‘Decision fatigue’ in hospitalists: What’s the biggest source?

High patient volume may be a bigger driver of “decision fatigue” in hospitalists than the number of days they work on service.

A study in the Journal of Hospital Medicine looked at the causes of decision fatigue, which the authors defined as a “deterioration in decision-making ability” that comes from repeated decision-making. Their data found that decision fatigue in hospitalists increased when average patient census levels jumped above the median in two large academic hospitals.

Researchers looked at full-time day-shift hospitalists working in the Midwest hospitals in early 2022. The hospitalists at those institutions worked an average of seven consecutive days with an average census of 13 patients per shift.

To detect decision fatigue in hospitalists, the study looked for “outcomes of interest” like the use of contraindicated medications, potentially preventable hypoglycemia, blood transfusions not supported by guidelines and the inappropriate use of CT scans. Researchers looked for an association between those outcomes and factors like days on service, gender, weekend vs. weekday shifts and patient census.

The study examined more than 1,000 shifts worked by 43 hospitalists and found no events occurred during three-quarters of those days. Hypoglycemia was the most common event linked to decision fatigue among hospitalists; researchers logged 220 incidents that could be associated with decision fatigue.

Researchers concluded that only one factor—patient census—could be associated with incidents of decision fatigue. For every additional patient hospitalists saw above the median census of 13, the odds of a decision-fatigue event increased by 10.7%. Put another way, the odds of an incidence of decision fatigue were 1.58 times greater when hospitalists had a census above the median of 13 patients.

The study could find no correlation between days of service and decision fatigue in hospitalists.

Researchers wondered whether working with new patients—like when hospitalists return to a seven-day block after an extended period away from work—affected decision-making. To do that, they calculated hospitalists’ “degree of familiarity” with patients to see if there was a correlation between new patients and decision fatigue.

“Anecdotally, many hospitalists dread the first day on service when they must learn a large amount of information about the patients on their teams,” the researchers wrote. Their data, however, didn’t support any correlation between treating new patients and decision fatigue.

The researchers noted that in other studies of decision fatigue in inpatient physicians, some have suggested that physicians may be able to “replenish their decision-making reserve” over the course of a shift to blunt the effects of decision fatigue. Physicians may be able to “tune up” their clinical decision-making with each patient they see over the day to counteract decision fatigue.

“It is possible that a similar phenomenon occurs among hospitalists and improved judgement,” the JHM researchers wrote, “heightened attention, and self-awareness of fatigue over the course of a clinical block may mitigate the impact of the fatigue itself.”

Most previous studies have looked at emergency medicine physicians, not hospitalists. Previous research has often found that decision fatigue can be associated with higher rates of inappropriate antibiotic prescribing, higher likelihoods of opioid prescribing, and lower rates of breast and colon cancer screenings during appointments later in the day.

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