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I have gotten several complaints from our hospitalist staff about one of my new physicians. He has one of our shortest lengths of stays and a really short time to disposition, but the in-patient docs feel like he’s admitting patients from triage. The hospitalists tell me that he’s calling with a diagnosis of “sick and needs admission” before he’s completed a work up and they’re not sure how to proceed with further in-patient care when the ED care hasn’t been completed. I’m torn between wanting efficiency and not wanting to irritate our hospitalist group.
-Concerned about Dr. E.D. (Early Dispo)

Dear Concerned,
I appreciate your mixed feelings. Given the clear inverse relationship between length of stay and patient satisfaction I’m all about getting patients dispo’d quickly. I actually applaud Dr. E.D. for his early dispositions. In many ways, EPs are victims of their own success. We are the diagnosticians for the hospital and admitting physicians have come to expect that every patient who comes through our doors will have an over-the-top work up and a diagnosis stamped on them so that the inpatient flow can follow a set protocol. But some elements of the work-up simply need to wait until the patient has been admitted.

As chairman you must realize the importance of maintaining a respectful relationship between the EPs and hospitalists, or other in-patient admitting physicians. Recognize that most hospitalists have spent at least some portion of their lives, albeit probably during residency, working in the emergency department, whereas only a small percentage of EPs have ever been hospitalists.

You have two problems that you need to address. The first is with your in-patient physicians. For the hospitalists, explaining how today’s emergency department works and trying to “get ahead” with beds for admitted patients can help them to understand our operational issues and length of stay components. Pre-admission requisite lab work is an abuse of the emergency physician and shows a lack of understanding of our processes. Clearly, there is critical information that must be obtained prior to the request for admission in cases in which the disposition or emergency management will be impacted by that data. You should be able to reach agreement that there are some patients who can be admitted without any lab tests. Take, for instance, the febrile diabetic with a cellulitis. The minute you see that red leg, you know the patient is going to be admitted. Make sure their finger stick glucose is okay and order labs for the inpatient team, but assuming the patient doesn’t look toxic, you know it’s a floor admission and the hospitalists should accept that. This give and take should be fine as long as you reassure the inpatient team that  all pertinent emergency needs will be met for their patients and that just because Dr. E.D. admits the patient, doesn’t mean that he’s delaying, withholding, or postponing care.

Your work with Dr. E.D. will be a little more challenging. For starters, he needs to be educated that “sick” is not an admission diagnosis. Even admitting just off the chief complaint, such as chest pain or a COPD exacerbation, is not appropriate. Admitting physicians want at least some of the details so they can proceed with their in-patient work and have a better understanding of what will happen during the hospitalization. I remember when I was finishing residency, I wondered how I would supervise residents and see patients in such a brief period of time yet still get the right information. I asked one of my mentors and his response was this: Each chief complaint and diagnosis has a few pieces of critical information that needs to be obtained before we move on to the next step in the patient care plan. If a test will change the patient’s disposition, then it’s important to wait for it before admitting the patient. For example, a doctor should have the results back for a possible ACS patient who would go to the CCU for positive enzymes but a tele bed if the enzymes are negative. While many patients can get their CTs from the floor, others may need results back before admitting the patient. For example, a low risk cardiac patient who is being worked up for a pulmonary embolus. If your tele floor is the same for either, admit the patient, but if you have one floor for cardiac patients and another for pulmonary, then I think you need to wait. While I might call the ICU resident for the COPD patient on BiPAP, I would hold off on calling the attending until I had the chest radiograph and blood gas back. As a team player on the hospital healthcare team, I think we have to understand that the in-patient physicians have certain data elements that they want so they can make their treatment plan and it’s part of our job to help them do their job. However, it’s not our job to do their entire work up.

Since you promised the hospitalist group that the ED work up will continue to be thorough even after the patient is “admitted,” your job as chairman is to make sure that Dr. Speedy is on board with this plan. Doing the job of the EP must come first and foremost before making the disposition.

There is still a place for efficiency. I’ve had hospitalists call me back for one patient right after I’ve come out of another patient’s room who I know will be admitted to them. I’ll usually give them the heads up about this second patient and ask if they want a call when all the data’s back or only if things are abnormal. (hint—if you say you’ll call them back with an abnormality and ever forget to do this you’ll lose their trust and they won’t accept admissions until all the details are back). I’ve also called our ICU resident when EMS has brought in an intubated COPD patient knowing that there is no other place in the hospital that patient will go and that the only way to get them a bed is to call the resident. However, I’ve also held off on calling the attending until I’ve completed some of the basic evaluation. Be aware that attendings might be more willing to accept incomplete work ups towards the end of the business day before they close the office and also before it gets too late at night. I find our hospitalist group much more interested in patients when I call them at 10 pm vs. 2 am.

After educating Dr. E.D. about the minimum details that attendings want and confirming that he will continue to do the proper work-ups regardless of whether the patient has been admitted or not, you need to convince Dr. E.D. that he needs to change his practice habits just a little bit. While we all appreciate efficiency and decreased length of stay, Dr. E.D. must accept that there are certain basics that need to be done prior to admitting a patient and that ultimately, in this instance, being a huge outlier from the group isn’t necessarily a good thing.

Mike Silverman, MD is chairman of EM at Harbor Hospital in Baltimore and is on the faculty at the TeamHealth Leadership Academy
 

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