Workforce Planning Key Clinical Questions
01. How did hospitals and health systems adapt work tasks and the work environment to deal with an influx of patients with a highly infectious and novel disease (organization-level adaptations)?
a. HOMERuN institutions
At the organization level, 89% of the organizations surveyed employed geographic cohorting, 59% increased patient care units/beds covered, and 67% reduced non-essential services. Sixty-three percent of sites utilized virtual visits and 41% would transfer patients to other facilities as needed based upon surge needs. Forty-four percent of sites reported a decrease in documentation requirements. Other strategies utilized were restructuring teams (74%), decrease in team census (55%), changes in the frequency of team/provider rotation (30%), and use of community surge areas (19%).
b. What is Known
Single center reports have utilized a combination of these adaptations.4,5 Prior to the pandemic, geographic cohorting of general medicine patients has been challenging11 and initiatives have had variable success.12,13 However, with COVID-19, the majority of institutions both planned and were able to execute on geographically based teams. Telemedicine has seen a marked increase in use both in the outpatient setting but also expanded use in the inpatient setting.
c. What is Not Known
Hospitals across the country were able to successfully implement geographically based teams and were able to quickly institute modified visits such as reduced documentation requirements as well as remote/telemedicine visits. The impact on patient care is unclear (i.e., impact on communication and overall quality of care). Institutions across the country also varied in their approaches, with approximately half of respondents reporting that they lowered their patient numbers and the other half increasing them. In 2014, a landmark paper by Elliot and colleagues noted that increasing a hospitalist’s workload was associated with clinically meaningful increases in length of stay and cost, where a census greater than 15 was noted to be associated with increased length of stay, although without any compromise in patient safety.14 Zoucha and colleagues found that for every one-person increase in census the discharge order time increased by 6 minutes.15 While previous literature has indicated increased patient numbers may lead to a decrease in efficiency that can result in longer lengths of stay, it is unclear if the same is true in this patient population. Given the increased geography and telemedicine, it may be that these inefficiencies may not result.
Key Clinical Questions
- Bowden K, Burnham EL, Keniston A, et al. Harnessing the power of hospitalists in operational disaster planning: COVID-19. J Gen Intern Med. 2020;35(9):2732-2737.
- Auerbach A, O’Leary KJ, Greysen SR, et al. Hospital ward adaptation during the COVID-19 pandemic: a national survey of academic medical centers. J Hosp Med. 2020;15(8):483-488.
- Nguyen AL, Wang FY. Wide-reaching effects of and concerns regarding geographic localization of hospitalist units. Hosp Pract (1995). 2018;46(1):43-44.
- Singh S, Fletcher KE. A qualitative evaluation of geographical localization of hospitalists: how unintended consequences may impact quality. J Gen Intern Med. 2014;29(7):1009-1016.
- Bryson C, Boynton G, Stepczynski A, et al. Geographical assignment of hospitalists in an urban teaching hospital: feasibility and impact on efficiency and provider satisfaction. Hosp Pract (1995). 2017;45(4):135-142.
- Elliott DJ, Young RS, Brice J, Aguiar R, Kolm P. Effect of hospitalist workload on the quality and efficiency of care. JAMA Intern Med. 2014;174(5):786-793.
- Zoucha J, Hull M, Keniston A, et al. Barriers to early hospital discharge: a cross-sectional study at five academic hospitals. J Hosp Med. 2018;13(12):816-822.