What is the safe census size for inpatient/ICU

[pgy0246]

Started a job as hospitalist 4 months ago; great coworkers; and consultants

I am concerned about my malpractice exposure with a consistently high census.
My census has been consistently 19-21 while I am here.

In addition, I also have ICU responsibility that means I carry 15-20 ICU patients, while I also see ED patient who's ICU bound.

I spoke with my coworkers at the academic tertiary hospital; who only see 15-16 and that census is divided with a PA/NP.
In my hospital, someone the PA/NP does not write good notes,

I am concerned about the long term malpractice exposure with such 20+ patients daily and ICU responsibility, should I be looking for a new position with a lower census?

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[thumbz]

I'm going to hope and pray that you see the hospitalist patients on a different shift than the intensivist patients?

Big question is if you're admitting - if you are then 19-21 is frankly too many to practice good patient care. If you're not admitting then that's a reasonable number for a 12 hour shift assuming you have a good mix of acuity (not 19 patients with a 1 day LOS).

The ICU number seems ridiculous for a non-intensivist to be covering. That's where you're going to find you're liability issue IMHO.

 

[jdh71]

Started a job as hospitalist 4 months ago; great coworkers; and consultants

I am concerned about my malpractice exposure with a consistently high census.
My census has been consistently 19-21 while I am here.

In addition, I also have ICU responsibility that means I carry 15-20 ICU patients, while I also see ED patient who's ICU bound.

I spoke with my coworkers at the academic tertiary hospital; who only see 15-16 and that census is divided with a PA/NP.
In my hospital, someone the PA/NP does not write good notes,

I am concerned about the long term malpractice exposure with such 20+ patients daily and ICU responsibility, should I be looking for a new position with a lower census?

so how many of your patients are in the ICU on a daily basis?

 

[chessknt]

Also are your ICU patients actually critically ill or are they just there for vascular/neuro checks and not vented on pressors etc?

 

[pgy0246]

we have 16-18 ICU patients
3-4 of which is after the stent/vascular surgery/neurosurgery.
the surgeons put them in ICU because they do not want to be paged by nurse.

also have a critical care training attending that rounds with me in the morning and available till 6pm-9pm
however, my name is on all 18 ICU patients.

 

[chessknt]

we have 16-18 ICU patients
3-4 of which is after the stent/vascular surgery/neurosurgery.
the surgeons put them in ICU because they do not want to be paged by nurse.

also have a critical care training attending that rounds with me in the morning and available till 6pm-9pm
however, my name is on all 18 ICU patients.

So your entire census is icu patients? How many are vented or need Vaso active meds on average? It sounds like you are basically serving as the intensivists np.

 

[CCM-MD]

Question is what is your level of responsibility for the ICU patients.

I have worked as an Intensivist in “consultant” capacity for most of my post fellowship practice. This is how many community hospitals are set up. Relieves the Intensivist of some of the responsibilities of being primary - discharge summaries, transfer orders, med rec etc etc. Hospitalists are primary on paper but reality is when I am managing a sick patient I am running the show and doing everything like I am primary.

If above is the case, then you don’t need to be too worried. There are obvious problems to this set up because sometimes the hospitalist will change **** I don’t agree with and vice versa. Also have a hard time getting hospitalists to move patients out of the ICU sometimes. There is no perfect model, a fully closed model usually doesn’t work well in a non-university hospital setting also.

Now if your role is to manage truly critical patients with minimal support then your exposure medicolegally is probably high.

 

[pgy0246]

So your entire census is icu patients? How many are vented or need Vaso active meds on average? It sounds like you are basically serving as the intensivists np.

out of census of 16-18; 4-5 are on ventilation; which the ICU attending management on weaning.
pressor, such as NE, I usually initiate them on my own without input from critical care specialist;
the only cavent is when patient has cardiogenic shock and GI bleeding, then I called cardiology and ask for ICU attending input

as a new graduate, I do round on ICU with co-management from intensivists; I learned a fair amount of critical care concept, I wouldn't otherwise has known. but my main concern is the long term medical legal consequence of managing critically ill patients for someone without a critical care fellowship training

 

[MedicineZ0Z]

out of census of 16-18; 4-5 are on ventilation; which the ICU attending management on weaning.
pressor, such as NE, I usually initiate them on my own without input from critical care specialist;
the only cavent is when patient has cardiogenic shock and GI bleeding, then I called cardiology and ask for ICU attending input

as a new graduate, I do round on ICU with co-management from intensivists; I learned a fair amount of critical care concept, I wouldn't otherwise has known. but my main concern is the long term medical legal consequence of managing critically ill patients for someone without a critical care fellowship training

You're basically doing what midlevels are doing nationwide in ICUs.

 

[CCM-MD]

You're basically doing what midlevels are doing nationwide in ICUs.

Really? You’re a family medicine intern right? Having read your prior posts I am not going to apologize for my tone here. What you are saying is, based on your extensive knowledge of the utilization of midlevels in ICUs nationwide, you have concluded that they do what was written in the post you quoted? You have concluded that midlevels are independently managing patients with circulatory shock in ICUs nationally and they are seeing 16-18 patients everyday?

 

[MedicineZ0Z]

Really? You’re a family medicine intern right? Having read your prior posts I am not going to apologize for my tone here. What you are saying is, based on your extensive knowledge of the utilization of midlevels in ICUs nationwide, you have concluded that they do what was written in the post you quoted? You have concluded that midlevels are independently managing patients with circulatory shock in ICUs nationally and they are seeing 16-18 patients everyday?

Yes absolutely to the former and no to the latter. I just can't wrap my head around why a board certified IM is questioning their ability to do the type (not volume) of work that a midlevel does.

 

[chessknt]

out of census of 16-18; 4-5 are on ventilation; which the ICU attending management on weaning.
pressor, such as NE, I usually initiate them on my own without input from critical care specialist;
the only cavent is when patient has cardiogenic shock and GI bleeding, then I called cardiology and ask for ICU attending input

as a new graduate, I do round on ICU with co-management from intensivists; I learned a fair amount of critical care concept, I wouldn't otherwise has known. but my main concern is the long term medical legal consequence of managing critically ill patients for someone without a critical care fellowship training

What is the point of you rounding on only ICU patients in addition to the intensivist? usually open ICUs have hospitalists rounding on some of the patients in the ICU but not all of them (or at least not a single hospitalist rounding on all of them). Why would you have a dedicated hospitalist rounding on only ICU patients, but also have an intensivist?

 

[CCM-MD]

Yes absolutely to the former and no to the latter. I just can't wrap my head around why a board certified IM is questioning their ability to do the type (not volume) of work that a midlevel does.

You are wrong.

 

[MedicineZ0Z]

You are wrong.

What part of the country are you in? This stuff heavily varies by the state and there are 180 differences between regions of the country.

 

[deleted547339]

Academic intensivist in a closed icu. My census is usually around 15. Can to you a little, not much. Sometimes a little less. On nights, I’ll cross cover for about 40 and staff new admissions and procedures.

In fellowship, the largest icu teams were 20 - that was probably too many.

 

[CCM-MD]

What part of the country are you in? This stuff heavily varies by the state and there are 180 differences between regions of the country.

Really? I didn't realize that. I just live under my rock. I needed a family medicine intern to educate me on regional variation of "this stuff". Thank you so much.

In addition, you just made my point for me by invalidating what you said previously. I quote, "what midlevels are doing nationwide in ICUs". What you seem to think midlevels do in the ICU is not the norm, and is rather the exception. You are wrong.

 

[MedicineZ0Z]

Really? I didn't realize that. I just live under my rock. I needed a family medicine intern to educate me on regional variation of "this stuff". Thank you so much.

In addition, you just made my point for me by invalidating what you said previously. I quote, "what midlevels are doing nationwide in ICUs". What you seem to think midlevels do in the ICU is not the norm, and is rather the exception. You are wrong.

Aren't you Canadian? Pretty tasteless to be condescending on family medicine; who are more well respected there.

And dude, right is right/wrong is wrong. I don't care if you have 50 years experience in 5 different specialties. Deferring accuracy to one's position is literally the worst argument of all time for why you're right. I'm only stating what I've seen from rotating in different parts of the country. And what many others are seeing. Lots of previous threads on this exact topic too.

 

[CCM-MD]

Aren't you Canadian? Pretty tasteless to be condescending on family medicine; who are more well respected there.

And dude, right is right/wrong is wrong. I don't care if you have 50 years experience in 5 different specialties. Deferring accuracy to one's position is literally the worst argument of all time for why you're right. I'm only stating what I've seen from rotating in different parts of the country. And what many others are seeing. Lots of previous threads on this exact topic too.

Not bashing your specialty. I was stating your level of training and specialty in the context of your essentially claiming to be the authority on nationwide ICU midlevel practice. To be honest, a few of us are tired of your countless posts containing misinformation. I had to call you out.

If I am using my position to support what I am saying, how are you doing any different? You're using your extensive experience as a medical student rotating in various ICUs in various parts of the country to support this flawed view of how ICU midlevels practice nationally. We are supposed to believe yours instead of mine? How have you amassed such an extensive knowledge in ICU midlevel practice experience in different geographical locations of the United States as a medical student? Even if your entire 4th year ICU rotations, your level of understanding of what is happening in the ICU as a medical student makes one question what you are saying. Things are not always as they seem when you are a medstudent, as much as it may look like bedside nurse is hanging a vasoactive agent, and the pharmacist dispensing it, and the midlevel is the one placing the order, the actual decision making process might be happening behind the scenes by a physician. Stating and believing something like ICU midlevels are managing patients with circulatory shock with vasoactive agents independently in ICUs nationally without input from a physician is just not true.

 

[Splenda88]

Started a job as hospitalist 4 months ago; great coworkers; and consultants

I am concerned about my malpractice exposure with a consistently high census.
My census has been consistently 19-21 while I am here.

In addition, I also have ICU responsibility that means I carry 15-20 ICU patients, while I also see ED patient who's ICU bound.

I spoke with my coworkers at the academic tertiary hospital; who only see 15-16 and that census is divided with a PA/NP.
In my hospital, someone the PA/NP does not write good notes,

I am concerned about the long term malpractice exposure with such 20+ patients daily and ICU responsibility, should I be looking for a new position with a lower census?

Are you managing 19-21 floor patients PLUS 15-20 ICU patients? If this is the case, may God be with you.

 

[pgy0246]

15-20 ICU patient; at the beginning of the day
2-3 ER direct admits during the day; and respond to rapid response on the floor

no floor patient while on ICU; except the rapid response and code blue
also have ICU attendings, but then often time intensivist left the hospital after 5pm

having talked to friends with work in large tertiary care with PA who see 1/3 of his census of 14-16, I was told census of 18-20 and ICU responsibility is a malpractice time bomb

 

[Splenda88]

15-20 ICU patient; at the beginning of the day
2-3 ER direct admits during the day; and respond to rapid response on the floor

no floor patient while on ICU; except the rapid response and code blue
also have ICU attendings, but then often time intensivist left the hospital after 5pm

having talked to friends with work in large tertiary care with PA who see 1/3 of his census of 14-16, I was told census of 18-20 and ICU responsibility is a malpractice time bomb

Did you talk to any physician at all before signing that contract?

You should not renew that contract even if you are getting paid well. It's not worth it.

 

[rokshana]

15-20 ICU patient; at the beginning of the day
2-3 ER direct admits during the day; and respond to rapid response on the floor

no floor patient while on ICU; except the rapid response and code blue
also have ICU attendings, but then often time intensivist left the hospital after 5pm

having talked to friends with work in large tertiary care with PA who see 1/3 of his census of 14-16, I was told census of 18-20 and ICU responsibility is a malpractice time bomb

Absolutely agree...that census is not safe...for you or the patients.

 

[Chemist0157]

This setup does not make much sense to me. I do not understand why as a hospitalist, you are primary on so many ICU patients and have critical care as consultants. Here, the critical care docs for the most part take over primary role until patients are ready for the floor. I will have ICU patients and be listed as primary, but I almost always consult critical care and let them run the critical care aspects for my patients while I focus on my specialty. I think that is the safest way to do things as that is their training, and I do not want too many cooks in the kitchen so to speak.

Maybe at a smaller hospital ICU patients are not quite so sick, but that is a hefty census from my understanding. That would be out of my comfort zone.

 

[jdh71]

This setup does not make much sense to me. I do not understand why as a hospitalist, you are primary on so many ICU patients and have critical care as consultants. Here, the critical care docs for the most part take over primary role until patients are ready for the floor. I will have ICU patients and be listed as primary, but I almost always consult critical care and let them run the critical care aspects for my patients while I focus on my specialty. I think that is the safest way to do things as that is their training, and I do not want too many cooks in the kitchen so to speak.

Maybe at a smaller hospital ICU patients are not quite so sick, but that is a hefty census from my understanding. That would be out of my comfort zone.

What I don’t understand is that this hospital sounds like it doesn’t have general medical beds. Just an ICU. None of the description makes much sense to me.

 

[pgy0246]

we have 7 other inpatient services (cardiology, oncology, surgery, respiratory, general medicine)
but the older doctors don't want to do ICU; so they put me and 2 other new hires to staff the ICU.