition to doing a lot of other things that could've been uncomfortable. The program never did that. We often times got out in less than 40 (minus calls). For that reason, I didn't decide to fire back because that can lead to the trap of a trench warfare mentality against people who are your superiors. (The juice has to be worth the squeeze).

I did mind other things. E.g. we had a time where one of the attendings just showed up, signed his stuff, and left--which put him on the unit for only about 1 hr a day. If you called him up, he didn't call back sometimes for 1/2 an hour, and when he was on the line you could barely hear him because his cell phone carrier blew. If the resident didn't know what to do, and it was an acute situation--SOTL, and the staff would try to blame the situation on the resident. That from my understanding violated his contractual and legal responsibilities with covering a unit. Blaming a resident when there should've been an attending present to handle the situation a resident can't handle? That was over the line. I was chief then, I felt I had to bring it up, and the then new dept chair fixed the problem.

So with the situation where a resident had over 12, and the attending wasn't there---that added the straw to the camel's back. I was not enforcing the cap which is fine by me so long as everything else was cool, but everything else wasn't cool. The guy wasn't doing his bare minimum responsibilities.

Any resident should be aware of the ACGME guidelines because they detail several of your rights and responsibilities as a resident.

I went to ACGME website.. the claim of 10 cap is for IM residents, i did not spot ones for psychiatry... where did you see something that says this applies to psychiatry? We have been told that there is no official caps for psychiatry programs.

 

[kugel]

I don't see anything on the ACGME website about a cap on # of patients.
Caps have their pros and cons.
One unintended consequence is that physicians will sometimes keep pts in the hospital as long as possible in order to prevent getting new patients. I saw this become rampant at a hospital with no residents. The attendings never discharged someone over the weekend and regularly kept their services full, dumping excessive work on the 1-2 who didn't practice this way. When we lifted the cap, the Length of Stay dropped 15-20% in the first month and stayed that way.

Probably the most useful, successful form of cap I saw was a cap on the number of new patients residents could be forced to accept in one day. Once you'd had 4 (I think it was 4) new patients admitted to your service that day, any more new ones went onto others' services until after 5pm (when the count started over. So, if you got 4 new pt's over night, you had a lot of work to do the next day, but you knew that you'd get no more new patients. However, since there was no cap on total # pt's on your service, you could not use delaying tactics (even unconsciously) to keep your census high and prevent getting new patients. It taught us to deal with that issue. It also meant that if you had a few "rocks" or "stones" (patients who just sit, and you aren't able to move them off the unit), they could not protect you from new patients - and that seemed fair since such pt's generally don't require much day-to-day work. On the other hand, if you got 4 new ones, you knew there was a limit to your work the next day, a light at the end of the tunnel. If you got through your new pt evals and all your other ward work by 2-3pm, you were "done."

This process also provided us with incentive to "request" all the new pt's we admitted while on-call (rather than distribute them via the usual rotation). With the choice to admit them to my own service, I knew that the high majority of patients on my service would always be ones I admitted and so I knew the entire case from start to finish - rather than getting pt's whose CC and HPI I never really completely understood. The downside is that some residents used that option to fill their panel with "soft admits" who maybe did not really need admission - but they got admonished by the attendings and ended up discharging those patients quickly 1-2 days, which meant they were again open to new admits from other's call nights. If my peer was loading himself with "easy" patients, on my next call night I could use my choice to admit pt's to myself in order to alter the rotation so that "certain" pt's ended up on his service. I don't think I ever used that option, because “Before you embark on a journey of revenge, dig two graves.” (Confucius)

 

[whopper]

We have been told that there is no official caps for psychiatry programs.

And you may be, or at least the people who told you this may be right.

You could try to contact ACGME yourself...
or call the GME
http://www.acgme.org/acWebsite/about/ab_contact.asp

I'm going to read between the lines and assume you may be looking this up because there may be an issue of capping that you'd like to see happen. From my own experience at ARMC, I didn't mind having over 12 patients (and if you got your work done well, you could finish all of it up by 1-2pm leaving plenty of time till your duty ended), what I minded is if I was doing more work because others weren't doing their work. E.g. if I asked the attending how to handle a siutation, that attending blew me off, and then the staff tries to blame me for not handling the situation right, that to me was over the line. Classic politics because the staff have nothing to lose by blaming the resident. I'll take responsibility for a screw up that was of my own making. I'm not going to take one if I didn't know how to handle it, and the guy who was supposed to show me blew me off.

Or another situation where a resident wasn't seeing all his patients, so I was asked to cover for him. I don't mind covering for someone becuase of an emergency, but in this case, the guy was just blowing off his responsibilities--and no one was holding him accountable. I told the program that I would only do that guy's work for that day if they started holding him accountable, and I would take it to higher authorities if they held that against me while doing nothing to that guy. Take into consideration that this was not the first time--I did cover for that guy several times because I did consider him a friend and a nice guy (outside of work). I also told the program upfront that this had to stop well ahead of the incident, and that I thought they were punishing the residents that actually worked while letting the lazy get away. (You should've seen that day--showdown between me and the chief and an attending who didn't want to deal with the issue).

A person that should also be on top of this is the chief. If the chief doesn't know, and you tried that outlet, then you're going to have to go one rung up, and ask her superior (the PD?).

Another situation is you can talk about the issue with some attendings, and they may be able to intervene. I didn't like pulling out citations and trying to stick it to the man If anything the program can cite citations back at you and make you work harder which was well within their power. You also want to work in an environment where people are doing their part--you included. Sometimes situations like this can be solved by simply making a subtle change, or giving leeway under the table....e.g. a guy who has step 3 coming up in a few days, so his attending told him he could use most of the day studying in the library, and the attending would do more work.

One of the attendings while I at at ARMC inpatient if he noticed I had 10 or more would take up a few for me, and was more lenient if he knew I had something coming up-e.g. the board exam or preparation for a presentation.

 

[DebDynamite]

.........

 

[Faebinder]

The max number of patients in the unit is increasing... hence my outlook. It wont affect me of course.

 

[beezley]

we have 2 different inpatient units and we have up to 6 each on one and 7-8 on the other.

 

[rtennis18]

We cap at 6 patients on inpatient child psychiatry, and up to 8 patients on inpatient adult/geriatric psychiatry units.

 

[aesop]

Psych cap = 5 inpatient w/ poss of up to 2 subacute waiting placement

 

[Anasazi23]

In my first program, I think the cap was 8, but the residents routinely carried up to 12. If a co-resident was out sick or on vacation, your load doubled till they got back.

 

[beezley]

today I had 3 but with one staffing and two family meetings and family phone calls plus 1.5 hours gone for grand rounds, trying to get drugs approved by p harmacy, blah blah blah it was a wild day. I hate that. It makes me wonder how I manage when I have 6-8 but I always do. Wierd.