“Do what you can, with what you have, where you are.” ~ Theodore Roosevelt
WE ARE ALL too familiar with being short-staffed. Program growth, turnover, and vacation or parental leave coverage are just a few of the factors that contribute to acute, chronic, or acute on chronic staffing deficiencies.
In surveying hospitalist groups, the 2018 State of Hospital Medicine Report presented five options to cover unfilled positions: using locum tenens or moonlighters, having existing hospitalists volunteer for extra shifts, requiring extra shifts, and leaving some shifts uncovered.
But how do you keep your head above water when no external resource—locums, moonlighter or volunteer—is available, mandatory overtime is an invitation to rebellion, or an uncovered shift threatens patient safety? Here are five tactics to help you stay afloat when no cavalry can ride in to save the day.
1. Transition orders
Whether your program uses dedicated admitters or blends rounding with admitting, it’s often inefficient (and unnecessary) to hold patients in the ED until you complete an H&P and orders. The bottlenecks that inevitably arise harm bedflow, heighten tensions, and make for long delays and poor patient experience. Good protocols between hospitalists, ED and nursing can safely settle patients in their rooms with basic orders to tide them over until you can do a full assessment.
2. Flex existing staff
Even when you have external resources, that may not be your best option. Sure, if someone can arrive and hit the ground running 30 minutes after being called, go for it. But it often takes hours to get people onsite and direct them where to go and what to do.
With strong esprit de corps, doing more with less is possible.
Always ask: Is your existing scheduled staff optimally deployed? Can one provider (or a few) stay an hour later, come in an hour earlier or be flexible to help the cause? A nocturnist might round on a few patients before, during, and/or after her shift to give the day staff room to breathe. And the day team could knock out a few admits to lighten the load for the night team.
With strong esprit de corps, doing more with less is possible. “Shift mentality” is sometimes disparaged. But when it’s reframed as, “Doing anything necessary to help the team during my time here,” it takes on a very different meaning.
3. Remote coverage
Are you part of a multihospital system that has staffing and volume imbalances? If so, consider offloading certain tasks to a less strapped facility or floating staff intra-day. To tame an exploding pager, direct routine calls for nonurgent issues offsite to another facility or even a provider at home.
4. Consult/consultant management
Comanagement arrangements can be a boon for all parties; physicians concentrate on their areas of expertise, and patients reap the benefits. But while some consults require intensive ongoing attention, many do not. When your clinical contribution to a case is or has become minimal, you may want to responsibly reduce your number of visits, follow peripherally or sign off outright.
And how often do hospitalists find themselves the attending for what’s essentially a pure general surgery, orthopedic or gynecologic case? During a staffing crunch, ask consultants to serve as the attending, then re-engage if medical issues arise. To skeptics who think consultants would never say “yes” to such a request: You’ll never know if you don’t ask.
5. Bonus tips
Finally, consider the following micro fixes. They individually may save only a bit of time, but collectively they may allow you to fit in another few patients.
■ Alternative level of care: Every hospital has stable patients waiting for disposition plans. Guardianship, group home, nursing or rehab facility patients may languish for days or weeks. Check your staff bylaws to see if there’s an alternative level of care designation or a similar arrangement that permits fewer visits. And tailor your documentation appropriately to save precious time.
■ Same-day-admit progress notes: By all means, interview and examine these patients and review all data and orders as usual. But assuming this is a nonbillable encounter, consider an abbreviated version of your typical full progress note. Reference the H&P, document any updates and move on.
■ Work the phones: Communicating with families is key to good patient care and experience. But face-to-face is not always practical, particularly with high workloads and patients who aren’t distributed geographically. When a nurse calls because a family member at the bedside has questions, rather than stressing out over when you can get there, just say “Sure, put them on the phone right now.” You resolve the matter, the family is satisfied and you can move on without having another task looming over your head.
■ Self care: Hospital medicine is physically, emotionally and intellectually draining. The standard seven-day stretch of 12-hour shifts is hard enough. Don’t sabotage yourself and compound those challenges by depriving yourself of adequate nutrition, hydration or bio breaks. These, along with moments of emotional reset—a call to a loved one or two minutes alone in a stairwell—can boost your physiology enough to keep going.
When a busy colleague once complained that his “mucous membranes are parched,” I told him to get a drink of water. It’s too easy to neglect ourselves, and patients suffer for it. Better self care means better care for your patients.
These suggestions aren’t miracle cures. But they may buy you enough time and sanity to help you weather tough times until better conditions emerge.
John Krisa, MD, is a former regional medical director for a national hospitalist group and currently serves as a physician advisor/hospitalist for St. Peter’s Health Partners, a large integrated health system in the Capital District of New York. You can contact him at email@example.com.
Published in the 2020 issue of Today’s Hospitalist