Rough Admission Night

Last Friday I moonlighted working overnight as a hospitalist doing admissions and cross-covering patients. It was a 12 hour shift (7 pm - 7 am). During that stretch we had 14 (!) admissions. I had the help of a fantastic intern and resident. They cap out at 8 patients total, so I had to supervise their care and do six admissions on my own. This was one of the hardest nights I've ever worked. In general, I did not feel like I was doing a satisfying job with the care I was providing. We kept getting "boluses" of 3-4 patients from the ED all at once. I just barely learned a patient's story, put in admission orders, and wrote a cursory note when I had to move on to the next patient. In the early hours of the morning it became hard to keep the patients' stories straight. Each of these patients were very complex, so to admit them properly really requiring doing some chart biopsy to find out about co-morbid conditions and home medications. There simply was not time to do this at a rate of 1.25 patients/hour. Even worse, I signed out the patients to the day teams at 7 am and ended up staying on site for an extra 2.5 hours to finish up all the documentation.

What could have happened differently to make this a better night?

Two patients had primary neurological problems, but at this hospital the neurology service doesn't have an admitting team so we had to admit the patient and follow the neurology consult recs. One patient was an orthopaedic surgery patient because of a bone fracture, but the surgery team wanted us to admit the patient because they were "medically complex." Then at least two patients didn't have a strong reason for admission, but the ED thought the patients would be "lost to follow-up" and decided to admit. If these 5 patients had gone to a different service or had been discharged home, it would have made it a much safer night for everyone. Alternatively, it might be necessary to have a back-up physician to come in when nights get busy like this one did.

I ran this situation by some physician friends asking for their advice. The consensus was that 14 patients in 12 hours is not sustainable or safe, especially if even one of those patients is very sick. I was very thankful for the day teams that took over the care for these patients. They expressed empathy and reassured me that they'd finish up the treatment plans and work-ups that were still half-baked by the time the sun started to rise.