What's a normal/reasonable patient load?

[epsilonprodigy]

What's a normal/safe number of patients for an intern at this point in the year?

I carry 20-25 ICU patients; on the floors, it's usually around 40. I have to say, especially with this silly sign out/night float system we have, it feels very unsafe.


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[Raryn]

Are you talking about as primary or cross covering at night? If you're primary, the numbers you describe are well above the caps that IM interns have. In fact, they sound unsafe regardless of the service. I know that surgical services routinely see larger numbers of patients than medicine, but no intern in the hospital at any ACGME accredited program I'm aware of is responsible to write 40 notes.

If that's not primary but it is cross cover (which your night float comment makes me suspect), then yeah, that's perfectly normal. An intern cross covering 40, 50, 60 or even more floor patients overnight is typical. Most of the time they're also responsible for some proportion of the admissions/consults that night as well. As long as there's an upper level in house to help, I don't see a problem.

 

[J ROD]

Yeah, I handle around that number on cross coverage. Cant speak for ICU and nights. Have not done those yet. And I had to see and admit new patients. With senior support.

I do have to do 24 notes on weekends when 2 interns cover our inpatient Psy unit. We split the unit. It sounds like a lot but they are Psy notes and not nearly as complicated. But still more than most Psy programs do.

 

[AdmiralChz]

That's a pretty typical load for surgery

Yeah, encountered that on a few of the rougher surgical rotations during internship. I wouldn't say it's optimal patient care.

In fact, as catastrophic events have happened on the floor on the huge services (acute care surgery, vascular) they have been forced to either add an extra intern to share the load (during the day) or hire an extender. Nights are still rough, but thankfully the majority of patients have a set plan for the night requiring minimal effort on the intern's part.

 

[Raryn]

That's a pretty typical load for surgery

There's surgery interns who are primary for 40 patients? As in they write 40 progress notes?

 

[ThoracicGuy]

There's surgery interns who are primary for 40 patients? As in they write 40 progress notes?

Surgery notes are far less detailed than IM notes... They probably have students to help as well plus a midlevel resident. When I was in residency (partially before EMR), we wrote the notes as we rounded.

 

[Raryn]

Sounded to me like they were talking about night coverage. Many/most surgery programs don't really do the "primary" resident thing. There's a team of interns (plus midlevels) who collectively take care of all the patients during the day, then at night whoever is on call takes care of all of them

Right. The numbers described sound appropriate for the night cross cover person.

But would be absurdly high for the day person actually responsibly for the majority of the patients care.

 

[gutonc]

But would be absurdly high for the day person actually responsibly for the majority of the patients care.

But, again...very typical for a surgery census.

 

[MLT2MT2DO]

But, again...very typical for a surgery census.

But again, we're guessing you're not taking primary?

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[akwho]

For surgery and cross cover at night.
SICU: 40 patients, fellow in house a phone call away, on call team admits and writes initial ICU orders.
Ortho: 90 patients in house, I bust my ass to help the on call admit and see new consults


I'm not "primary" on any of them, but I treat them like they are my "primary" because I think it leads to better outcomes.

 

[evilbooyaa]

40 patients on a service hopefully means 2 interns or help from the junior in terms of writing daily notes. However, there are days of 25-30 notes in the morning on busy, poorly managed services.

 

[gutonc]

But again, we're guessing you're not taking primary?

I'm not primary on anybody. I chose my specialty better than that.

 

[epsilonprodigy]

Uh no. I am talking about being primary on the vast majority of these patients-like, 2 of them are consults. It's split up so the night person writes notes (yep, all 40) and the day person does procedures, rounds, consults, discharges, etc. there's a lot of bickering about signout, because due to tume constraints, the night person can't give a good, detailed list/note, so day person doesn't know squat for rounds, and day person can't help but sign out a ton to night person for the same reason.

Also, not a student in sight. +\- a mid level occasionally.


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[Raryn]

Uh no. I am talking about being primary on the vast majority of these patients-like, 2 of them are consults. It's split up so the night person writes notes (yep, all 40) and the day person does procedures, rounds, consults, discharges, etc. there's a lot of bickering about signout, because due to tume constraints, the night person can't give a good, detailed list/note, so day person doesn't know squat for rounds, and day person can't help but sign out a ton to night person for the same reason.

Also, not a student in sight. +\- a mid level occasionally.


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Sounds like ****ty patient care and even worse education.

The person rounding should be the one writing notes, otherwise the dedicated note person is just a scut-monkey. Also, that's just asking for things to get missed and patients to be hurt. Even for surgical patients.

 

[AdmiralChz]

Sounds like ****ty patient care and even worse education.

The person rounding should be the one writing notes, otherwise the dedicated note person is just a scut-monkey. Also, that's just asking for things to get missed and patients to be hurt. Even for surgical patients.

Agree, it was this case on a couple services until a couple NPO orders were missed for surgery and admits were completely missed after initial consult note leading to a couple sentinel events. Now these services have more interns and more extenders to help. It's dangerous to have that many patients at once, to be honest.

 

[evilbooyaa]

Uh no. I am talking about being primary on the vast majority of these patients-like, 2 of them are consults. It's split up so the night person writes notes (yep, all 40) and the day person does procedures, rounds, consults, discharges, etc. there's a lot of bickering about signout, because due to tume constraints, the night person can't give a good, detailed list/note, so day person doesn't know squat for rounds, and day person can't help but sign out a ton to night person for the same reason.

Also, not a student in sight. +\- a mid level occasionally.


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Why is the night person writing notes? That's literally the main job of the day intern. Night shift cross-covering 40 patients to put out fires and deal with nursing calls is fine. Night shift writing 40 progress notes for the next day is beyond stupid, and the day intern writing 40 notes (while possible) probably isn't the best idea, but if the residency prioritizes working interns to the bone with no education or help for a service of that size (with a 2nd intern, PA, or help from the junior on service), that's feasible.

Part of why people write notes in the morning is so they know what happened with their patient so they can present on rounds. Having gone through a surgical year last year, I can't imagine the night person writing 40 notes (they're busy cross-covering multiple services, dealing with consults/admits, and putting out fires overnight), signing that list out to me, and me looking like anything except a complete ****** on rounds.

Sounds like an institutional problem to me, OP.

 

[Psai]

Why is the night person writing notes? That's literally the main job of the day intern. Night shift cross-covering 40 patients to put out fires and deal with nursing calls is fine. Night shift writing 40 progress notes for the next day is beyond stupid, and the day intern writing 40 notes (while possible) probably isn't the best idea, but if the residency prioritizes working interns to the bone with no education or help for a service of that size (with a 2nd intern, PA, or help from the junior on service), that's feasible.

Part of why people write notes in the morning is so they know what happened with their patient so they can present on rounds. Having gone through a surgical year last year, I can't imagine the night person writing 40 notes (they're busy cross-covering multiple services, dealing with consults/admits, and putting out fires overnight), signing that list out to me, and me looking like anything except a complete ****** on rounds.

Sounds like an institutional problem to me, OP.

Totally agree. 40 floor patients and 20-25 icu patients is completely unreasonable. You would barely have time to copy/paste all those notes, never mind think about people critically and take good care of them. Even half that number is a lot.

 

[evilbooyaa]

Totally agree. 40 floor patients and 20-25 icu patients is completely unreasonable. You would barely have time to copy/paste all those notes, never mind think about people critically and take good care of them. Even half that number is a lot.

I will say that 20ish surgery notes, while not necessarily the norm on most days, was a possible day depending on the service and if the junior or other intern had a day off, etc. The one saving grace is that for most simple post-op patients, it's all the same - advance diet, pull Foleys, AROBF if a complicated surgery. Versus the medicine notes I saw colleagues right which were just filled with so much crap day in and day out.

 

[epsilonprodigy]

I think it's ridiculous. The night person is not only a scut monkey, they're a scapegoat- everything's by from ordering labs to following up on consult notes (no easy feat when we're partially on paper) to notes falls to them. Then, the one who actually examines the patients isn't there in rounds, and they're not there to defend themselves either, when things inevitable get missed. Also, yes, the day person is clueless. I've found that there's really no way around prerounding when you're on days, because there simply isn't time for the night person to get a decent signout together. Of course, this defeats the whole purpose of night float, which is supposed to be for work hour restrictions.


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[WheezyBaby]

Uh no. I am talking about being primary on the vast majority of these patients-like, 2 of them are consults. It's split up so the night person writes notes (yep, all 40) and the day person does procedures, rounds, consults, discharges, etc. there's a lot of bickering about signout, because due to tume constraints, the night person can't give a good, detailed list/note, so day person doesn't know squat for rounds, and day person can't help but sign out a ton to night person for the same reason.

Also, not a student in sight. +\- a mid level occasionally.


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Don't really have much more to say about that. Nonsensical. We have an ICU service where interns have been primary for up to 20 (though numbers quite that high aren't typical), but staff is available and can pick up slack as necessary (and is good about doing so).

 

[Psai]

Don't really have much more to say about that. Nonsensical. We have an ICU service where interns have been primary for up to 20 (though numbers quite that high aren't typical), but staff is available and can pick up slack as necessary (and is good about doing so).

1 intern tho? Maybe 4 or 5 interns depending on patient complexity imo

 

[evilbooyaa]

I think it's ridiculous. The night person is not only a scut monkey, they're a scapegoat- everything's by from ordering labs to following up on consult notes (no easy feat when we're partially on paper) to notes falls to them. Then, the one who actually examines the patients isn't there in rounds, and they're not there to defend themselves either, when things inevitable get missed. Also, yes, the day person is clueless. I've found that there's really no way around prerounding when you're on days, because there simply isn't time for the night person to get a decent signout together. Of course, this defeats the whole purpose of night float, which is supposed to be for work hour restrictions.


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I don't get how any residency in the world thought that was a good idea. Needs more extenders or juniors/additional interns needs to help cover the additional census. The day resident SHOULD be pre-rounding on all of the floor patients that he/she will be presenting going forward. I would bring it up at any resident meetings or meetings with the PD that you have.

How does the night resident get all of the day resident's work done as well as dealing with patient issues along with new consults and admits at night?

The day resident should be ordering labs for the next day. The day resident should be following up on consult recommendations, either the afternoon the consult is placed, or the next morning prior to rounds, or getting ready for an ass-kicking as to why the cardiology consult that was discussed in rounds yesterday AM still hasn't been done by Cardiology.

 

[gutonc]

Well that sounds like it sucks.

But, in answer to the OP's original question of what is a "normal" or "reasonable" patient load?

It's whatever your program tells you it is.

General surgery doesn't have caps or admit rules like medicine. So there isn't much else to do except suck it up and try to get the work done as best you can.

It's definitely not good or safe patient care. But, as Southern points out...it's "normal" for the situation.

 

[WheezyBaby]

1 intern tho? Maybe 4 or 5 interns depending on patient complexity imo

It was 1 intern. I actually just heard it changed to a 2 intern service this month though

 

[QofQuimica]

When I was on ICU nights as a resident, if we had time, we would start all the daily progress notes after midnight and summarize the overnight events for the day team in the subjective sections. But the day team did the exams, assessments, and plans. And we still had a signout.

Getting back to OP's question, unfortunately, SS is right: as a resident, "normal" is what your program says is "normal." If you have a sympathetic upper level or chief, I would suggest asking them for any tips they might have to improve your work flow. But beyond that, all you can do is dance as fast as you can, and be glad that intern year is already 1/3 over. :-/

 

[epsilonprodigy]

Here's the best part: this back-asswards system came about because there used to be only ONE tern on service. They would have to pre-round and write notes in the morning on all 40 patients AND do all the day stuff. When the "no 24-hour shifts" rule was born, there was practically rioting in the streets- obviously pre-rounding on that many patients means getting there at like 3 am every day, and writing that many notes paired with discharges and procedures means staying until God knows when. IMO, the reasonable thing to do is have a second intern on days so that notes can be done by the people who round, and then having one night person to put out fires. Would be better for morale and patient care.

I really like my co-residents, but we snipe at each other a lot because everyone is constantly taking the hit for someone else's oversight, even though we all know that it's just an issue of time and trying to prioritize the actual safety stuff.


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[shoal007]

SICU weekends as a intern, we had to cover 20-25 patients with 1 intern. Id get there at 4am. preround to 7am and then attendings would get pissed why my hand written notes had not been completed when i had 6 minutes to grab vitals, grab labs, see the patient and talk to nurses and figure what the **** was going on with the patient. very unsafe and really not reasonable. If you had one patient crashing, forget it. it was all over.

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