Patient Census: What It Is, Causes, How to Manage It

Healthcare facilities face the daunting task of guaranteeing adequate staffing levels without knowing the number of patients they will have on a given day.

Understaffing leads to poor health outcomes and staff dissatisfaction, while overstaffing is an inefficient use of resources and also leads to staff dissatisfaction.

Balancing staffing levels with a facility’s patient census is one of the most critical tasks healthcare administrators can achieve. This balance leads to:

Improved patient care outcomes
Staff satisfaction
Efficient use of resources

What Is Patient Census?

Patient census is the number of patients receiving care at a healthcare facility at a given time. Patient census can include both inpatient and outpatient services, though it typically refers to the number of inpatients or patients admitted to the facility.

Many facilities analyze patient census data to identify daily and weekly trends. Predictable factors that influence hospital patient census include the following:

Nursing home and work schedules
Elective surgery scheduling
Tendency to discharge patients around midday

Some medical facilities calculate patient census once a day to measure the average daily census (ADC), while others calculate it hourly.

Facilities often use data from previous years to predict patient census. An average census period refers to patient numbers that are comparable to the previous year’s numbers.

When patient numbers are significantly above average, there is a high patient census. When numbers are below average, there is a low patient census.

High Patient Census

A high patient census is when a medical facility or hospital has a large number of patients needing care, and typically implies high patient-to-nurse and patient-to-CNA (certified nursing assistant) ratios. In other words, staff members must care for more patients at a time.

One concrete consequence of a high patient census is that rounding teams spend less time discussing essential patient population topics, especially regarding low-acuity patients.

Low Patient Census

A low patient census is when a facility has fewer patients to care for than normal. A low patient census typically results in an overstaffed facility, in many cases leading to canceled shifts.

In these cases, clinicians are typically not paid for the canceled shifts. However, policies vary across facilities:

Nurses may use vacation time to make up the lost wages and maintain their benefits. However, this often means nurses are left without real vacation time.
Nurses may be sent home once they arrive at work or at any point during the shifts. However, some contracts stipulate how and when facilities can alter a nurse’s schedule and require minimum pay if a nurse is sent home due to low census.
Some hospitals require nurses to be on call if their shift is canceled. Others even require nurses to call every few hours to ask whether they are needed.
Some hospitals cancel shifts based on seniority, others on a rotating basis.
Very few hospitals have no-cancellation policies.
Some facilities have a budget to fund other projects during low census periods. Thus, nurses can continue working and getting paid despite a low census.

As shown above, clinicians often bear the pain of a low or decreasing patient census more than the patients or medical facilities. How can healthcare facilities optimize their staffing strategy to avoid understaffing without penalizing staff clinicians during a low census period?

Now, let's explore why monitoring patient census is so important for optimizing staffing levels at healthcare facilities

Why Does Patient Census Matter?

Changes in patient census can affect patient safety, health outcomes, and resource capacity planning. They can also negatively impact morale and turnover rates among staff. Therefore, healthcare facilities must accurately predict patient census and prepare for fluctuations.

Stay in Compliance with Nurse-to-Patient Ratios

Not all states mandate specific nurse-to-patient or CNA-to-patient staffing ratios. However, whether or not ratios are mandated, suboptimal staffing levels are detrimental.

High patient-to-nurse ratios decrease quality of care, patient safety, and patient satisfaction. There is evidence of increased adverse patient outcomes, including increased 30-day mortality and failure to rescue.
High patient-to-nurse ratios also increase the risk of emotional exhaustion and job dissatisfaction among staff.

Improve How Facility Resources Are Allocated

Accurately predicting patient census can guide administrative and clinical decisions, such as bed management. Inaccurate predictions result in suboptimal staffing levels, whether that may be over or understaffing. Facilities must predict patient census to provide safe patient care while using resources efficiently.

Improve Budgeting and Financial Planning

By analyzing past and present data to make informed predictions, facilities can budget for the necessary resources to maintain adequate staffing levels. A staffing strategy that doesn’t take into account the patient census can result in a dramatic mismatch in a facility’s staffing levels and the amount of care needed to help its patient population.

Challenges in Managing Patient Census

Managing patient census is no simple matter. Predicting and preparing for fluctuations in the patient census has long been a concern of hospital leaders.

Patient census affects staffing, especially of nurses and nursing assistants. It also has implications for hospital bed allocation and operating theater and radiology equipment run times. In short, it is intricately related to numerous aspects of a healthcare facility’s management.

The following are aspects that add to the complex nature of managing patient census:

Fluctuating Demand for Care

Predicting patient census is complex. Facilities may be able to predict seasonal patient surges based on data from previous years. However, natural or manmade disasters are much harder to predict.

The COVID-19 pandemic is the perfect example of unexpected increases in the demand for care.

Nurse Staffing Shortages

The ongoing nurse staffing shortage adds a layer of complexity to managing patient census. Due to the shortage, many facilities struggle to maintain adequate levels of internal staff.

The nursing shortage stems from numerous causes:

An aging population requiring more care
A large segment of the nursing workforce reaching retirement age
Limited resources to educate new nurses
A significant percentage of nurses leaving the profession

Nurse Burnout

Nurse burnout is both a cause and a result of inadequate management of patient census.

High patient census with high patient-to-nurse ratios leads to nurse burnout. Burnout can lead nurses to leave their jobs and, in some cases, the profession altogether. In turn, this contributes to the nursing shortage, which makes it difficult for facilities to maintain adequate staffing levels.

Patient Satisfaction

Just as high patient census and high patient-to-nurse ratios lead to nurse burnout, they also lead to patient dissatisfaction. The higher the number of patients a nurse provides care for, the less time they have for each patient. This decreases the quality of care, patient safety, and patient satisfaction.

How to Plan for and Manage a Fluctuating Patient Census

Many facilities use the average census from the previous year or years to predict patient census. This is called the fixed average census approach. However, this approach alone does not offer facilities enough information to manage fluctuations in patient census adequately.

Besides analyzing past data, the following strategies can help healthcare facilities plan for and manage fluctuating patient census.

1. Track Average Daily Census (ADC) Regularly

The average daily census (ADC) can help facilities adapt to current demands. For example, a hospital may notice that the ADC has been consistently higher than it was at the same time the previous year. In these cases, the fixed average census is no longer helpful, and facilities should base their predictions on current trends.

Furthermore, the time of day facilities calculate the ADC is crucial. Many calculate the average daily census at midnight. However, a study that analyzed hourly fluctuations in the ADC found that it peaked at 11:00 a.m. and was lowest at 7:00 p.m.

Understanding these hourly fluctuations can help facilities manage staff more effectively. Facilities should also consider calculating the ADC during higher patient census hours to guarantee sufficient staff throughout the day.

2. Leverage Technology to Make Data-Driven Decisions

Most hospitals now use electronic health records (EHRs). Access to each patient's status in real time can help facilities anticipate short-term changes in patient census.

EHRs allow facilities to know the current patient census at any given time and help them predict what the patient census will be in the following 12 or 24 hours. By analyzing EHRs, facilities can predict when each patient will be ready for discharge.

3. Reduce Readmission Rates

Another way to manage patient census is to reduce hospital readmission rates. Reducing readmission rates enhances patient outcomes and lowers healthcare costs. The following are crucial considerations for reducing readmissions:

By improving the quality of care, hospitals can prevent unnecessary readmissions.
Hospitals can guarantee higher quality of care by maintaining adequate staffing ratios.
Hospitals should also identify high-risk patients to prevent readmission. Healthcare staff must provide these patients with sufficient education and comprehensive plans for care after discharge. This can include coordinating referrals for outpatient services or home health care and scheduling follow-up appointments.

4. Lean on Flexible, Short-Term Staffing Solutions

Nurse staffing is so complex that facilities cannot rely on a single solution to meet all their needs. There is a place for long-term employment. Travel nursing is another practical (although expensive) alternative. However, the most effective solution for short-term staffing needs is contracting PRN clinicians.

Nursa is a PRN healthcare staffing platform that connects facilities and clinicians in real time. Facilities can post the shifts they need to fill and get the required coverage on the same day. They can also prepare for expected increases in patient census by posting PRN shifts days or weeks in advance.

By relying on contingency staff during periods of high patient census, facilities can maintain safe patient-to-nurse ratios.

During periods of low patient census, facilities simply do not post PRN shifts and instead conserve their resources. This is a significant advantage over utilizing travel nurses since travel nursing contracts often protect nurses from shift cancellation.

5. Optimize Patient Length of Stay

Facilities must understand and effectively manage the flow of patients from arrival to discharge.

Hospitals can develop guidelines to avoid admitting patients who will not benefit from the transfer.
Hospitals can postpone elective transfers during periods of high patient census.
Social workers in emergency departments can help arrange home services and facilitate follow-up, reducing unnecessary admissions.
Physician-led, daily census huddles can review projected patient census issues and help overloaded services to improve bed turnover. These huddles can also reorganize staff to satisfy current needs.

Seamlessly Manage Patient Census with Nursa

With Nursa, healthcare facilities can access vetted, qualified nurses to meet their short-term needs.

They need not make long-term commitments to PRN staff. Facilities can post shifts only when they need extra coverage and do not need to worry about what to do with PRN staff during low-census periods.

Furthermore, this flexible staffing option helps facilities reduce overtime and avoid other costs associated with understaffing.

Adapt to a fluctuating patient census by contracting PRN staff to meet your facility’s changing needs. Post the PRN jobs you need to fill today.

Sources:

How Facilities Can Measure and Manage Patient Census