Inpatient NPs - what is your patient load?

mammac5 · Dec 18, 2013

I see inpatients on part of a specialty consult service. So we are called to see patients at various times throughout the shift and it varies a LOT from day to day. We do not have a limit on the number of patients on our list to be rounded on, nor do we have a limit on the number of consults we may be requested to see on a shift.

The most I've seen in a day was, probably, 22 and that was a mix of rounding patients, new consults, and discharges. However I am assessing and managing only one of the patients' concerns. There is another NP service within our hospital that does NOT see new consults but rounds on patients and their limit is 15 patients per day. We work 11-12 hours shifts.

Advanced Practice Columnist / Guide · Dec 18, 2013

As you know, I'm a Critical Care Unit Nurse Practitioner and part of a group of NP's in the same role. Our patient load varies since we rotate to different specialty ICU's within the Adult Critical Care Medicine Division.

Our main home is a 16-bed Combined Medical Surgical ICU (high acuity pulmonary pathology, general medical pathologies, solid organ transplant patients - lots of liver, some sick kidney and pancreas, acute care surgery disasters). Day shift is well staffed. The unit load is split among 2 ACNP's and 2 or 3 residents (Anesthesiology, Internal Medicine, +/- Emergency Medicine). That makes it about 3-4 patients/day.

Days start at 7 AM and early morning is spent pre-rounding on assigned patients. Most of the rest of the morning is spent rounding on all 16 patients. It is an academic medical center so rounds are loooong with a lot of teaching. Patient presentations during rounds for each provider (NP or resident) follows a script and are thorough. We are expected to summarize our assessment and plan systematically and coherently and verbalize them on rounds so there is a lot of talking and "acting smart" and resident/medical student "pimping".

We carry a workstation on wheels during rounds. Our medical center uses Epic for EMR and orders are entered on the computer while we round - that way the nurse is aware of why the orders are being written. We take a lunch together as a team to de-stress and gossip (lol) so the rest of the work gets done in the afternoon. This includes progress notes (easily done on the computer), checking and following up, placing lines, admitting new patients.

Residents have a strict 80/hr week policy. They have to leave on time so the NP's stay until 7 PM to sign out to nights unless the resident is doing a 24-hr call. Emergencies happen regardless of time, we sometimes get pulled out of rounds for an emergency intubation, code blue.

Nights is different - one NP to all 16 patients! It can get rough but there is no rounding or note writing except admission H&P's and Procedure Notes. There are admissions at night and line placements and codes and intubations, etc.

We cover the other Adult ICU's differently (16-bed Cardiovascular ICU and 30-bed Neuro/Neurosurgery ICU). We are mainly a consult service in those units - we are responsible for lines, pain and sedation, and airway/vent management. We don't round on all the patients, just the ones we are consulted on and need to follow. The staffing numbers are less but the patient load is about the same: on days (4-5 patients) and nights (8-10) patients. We also do notes and procedures there.

canchaser, BSN, RN · Dec 18, 2013

I work inpatient neurology my highest load was 12 pts, I have no Office so i stay. On one floor where most of my pts are.

BeeGeeRN · Dec 18, 2013

Pardon my stepping in to this thread as a regular RN (about to start FNP program). Something stuck out in your post... When you say you constantly have to follow up with staff to tell them they have orders, then follow up with ancillary services to find out results etc. This. This is why you are not able to see more patients like your MDs probably like. Why are you having to do this?! Do you use an EMR? Do nurses effectively use their order review? If results are on EMR, do you have realistic time frames for labs/results (I don't mean to be rude.. At all, but I get impatient with labs where I currently work bc I'm used to ICU and rushed results ... Or does this need to be brought up a chain of command as why stuff is so delayed. I feel as though there is a process issue for the unit you work on.

When I was on a floor, I was responsible for carrying out all orders, if there was a delay- it was MY job to get the ball rolling and ask why stuff was delayed. If I missed order, it was my butt for not checking my orders Etc. I've worked closely with NP's and they were not responsible for all of what you do, it was my job as an RN. If my NP noticed something wasn't completed in a timely manner, she we talk to me and I followed up with it.

thanks! ~b. Sent from my iPhone using allnurses.com

allnurses Guide · Dec 18, 2013

Thanks for the replies.

BeeGeeRN, it's a transplant floor with very sick/complex patients, so the RNs are usually very busy. I'm the one the physicians ask for results on rounds, and I can't say "uh, I don't know, maybe the nurse called...". It seems that there are some process problems too, but mostly it takes a lot of coordination. Our patients have a lot of tests and transfers, and it's usually up to me and not the RNs to prioritize which tests are most important, assess if the patient needs to go on/off monitor, if they are even stable enough to go off the floor... we also have a lot of new nurses, so we (the NP/PAs) do find that we need to follow up and make sure our orders are carried out in a timely manner, as sometimes they don't have the experience yet to know what should be done first.

Then - there are the incessant interruptions for insurance issues, or to discuss things with social work/case management, or to do billing, compete discharge summaries, call consults, round... heh. Seeing patients is the smallest part of my day, with documentation by far being the largest. We do have EMR but that is still a LOT of work, especially with patients who are on 10-20 medications each; the med reconciliation and discharge paperwork alone takes at least an hour per patient.

Juan - I am jealous! That sounds like my dream job. I always worked CTICU and initially that's what I was hired for in this role, but there just was no room for me in the CTICU due to the CCM/fellows/residents etc all vying for patient contact and procedures and billing opportunities. I was essentially wasted there and it turned out that a PA was pregnant and they were short-staffed on my specialty floor, so I moved there. I think it's been valuable for time management and learning as a new NP, but I miss critical care and have lost all my procedure skills I learned in clinicals!

core0 · Dec 19, 2013

Thanks for the replies.
BeeGeeRN, it's a transplant floor with very sick/complex patients, so the RNs are usually very busy. I'm the one the physicians ask for results on rounds, and I can't say "uh, I don't know, maybe the nurse called...". It seems that there are some process problems too, but mostly it takes a lot of coordination. Our patients have a lot of tests and transfers, and it's usually up to me and not the RNs to prioritize which tests are most important, assess if the patient needs to go on/off monitor, if they are even stable enough to go off the floor... we also have a lot of new nurses, so we (the NP/PAs) do find that we need to follow up and make sure our orders are carried out in a timely manner, as sometimes they don't have the experience yet to know what should be done first.
Then - there are the incessant interruptions for insurance issues, or to discuss things with social work/case management, or to do billing, compete discharge summaries, call consults, round... heh. Seeing patients is the smallest part of my day, with documentation by far being the largest. We do have EMR but that is still a LOT of work, especially with patients who are on 10-20 medications each; the med reconciliation and discharge paperwork alone takes at least an hour per patient.
Juan - I am jealous! That sounds like my dream job. I always worked CTICU and initially that's what I was hired for in this role, but there just was no room for me in the CTICU due to the CCM/fellows/residents etc all vying for patient contact and procedures and billing opportunities. I was essentially wasted there and it turned out that a PA was pregnant and they were short-staffed on my specialty floor, so I moved there. I think it's been valuable for time management and learning as a new NP, but I miss critical care and have lost all my procedure skills I learned in clinicals!

So I've done a job similar to yours but it seems to me we have more help. When I did liver transplant we each carried 12 or so patients. We generally got in around 7am. Got sign out, looked through all the labs, did the notes and then rounded from 930 to 12. After lunch was discharges and follow up on any tests as well as admit transfers from the ICU. It wasn't unbearable. The social worked took care of the placement. The nurse coordinators were responsible for insurance issues. We transitioned to EMR after my first year there and I remember it initially took around an hour to D/C someone, but eventually I got it down to around 30 minutes. We dictated the D/C summary and the medical reconciliation is actually easier with EMR.

Now I work in the Surgery/Transplant ICU and the turnover is much higher and the acuity is also much higher. We generally carry 5-8 patients a day depending on if we are up for admits. Lately we have been carrying six and thats very doable. I average around 75% of my time in billing.

If you are having nursing issues, you need to talk to the charge nurse or nursing manager. You are not hired to be the nurse, you are hired to be the provider and the nurses are hired to be the nurse. If you do their job for them, you don't have time to do yours. I see this a lot with new grads. They have a hard time in a new role and fall back into a role they are comfortable with.

lovemyplants · Dec 20, 2013

I work inpatient psych. I round on 12 pts. (Including some intakes, generally), and usually have 1-3 consultations.

allnurses Guide · Dec 22, 2013

David, I appreciate the input. You may be correct, although I haven't worked a floor nurse for a long time. I definitely need to be better at delegating things that I "can" do easily myself to the people who "should" do them though.

automotiveRN67 · Dec 22, 2013

David, I appreciate the input. You may be correct, although I haven't worked a floor nurse for a long time. I definitely need to be better at delegating things that I "can" do easily myself to the people who "should" do them though.
I just had my first annual review yesterday, which was interesting. Went well, and we are hiring another NP. Plus I get a promotion to be the supervisor for 5.5 APPs... should be interesting once the others hear about it - one PA has been there for 15+ yrs so I don't know that they'll love having a newbie "supervising", although it mostly means scheduling and administrative input.

At first it seemed like you had a question. Then it turned out you just want to talk about you.

As you may have noticed, the norm is very broad. Teaching hospitals are much different than private practice. Juan has a pretty nice position, but is very heavy on intellectualism. This in itself can be rewarding and stressful. Most hospitalist inpatient NP's will see about 15-20, depending on the season, and will probably admit or discharge 5 of those, which takes more time. Some of those require no work at all most days. If the ICU is a close unit, they may only check in on those patients so they are up to speed when the patient transfers out. One of our hospitals has now added a "nocturnist" NP for the first time. They will admit 10 or so, put out a bunch of fires overnight. It's actually a pretty good position if you like nights. Money is good. For those in private practice like me, I round on our patients early, maybe 5 or so, see 12-16 in the office, and go back at lunch or later for added consults. You have to work as late as you have to.

Hope this helps.

allnurses Guide · Dec 30, 2013

At first it seemed like you had a question. Then it turned out you just want to talk about you

Uhh.. okay. My question was asked and answered. There are several members here who have "known" each other and discussed various issues over years. But thanks for the input and have a nice holiday.

SC ANP · Jan 8, 2014

I am a newer NP (~18 months) and I am on my second job. My first position was hectic & chaotic. I went from office to inpatient to nursing home daily. When I was rounding in the hospital, I had as many as 25-30pts, sometimes split with another doc, most times not. My new gig is much better- I'm a dedicated NP on a new specialty unit. Our census is still low, but we have a 16 bed unit that I am responsible for. I also start my day at 7am, reviewing labs & checking with nurses on both shifts. When docs come in, I have already rounded myself and I present the patients and my plans for each. Then we round together, and I write notes. We have interdisciplinary rounds every morning. Then during the afternoon, we take admits or finalize dcs. Right now our census doesn't justify 24hr coverage by NP, so I sign out to hospitalists when I leave. The docs I work with are great, and very, *very* supportive of NP role. I *love* my job!!