Duty hour limitations have raised concern that shorter work shifts are compressing resident workload, which may result in a negative learning environment. Increasing patient complexity intensifies workload compression; however, temporal trends in complexity of patients at admission have not been adequately defined or evaluated.
We conducted a retrospective chart review of all general internal medicine teaching service admissions at the Louis Stokes Cleveland VA Medical Center from 2000 to 2015. This observational study was granted IRB approval by the institution’s Research and Development Committee. Inclusion criteria included admission to the non-ICU internal medicine service and admission note completed by a trainee. We define admission complexity as a combination of patient comorbidity, number of notes in the electronic medical record (EMR) at admission, medication count, and problem list count. The Charlson Comorbidity Index (CCI) Deyo version was used to calculate comorbidity, which is a validated method of categorizing comorbidities based on International Classification of Diseases (ICD) diagnosis codes. Each comorbidity category carries an associated weight to result in a single comorbidity score for each patient. Higher scores predict increased mortality and resource utilization. Using each patient’s active problem list at the time of admission, ICD-9 and ICD-10 diagnosis coding, a Deyo Charlson Comorbidity Index (CCI) for each patient at admission was formulated. In addition to average CCI, the average number of notes, medication count and problem list count at admission were calculated for each year from 2000-2015. Descriptive statistics were used for analysis.
A total of 66,879 admissions were included in the analysis from 2000-2015. There was an increase in all measured parameters of complexity over the 15-year evaluation. The medication count increased over time, averaging 13 medications in 2000 to 16 in 2015. The average CCI of 2789 admissions in 2000 was 0.75 (sd 1.41, CI 0.05) and the average CCI of 4583 admissions in 2015 was 3.23 (sd 3.29, CI 0.09, p<0.001). Total number of admissions per year has increased over the past 15 years as well.
The average complexity of a medical admission among internal medicine patients has substantially increased over time. While the CCI has been validated for patient comorbidity, there is no current measure of patient complexity. Increased number of notes, problems, and medications suggest increased time spent during each patient encounter reviewing documentation and prior data. These collective findings suggest a higher level of complexity and thus workload per admission. These findings have significant implications on workload compression in the era of duty hour limitations.
To cite this abstract:Clark, AV; LoPresti, CM; Smith, TI . TEMPORAL TRENDS IN ADMISSION COMPLEXITY: A 15-YEAR REVIEW OF MEDICAL ADMISSIONS TO A VETERAN’S AFFAIRS HOSPITAL. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 31. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/temporal-trends-in-admission-complexity-a-15-year-review-of-medical-admissions-to-a-veterans-affairs-hospital/. Accessed September 16, 2019.