Hospitalist Understaffing Hurts Patient Care, Study Says

January 28, 2013

Thirty-six percent of hospitalists report shouldering an unsafe load of patients more than once a week, leading to poor communication, treatment errors, potentially unnecessary tests, sloppy handy-offs, and sometimes complications and death, according to a new study published online January 28 in JAMA Internal Medicine.

Other studies have uncovered the deleterious effects of understaffing when it comes to residents and nurses, lead author Henry Michtalik, MD, MPH, MHS, and coauthors write. They set out to determine whether there is a similar association between patient safety and the workload of attending physicians. To do that, they surveyed 890 self-identified hospitalists who belong to, an online physician community. Almost 60% responded.

The online survey asked the hospitalists to evaluate only their standard daytime shifts. The physicians said they could safely care for 15 patients per shift — the number of hours per shift was not specified — as long they were engaged in only clinical duties.

Using this rule of thumb, 40% of the hospitalists said their typical inpatient census exceeded safe levels at least once a month, whereas 36% said it happened more than once a week.

Unsafe workloads often or very often had consequences, as the hospitalists reported using a Likert scale:

  • 25% percent failed to fully discuss treatment options with or answer questions from patients and family members;

  • 22% ordered potentially unnecessary tests, procedures, diagnostic imaging, and consultations because they lacked the time to adequately assess the patient in person;

  • 19% said patient satisfaction soured;

  • 18% said an excessive inpatient census marred the quality of patient hand-offs; and

  • 7% committed a treatment or medication error.

In addition, unsafe workloads often or very often led to adverse events:

  • transfers to higher levels of care (10%),

  • morbidity or complications (7%),

  • incident reports filed by the physician or someone else (6%), and

  • death (5%).

"I Wouldn't Pay Too Much Attention to the Percentages"

In light of these findings, Dr. Michtalik and coauthors recommended that hospitals should routinely study the workloads of attending physicians, create standards for what constitutes a safe workload, and develop ways to keep a physician's inpatient census at a manageable level.

The authors also urged third-party payers, providers, and researchers to find ways to reduce costs that do not hurt patient care. When insurers cut their fees, they noted, hospitals usually respond by cutting staff. "Excessively increasing the workload," however, may lead to poor patient care and consequently higher costs.

John Nelson, MD, a cofounder of the Society of Hospital Medicine, which represents hospitalists, agrees that more studies are needed to define a safe inpatient census. "We know there are staffing shortages," Dr. Nelson told Medscape Medical News.

However, Dr. Nelson said he questions the frequency of adverse events such as complications or death that hospitalists attributed to excessive workloads in the study by Dr. Michtalik and colleagues.

"I wouldn't pay too much attention to the percentages," said Dr. Nelson, the medical director of the hospitalist program at Overlake Hospital in Bellevue, Washington. "They suggest a greater level of specificity than a hospitalist can parse out in an online survey. It's just so hard for a single individual to speculate about the link between workload and outcomes."

A coauthor of the study, Daniel Brotman, MD, has received compensation of no more than $10,000 annually from Quantia Communications for developing educational content. The other study authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online January 28, 2013. Abstract