Home Cover Story Can physicians handle record-high inpatient volumes?

Can physicians handle record-high inpatient volumes?

Hospitalists report surges in both non-covid and covid patients

September 2021

IN EARLY AUGUST, veteran hospitalist Wes Chandler, MD, flew off with his family for a preplanned summer vacation. Over more than 20 years, Dr. Chandler has helped grow Pacific Hospitalist Associates, a private group in southern California, from three to 60 physicians—and August has always been the quiet time in the hospital.

But not this year. “Our hospitalist census now has reached January-February 2021 pandemic highs,” says Dr. Chandler, who works in Hoag Hospital Newport Beach and is president of his group. Inpatient volumes, he explains, began spiking up in July, mainly with non-covid patients.

However, his hospital’s covid daily census over only a few weeks jumped from three to 50—nowhere near the 150 covid cases the hospitalists there were treating in January and February. But when you add the covid numbers to the non-covid cases, “our hospitalist group is seeing 300 patients a day,” he says. “Normal for us is 230. It doesn’t feel right to be leaving when the hospital is so busy.”

Coming out of the pandemic—or, rather, when people (wrongly) assumed we were coming out—prognosticators weighed in on if and when inpatient volumes would rebound. While analysts predicted a return to pre-pandemic inpatient volumes by 2022, they were convinced that emergency room visits would remain a permanent covid-related loss.

During the pandemic, the thinking went, patients who came to appreciate telehealth and urgent care centers would steer clear of EDs and the long waits there.

“Our hospitalist group is seeing 300 patients a day. Normal for us is 230.”

Wes Chandler MD

~ Wes Chandler, MD
Pacific Hospitalist Associates

But hospitalists in non-covid hotspots now report packed EDs and inpatient volumes at least 10% or 20% higher than before the pandemic. And hospitalists battling the latest covid surge say they’re struggling with that same outsized medicine volume, along with a growing covid census and no end in sight.

Factors driving up census
Outside Philadelphia, hospitalist William Ford, MD, MBA, regional medical director for Jefferson Health-Abington, points out that “98% of my patients are currently covid-free.” Still, his hospitalist group’s volumes are between 15% and 20% higher than they were before the pandemic.

“Two years ago, we had 11 hospitalists rounding during the day,” Dr. Ford says. “Now, we’re up to between 15 and 16, and we had to supplement that with locum physicians to tide us over until we could recruit.”

Some patients, he says, clearly delayed care during the pandemic. But he also points to hospitals that have either closed or cut back services. Like other facilities in and around Philadelphia, his hospital now bears more volume due to the 2019 closure of Hahnemann Hospital, a 500-bed safety net hospital that used to take up an entire city block.

In Hyannis, Mass., Ricardo Nario, MD, who heads up hospital medicine at Cape Cod Hospital, says he and his colleagues expect 30% more patients in July and August, due to the influx of vacationers.

“Our case population has bloomed.”

Ricardo Nario, MD

~ Ricardo Nario, MD
Cape Cod Hospital

But this year, they were caught completely off guard when their typical post-July 4 census showed up in April instead. (They weren’t covid patients.) As for July, it was the hospital’s busiest July in the eight years that Dr. Nario has been tracking data, with inpatient volumes 40% above what they are the rest of the year.

Some are locals who delayed care, he notes, and some are tourists. But here’s also this fallout from the pandemic: “People from cities all over the Northeast are buying houses on Cape Cod and becoming permanent residents, so our case population has bloomed.” That’s put a strain on the hospital system—and revealed that the area doesn’t have enough primary care doctors to cover the burgeoning population.

A nationwide shortage of nurses
While rising volume is tough, an extreme nursing shortage is making it even more of a challenge. Nurses throughout the pandemic retired or were poached away by other hospitals. Or after they were lured out on the road to make money traveling from one covid hotspot to the next, they are now exhausted and trying to recover.

In Hyannis, the hospital’s nursing shortage is made worse by the shortage of nurses in local rehab and nursing facilities. “They’re having even more trouble finding nurses than we are,” Dr. Nario points out. “It’s created a backlog where nursing homes can’t staff to their capacity, so patients have to spend two or three extra days in the hospital waiting for a nursing home bed.”

Then there’s this problem: With city-dwellers snapping up Cape Cod real estate, property values have shot up. “That’s creating a new crisis,” he says. “We can try to hire, but new nurses have a hard time finding a place to live.”

“My nightmare is a scenario like New York City in March 2020.”

Lisa Kaufmann, MD

~ Lisa Kaufmann, MD
Appalachian Regional Healthcare System

That’s likewise become a problem in Boone, N.C., says Lisa Kaufmann, MD, director of hospital medicine at the Appalachian Regional Healthcare System. Her hospital is in the middle of the Blue Ridge Mountains, and retirees and vacationers continue to move in.

Doctors in residency struggle to afford housing, Dr. Kaufmann says, as do the hospitals’ non-physician personnel. As for her health system’s acute nursing shortage, the hospitals are “doing everything that everybody else is doing: recruiting, adjusting wages, and offering hiring bonuses and long onboarding programs to make new grads feel safer.” The hospitals are also short on X-ray and sonography techs, cardiac diagnostic testing techs, and physical and respiratory therapists.

But “our greatest shortages now are in environmental services and nutrition,” says Dr. Kaufmann. “Wages have gone up in our community, and the Kentucky Fried Chicken here is offering hiring bonuses.” Over the past six months, “a chef’s wages here have gone up about $10,000 a year,” putting pressure on hospitals to compete.

Service cutbacks?
As for hospitalist census, Dr. Kaufmann says it’s been going up every year since 2016, and this year is no different. As the health system’s reputation has grown, fewer patients are choosing to travel outside the area for care.

She and her colleagues have caught up with all the delayed-care patients—”most people I’ve seen over the past six months are coming in due to the normal progression of their diseases or with new disease”—but their rising census is now 40% higher, due to growing numbers of covid patients. During the height of the pandemic in her region, she was able to use telehealth to deploy an offsite hospitalist and advanced practice professional (APP) to round on a full service of patients in her health system’s largest hospital.

“The nursing shortage right now is our Achilles’ heel.”

Raj Mahadevan, MD

~ Raj Mahadevan, MD
Cape Coral Hospitalists

But the company her health system contracts with for telehealth is now full with other clients, so that option is no longer open. Her group continues to make use of locums, “but they’re very hard to find.” While the hospitalists have yet to cut back on services to handle the rising census, “as the surge worsens, we may physically be unable to care for every patient at the high level we normally take for granted,” says Dr. Kaufmann. “My nightmare is a scenario like New York City in March 2020.” At least, she adds, “we have adequate PPE.”

In the meantime, Dr. Kaufmann says the physicians’ morale is holding up, but “the longer it goes on, the more draining it is.” Plus, covid patients “are very time intensive and often emotionally draining because so many of them die.” (See “How hard it is to be here again.”)

Outsized sign-on bonuses
In the beginning of June, Raj Mahadevan, MD, president of Cape Coral Hospitalists in Fort Myers, Fla., says his hospitalists were treating 38 covid patients across a four-hospital system. Two and a half months later, that covid census is just shy of 600. Already, elective procedures have been suspended to free up space and conserve PPE.

That crushing covid census comes on top of what he says were his busiest (non-covid) March, April, May and June ever. “Our case mix index went up, and the patients were sicker.” In a typical year, Florida empties out “like clockwork” around May 31. But while Dr. Mahadevan notes that 1,000 people per day are moving to Florida, nurses are unfortunately among the snowbirds, flying down in the winter and leaving before the summer.

“The nursing shortage right now is our Achilles’ heel, and that shortage is stopping us from staffing beds,” he points out. One health system his group covers is now offering nurse recruits a $25,000 sign-on bonus—and up to $6,000 in bonuses when they pick up additional shifts for existing employees.

“The hospitals that are left will always be full.”

William Ford MD

~ William Ford, MD, MBA
Jefferson Health-Abington

As for giving the hospitalists some relief, one hospital his group covers just hired nine new hospitalists who will be available as soon as they take their boards. Hospitalists are also being offered additional shift rates for volunteering for shifts beyond their own seven-on/ seven-off schedule. And “we started a swing shift,” says Dr. Mahadevan, “to help with admissions and alleviate the census.” It also helps, he adds, “that the physicians know the health system is doing its best to get us through these unprecedented times.”

The new normal
To keep up with his group’s outsized census, Dr. Chandler in Newport Beach says, “we have extra doctors working every day for extra pay, and the hospital has opened an additional unit.” But his hospital’s new normal is having 25 patients being held in the ED in the morning waiting for a bed upstairs.

“The hospital is again considering canceling some elective surgeries,” Dr. Chandler says. While the hospitalists typically admit all surgical cases from the ED, including appendectomies, small bowel obstructions and acute cholecystitis patients, “we have asked our general surgeons to consider admitting some of these patients themselves if they have no underlying medical conditions.”

Outside Philadelphia, Dr. Ford says that his group’s APPs have really stepped up, “taking ownership” (along with a physician partner) of the hospital’s observation unit. “Because of the volume crunch, they’ve been given perhaps a little more independence.”

To handle higher volumes, his group also now assigns one or two dedicated physicians a day (along with APPs) to act as ED admitters. Their role: to shepherd patients through the ED, helping ED metrics as well as throughput, length of stay and “left without being seen” cases. “Instead of patients being held in the ED for up to 24 hours,” says Dr. Ford, “hospitalists can round on them there and discharge those who are stable.”

Worries about burnout
As a national company with more than 4,000 hospitalists, TeamHealth has its own cadre of traveling hospitalists and its own locum company. While locums saw a sharp decline in utilization in 2020 as daily census fell, “we are starting to see an increase in need,” says Rohit Uppal, MD, chief clinical officer of TeamHealth Hospital Medicine.

While the company’s more-than-200 hospitalist programs are spread throughout the country, TeamHealth has a strong presence in the Southeast, which is currently being the hardest hit with covid. As a result, TeamHealth is focusing its traveling and locum forces on those covid hotspots. While its hospitalists in other regions are seeing higher-than-expected non-covid volume, “it’s not at that level of urgency,” he says. “We’re used to fluctuating volumes, and we are adept at flexing with our standard staffing model.”

For the time being, hospitalist groups are hunkering down. In Hyannis, Dr. Nario’s colleagues have been pulling extra shifts and taking extra patients, going from 15 patients a day up to 21 and 22, and the hospital has opened more units. The program has also made ample use of its longstanding group of per diem doctors, many of whom live in Boston, and hospital administration has OKed hiring an additional floor team.

But with his doctors now running full speed for many more months than they are used to, Dr. Nario worries about burnout. “We didn’t lose any providers during the pandemic, and we gained a nurse practitioner,” he points out. “But everyone is working extra hours, and it’s stressing everyone out.”

How will it end?
Barring the truly catastrophic (another covid surge in the Northeast) where elective surgeries would be cut back again, “there are no more strategies,” says Dr. Ford from Jefferson Health. He counts himself lucky that his group is large enough to absorb, for now, an additional 20 or 30 patients a day, something much smaller groups can’t do for long.

But he also believes that rising inpatient volumes are here to stay, and not just a post-pandemic fluke. “We can’t bring docs on fast enough,” says Dr. Ford. “As soon as we bring in more doctors to expand our services, it seems like more community physicians relinquish their practice responsibilities.” Three years ago, his group’s daily census hovered around 180. “Now, it’s close to 300.”

He’s believes that the pandemic will wind down—after another year or two. More people will get vaccinated, he says, and vaccines will eventually be rolled out to even young children, shutting down another infection source. But he doesn’t think he’ll ever be able to walk through his or any other hospital without a mask, which in part is a good thing. “I used to get sick at least twice a year, but not this year. And I haven’t seen a case of flu in almost two years.”

And he has his own personal prognosis on inpatient volumes: “I think the volume will always be there, and I don’t think it will ever go away again,” Dr. Ford says. “The hospitals that are left will always be full.” TH

Phyllis Maguire is Executive Editor of Today’s Hospitalist

How hard it is to be here again

ROHIT UPPAL, MD, chief clinical officer for TeamHealth Hospital Medicine, notes that inpatient and ED volumes across the country are “at or above what we expected to see this time of year.”

But in terms of covid hotspots—and Dr. Uppal in early August singles out Florida, Alabama, Tennessee and Texas—”I hate to use too strong of a word, but it really is catastrophic,” he says. “We are seeing regions where there is zero hospital or ICU capacity, and our hospitalists and ED clinicians are forced to turn away acutely ill patients.” He doesn’t expect covid cases in those states to peak for weeks, starting with Florida in late August.

For the clinicians in those hospitals, this is their third or fourth surge, he points out. But this time around, “many of us were optimistic that we were on the other side of the pandemic,” says Dr. Uppal. For some hospitalists, that letdown has led to additional despair.

“There is pure fatigue in our clinical ranks, and adrenaline can carry you only so far.”

Rohit Uppal, MD

~ Rohit Uppal, MD
TeamHealth Hospital Medicine

They don’t have outpatient, anesthesia or emergency colleagues able to pitch in this time because non-covid census has returned to normal. Shortages in nursing and other essential personnel mean that “hospitalists are frequently working without the level of nursing, case management, therapy and other resources they once had, which makes care much less efficient.”

The intense politicization of public health measures like masking and vaccination has increased burnout. It’s also seemingly put an end to the public’s rallying around clinicians on the front lines.

“I think a lot of clinicians feel they’ve been forgotten about and that their communities really don’t care about them anymore,” says Dr. Uppal. “That’s another result of our inability to get high enough vaccination rates.”

Further, while doctors during earlier surges viewed patients as “innocent” victims of a novel coronavirus, that dynamic has shifted. With so many hospitalized covid patients unvaccinated, some clinicians “view those patients as irresponsible,” making it harder to feel compassion for their own patients.

“When you don’t have that compassion,” Dr. Uppal points out, “burnout becomes a bigger factor.”

For hospitalist teams dealing with covid surges, TeamHealth is doubling down on wellness and resilience efforts. Those include wellness checks, checking in with individuals on the front lines on how they’re dealing with what’s happening at work and at home, as well as access to—and the destigmatization of—the use of therapists for hospitalists who are struggling. Weekly leadership town halls allow leaders to get covid updates and to share challenges. The company also leverages its own behavioral health specialists to debrief with hospitalist teams and help them collectively process their experience.

But even with such resources, Dr. Uppal adds, and the hope that the current surge will pass quickly, “there is pure fatigue in our clinical ranks, and adrenaline can carry you only so far. We all had great hope that we were on our way to overcoming the greatest health care crisis of our time.” Instead, “it’s incredibly discouraging to be here again, fighting another battle and fearing that we may have another fall and winter like the ones we just had.”

Published in the September/October 2021 issue of Today’s Hospitalist

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D Marks, Twitter
September 2021 8:17 am

The ball is actually in the hospitalist court. They hold control. Hospitalists need to be firm and say they can handle a total of 18 to 20 max, including all admissions discharges and rounds. 20 max. No more.

A. Andrianov, MD, MBA, Twitter
September 2021 8:21 am

This depends on settings and is about specialty support. Open or closed ICU, code team composition. In many settings 20 is too many.