What's your bed:resident ratio?

[Hercules]

Hey guys and girls,
What do you think is a reasonable amount of resident coverage in your ED? When are you really booking it? I thought I'd use a beds to resident ratio, so we could compare the smaller and larger EDs equally.

Our program runs anywhere from 16 to 11. 16 beds per resident can feel pretty overwhelming to me. 11 is not too bad unless all hell breaks loose.

What kind of coverage do you have in your ED?

Looking over my past threads I think I do far too many of these program surveys, but it's nice to get an idea of everyone else's programs.

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[GeneralVeers]

At MLK the interns would see the bulk of the patients and the seniors would "supervise". It came to about 10:1 for the interns.

In Corpus Christi we will have two residents on shift, and it will average about 8:1, which is pretty reasonable.

 

[Dr.Evil1]

We kind of run a system where there is NO maximum beds. The patients just keep coming, even if we don't have an actual bed for them. Our residents each staff a module sometimes with an attending in each module, sometimes attendings cover 2 modules. Modules all have 15-18 bed spots in them. We also have an obs area for stable patients who are waiting for something. We also run a 29 min. guarantee so we have to see all the patients within 29 min of their arrival. Sometimes it is bad, on Friday night we were rocking and the modules each had 20-22 patients in them. That is really rare though. Usually there is between 8-14 patients in the module at any one time. During an 8 hr shift I usually see between 14-24 patients, usually anything over 18 I consider busy.

 

[southerndoc]

We kind of run a system where there is NO maximum beds. The patients just keep coming, even if we don't have an actual bed for them. Our residents each staff a module sometimes with an attending in each module, sometimes attendings cover 2 modules. Modules all have 15-18 bed spots in them. We also have an obs area for stable patients who are waiting for something. We also run a 29 min. guarantee so we have to see all the patients within 29 min of their arrival. Sometimes it is bad, on Friday night we were rocking and the modules each had 20-22 patients in them. That is really rare though. Usually there is between 8-14 patients in the module at any one time. During an 8 hr shift I usually see between 14-24 patients, usually anything over 18 I consider busy.

29 minute guarantee?

What happens if you break that? Free ED visit, free pizza, you do a little song and dance for them?

 

[deleted87716]

29 minute guarantee?

What happens if you break that? Free ED visit, free pizza, you do a little song and dance for them?

I've wondered that, as well. One of our local health systems is doing a big advertising blitz about their "30 minutes from door to doctor" guarantee in their EDs. I wonder how many patients actually time them? Basically, doesn't a doc just have to show up within 30 minutes to have fulfilled the terms of the guarantee? They're not promising to actually do anything within that timeframe, and you could still end up being there for eight hours anyway. Frankly, I don't see the point...it's actually kind of insulting, in a way.

 

[Apollyon]

We kind of run a system where there is NO maximum beds. The patients just keep coming, even if we don't have an actual bed for them. Our residents each staff a module sometimes with an attending in each module, sometimes attendings cover 2 modules. Modules all have 15-18 bed spots in them. We also have an obs area for stable patients who are waiting for something. We also run a 29 min. guarantee so we have to see all the patients within 29 min of their arrival. Sometimes it is bad, on Friday night we were rocking and the modules each had 20-22 patients in them. That is really rare though. Usually there is between 8-14 patients in the module at any one time. During an 8 hr shift I usually see between 14-24 patients, usually anything over 18 I consider busy.

I'm guessing you're at Detroit Receiving, right? If it is, the guarantee is a pair of tickets to a Tigers game if the patient isn't seen within 29 minutes.

edit: I didn't look at your location!

 

[EM2BE]

I have never seen such a guarantee. So, all it guarantees is that the dr will walk in and talk to them within 30 min?

 

[EctopicFetus]

First time i saw this was in Detroit, but I when I was in miami I saw it for one of the local places there as well. Seems dumb and desperate to me.

 

[EctopicFetus]

we have about 40-45 beds we have 3 ed residents at all times and from 1-10 we have another ED resident. Other than that we sometimes have others but thats the core.

 

[FISKUS]

I am curious as to the attending to bed ratio - There are some EDs that have one attending overseeing 4-5 residents and 30 beds. Others have 3 attendings for the same numbers.

Comments?

 

[EctopicFetus]

For us we never have more than 2 attendings. Urgent care has one attending for 9 rooms. Thats not included in the previous quote.

 

[dchristismi]

We have 42 (I think) acute beds, including the trauma bay, staffed by 3-4 EM residents (the fourth may be a medicine resident or another EM). Two attendings cover the area. I'm not counting the hallway.

Our 12 bed flex care is either a PA/NP or 1 resident. One of the acute attendings covers it.

Our separate peds ED currently runs 20 beds. When it's fully open, I think it has 36, but it's being opened in stages as it's brand new. Two residents, although one may be a peds resident, most of the day, with only one 3a-7a.

Or something like that.

 

[Seaglass]

About 1:8 for us.

 

[USCDiver]

We have two 'sides' in our ED both with approx 22 beds open (the acute side has 3 resusc bays and can open an additional 9 beds if we have nursing staff).

Each side has between 1 and 3 ED residents plus 1-2 off service residents depending on the hour of the day.

So ratio wise, we're 1:22 to ~1:7

 

[kbrown]

I don't know about the Main ED at the above hospital, but I know that the Children's Hospital associated with it Does Not adhere to the 29 min guarantee, they couldn't. I was there in Feb (RSV season) and pts routinely waited 2 hours to be seen. Now peds has true seasonal variability and this particular hosp has >90K peds visits/yr (so they are busy as hell all the time) but the whole 29min thing seems completely unrealistic. Crap for the residents and crap for the pts.
I tried hard to comply with their guarantees while I worked there, but the pts wouldn't even get out of triage until 1hr and 45 min later. The staff had even given up on the idea of 29 min.

 

[GeneralVeers]

I don't know about the Main ED at the above hospital, but I know that the Children's Hospital associated with it Does Not adhere to the 29 min guarantee, they couldn't. I was there in Feb (RSV season) and pts routinely waited 2 hours to be seen. Now peds has true seasonal variability and this particular hosp has >90K peds visits/yr (so they are busy as hell all the time) but the whole 29min thing seems completely unrealistic. Crap for the residents and crap for the pts.
I tried hard to comply with their guarantees while I worked there, but the pts wouldn't even get out of triage until 1hr and 45 min later. The staff had even given up on the idea of 29 min.

If a residency program had to abide by a hospital's arbitrary marketing ploy of 29 minutes, that would be a program I would never consider being a part of.

 

[Dr.Evil1]

You guys are making such a big deal out of this 29 min. guarantee thing. Yes basically it means that I walk to their bedside and at least start to talk to them. Yes, sometimes it is "Hello, I'm Dr. Evil, what's going on?" give them 2 seconds, then "OK well I have to run right now but I'll be back in a few min. in order to talk to you more". In situations where we are busy in a code etc. they just wait or someone will pop out in order to say hello for a second. During the RSV season the children's ED doesn't see everyone though in 29 min. We do see >80% of patients at our children's hospital and >95% of the patients at our main hospital within the 29 minutes though.

It is a whole different approach to the ED then I guess some of you are used to. You don't pickup charts when you have time to see a new patient, they just keep showing up, sick or well and it is your job to take care of all of them. Very few people leave the ED without being seen. If the people are there sitting in your face you feel more responsible for taking care of them. Yes there are times when I feel like I am more concerned about getting to the appropriate dispo rather than figuring out exactly what is wrong with them. But that is part of Emergency medicine.

You might think that it is desperate but you guys might not realize that Michigan and particularly Detroit is in a major recession right now. Things haven't gotten better over the last few years. There are market forces at work right now that are making things difficult for the hospital that I work at. It is how it is and I feel like I have to see alot of patients. Hopefully it will make me a better and more efficient doctor once I am done.

 

[waterski232002]

So ratio wise, we're 1:22 to ~1:7

1:22 ? Come on... There's no way a resident can effectively see 22 patients at once. Even if you had no new patients in an entire hour, that would give you 2 min 43 sec to check on each patient, follow up labs, look up x-rays, explain results, and dispo each patient (not including extra time to staff with attendings, call admitting services, take a piss, do an occasional procedure, talk to paramedics, etc...)

I smell smoke....

 

[TraumaCheers]

1:22 ? Come on... There's no way a resident can effectively see 22 patients at once. Even if you had no new patients in an entire hour, that would give you 2 min 43 sec to check on each patient, follow up labs, look up x-rays, explain results, and dispo each patient (not including extra time to staff with attendings, call admitting services, take a piss, do an occasional procedure, talk to paramedics, etc...)

I smell smoke....

I agree. Let's quantify this discussion a little, because there certainly seems to be a little liberty taken with respect to how many patient you have!

Having 10 patients at once where 4 are admitted and waiting for beds with nothing to do, 3 are waiting for consults for neurosurgery but are otherwise stable and one that is just cooking with some labs is a lot less taxing then even having two patients who have just been intubated, pan labbed, pan CT'd and on pressors.

At our place, there is approximately 15-18 beds on each of two sides. There is usually an attending, a senior resident and an intern or off-service resident and sometimes an extra off-service. Usually, the senior takes a disproportionate load -- so maybe of the 18, the senior might have 10, and the intern and off-service 4 each. But rest assured, if the trauma room is busy or there are several unstable and v. sick patients, not even the senior resident truly is "looking after" 10 patients! Oh sure, I might have my eye on 10, but 6 of 'em are just cookin'.

This talk of 22 patients per resident is either a place with many many borders, extremely low acuity (although even in a strictly urgent care this would be a huge number and quite impossible) or, more likely, we have gotten into our usual pissing contest on the board and talking about the fish we caught which is 'this big'!

 

[Jeff698]

I agree. Let's quantify this discussion a little, because there certainly seems to be a little liberty taken with respect to how many patient you have!

I think the problem likely is in our differing understanding of the question being asked. I think Driver was reporting on how many 'beds' a particular resident might, in theory, have to cover. This may be different than how many patients he has to take care of in down times where there are more beds than patients. It would likely be appropriate to downstaff during these times with fewer residents. The bed:resident ratio would be high but the actual workload not so much.

Or perhaps I misunderstood as well.

Our place is in flux with a new department that doubled the number of beds we had. We're honestly still trying to figure out how best to cover it. We have 47 beds with a max of 6 residents on at a time. The way things actually work most of the time, though, we have less coverage.

One area always has a senior and an intern covering 17 rooms. Another has a minimum of an upper level (PGY2 or 3) covering 16 rooms, frequently without an intern. The third has between one and two upper levels covering 15 rooms. Each 'pod' has two major resuscitation rooms. The 15 room pod has staggered coverage with each resident covering their rooms for several hours of their shift by themselves.

We do 12 hour shifts and see between 24 and 34 patients a shift, depending on the accuity that comes through the door and efficiency of the resident, faculty, consultants, nurses, janitors cleaning ER and floor rooms, transport, lab, etc, etc, etc.

Our interns have been carrying between 6 and 10 patients at a time, our second years between 8 and 15 at a time and third years between 8 and 10. As a second year, I probably average about 8-10 patients at a time. Regardless of how efficient you are, throughput drags to a halt when you get more than about 8-10 active patients at a time.

This is a question we're working with alot right now. While it can be painful, it is also useful to our education. This is the crux of emergency medicine (juggling multiple patients and being having our efficiency seriously influenced by almost every other individual in the hospital). I think dealing with it during residency is useful and something that I won't get from Tintinnali.

Take care,
Jeff

 

[EctopicFetus]

Jeff,

Seriously in 12 hours you can see 24-34 patients? Almost 3 per hour? This is damn near impossible IMO. The only thing I can imagine is that you have low acuity if you see that many. I can see 25 in urgent care in about 9 hours but thats urgent care. Not people needing central lines, intubations having STEMIs and other sickos. Please elaborate.

 

[southerndoc]

1 resident covering 22 patients? Doesn't the RRC cap the number of patients a resident may carry at one time on average?

We have two sections. Our staffing is varied. Each section has a critical care area and a central area for less acute patients. Fast track patients are sent to a separate area managed by the PA's and NP's.

Each section has at least 2 residents covering the central area (with an exception between 2a-11a where 1 resident covers one section and 2 residents cover another primary section during the night except for 7a-11a). In addition, there is a critical care resident covering each critical care area. One section has a senior EM resident (PGY-3 or 4) covering critical care and trauma airways during the day as the other section's senior resident covers full traumas, and the other critical care section has a PGY-2 medicine or EM person.

There is 24/7 senior (PGY-3 or 4) coverage on the north central area where the senior functions in a true supervisory role. The senior manages full trauma responses during the day, and during the night manages the trauma airways. This section also has a dedicated EM resident on at night to manage modified trauma responses.

Each section has dedicated attendings with overlapping coverage. Between 2 am and 9 am there is only one attending on duty. At peak times, there are 4 attendings on duty briefly. North critical care has a dedicated attending from 11a-8p (busiest times), north central has an attending 24/7 (that covers critical care from 8p-11a), south central and critical care have attendings from 7a-2a, but only a few hours of that is dedicated to critical care. (The theory is that senior residents do not need a dedicated attending coverage, so the central attendings see the critical care patients with the seniors.)

It's very confusing how our schedule is set up. At peak times, there may be 3 central residents + 1 critical care resident on each pod with a dedicated senior resident on the north pod. The north senior sees all patients and functions only as a supervisor of junior residents. It's primarily designed to teach a senior resident how to be an effective supervisor and teacher.

Usually residents will see about 15-20 patients during a shift with about 6-10 carried at one time, including admitted patients. The critical care persons average around 12 patients per shift, although this is highly varied (the evening shift may see only 6 patients and the day shift may see 20). The critical care areas have very high acuity with the resident getting frequent procedures and ICU admissions.

 

[Dr.Evil1]

If a residency program had to abide by a hospital's arbitrary marketing ploy of 29 minutes, that would be a program I would never consider being a part of.

I seriously doubt the validity of that statement.

 

[GeneralVeers]

I seriously doubt the validity of that statement.

True. Beggars can't be choosers.

 

[TraumaCheers]

I think the problem likely is in our differing understanding of the question being asked. I think Driver was reporting on how many 'beds' a particular resident might, in theory, have to cover. This may be different than how many patients he has to take care of in down times where there are more beds than patients. It would likely be appropriate to downstaff during these times with fewer residents. The bed:resident ratio would be high but the actual workload not so much.

Or perhaps I misunderstood as well.

Our place is in flux with a new department that doubled the number of beds we had. We're honestly still trying to figure out how best to cover it. We have 47 beds with a max of 6 residents on at a time. The way things actually work most of the time, though, we have less coverage.

One area always has a senior and an intern covering 17 rooms. Another has a minimum of an upper level (PGY2 or 3) covering 16 rooms, frequently without an intern. The third has between one and two upper levels covering 15 rooms. Each 'pod' has two major resuscitation rooms. The 15 room pod has staggered coverage with each resident covering their rooms for several hours of their shift by themselves.

We do 12 hour shifts and see between 24 and 34 patients a shift, depending on the accuity that comes through the door and efficiency of the resident, faculty, consultants, nurses, janitors cleaning ER and floor rooms, transport, lab, etc, etc, etc.

Our interns have been carrying between 6 and 10 patients at a time, our second years between 8 and 15 at a time and third years between 8 and 10. As a second year, I probably average about 8-10 patients at a time. Regardless of how efficient you are, throughput drags to a halt when you get more than about 8-10 active patients at a time.

This is a question we're working with alot right now. While it can be painful, it is also useful to our education. This is the crux of emergency medicine (juggling multiple patients and being having our efficiency seriously influenced by almost every other individual in the hospital). I think dealing with it during residency is useful and something that I won't get from Tintinnali.

Take care,
Jeff

You have INTERNS taking up to 10 patients??? Are you kidding me? So you're telling me someone with less than a year of experience in medicine is capable of handling the initial history, doing a full, comprehensive examination, typing the history into the computer, getting the nurses to get blood, urine, put the patient on a monitor, order tests, interpret tests, get xrays/CTs/ etc., interpret the radiology and 'confirm' it with rads, decide who goes/who stays and call the admit consult, staff with a senior or attending, and all the other things that can and do go wrong, to say nothing of frequent re-evals.... on multiple patients -- what, at least 5 assuming that even up to half of the '10' are people that might be waiting for a bed and essentially have nothing to do?

I mean, I just don't see how it's possible! Unless some (most?) of these patients are so low acuity that they don't need labs and rads.

Jeff, I'm really not trying to flame you or anything... I'm just thinking that as I, about to enter my senior (PGY-3) year of EM, think of an intern doing this at the level you describe, either I (and the other people in my class) are totally behind the curve in terms of speed or else we just have way higher acuity than realized compared to some places...

 

[Jeff698]

You have INTERNS taking up to 10 patients??? Are you kidding me?

Nope. Not kidding and our accuity is not anywhere close to being low. Plenty of central lines and intubations to go around. Keep in mind though, this is the end of the year. Next month, our interns will be carrying 1-3 patients at a time. As with most places and class years, we start handling more patients as we progress through the year.

Having said that, in June, it is not unusual for our interns to have 10 patients at a time. Please understand that this is not bragging. When they're sitting on 10 patients (with maybe 6-8 active, ie not dispo'd), there is no hint of moving meat. Hell, the meat begins to get stagnant. At that pace, they won't be turning their rooms over all that fast.

Someone else asked about the PGY2s seeing 24-34 patients in a 12 hour shift. Again, remember this is June. I'm one of our slower guys. My max is 33 in 12. I'll see 22-25 pretty regularly. Actually, if I see under 22, I feel like I had a pretty easy shift. Our faster guys have broken 40 and, yes, the accuity on those days dropped pretty significantly but they still saw some truly sick folks on those days.

We got rid of our urgent care when we moved to our new department so each resident now gets the full spectrum of patients. It isn't unusual to have a septic, intubated, central lined patient, a couple of ACS patients, a geriatric belly pain, a low back pain, a sore throat and a couple of snotted kids at a time.

Our PGY3s usually drop down in patient load since they are always guaranteed of having an intern while the PGY2 may be swinging solo. The 3s act as teaching resident early in the year while the 'terns are learning to fly.

Please understand, though, that carrying 15 patients is not a good thing. It is happening temporarily at our shop because we doubled our room count, increased our volume by about 20% and are still trying to figure out how to compensate. We're slowing improving and that number should decrease.

Take care,
Jeff