How the ER is now used to triage every patient

The ER is the portal of entry to our hospitals now, for better and for worse.

On the plus side, this means that most patients being admitted to general medical and surgical services have a workup at least started and are triaged appropriately to their destination.

A good ER evaluation should answer the following questions:

1. What’s the nature of the illness?

Are we dealing with the heart, the brain, or an abdominal organ? Is the cause an infection, a blockage, or a blood clot?

2. Based on #1, where will the patient best be situated?

Will the patient need intensive care, or will the “regular” floor be sufficient to attend to the issues at hand? Should the patient be admitted to a surgical team or a medical (non-surgical) team?

Depending on the hospital, does the patient get admitted to a teaching service (where residents perform the care under the supervision of attending [fully trained] doctors) or a non-teaching service? Should the patient be on a specialty service (e.g. cardiology, GI, or oncology), with a hospitalist (a trained internist who mostly sees only hospitalized patients) or a generalist (an internist or family physician who sees hospitalized patients as part of the spectrum of services they provide).

Even with these two straightforward questions, the decision-making can become fairly complex, given all of the available options.

And in teaching hospitals, an extra layer of complexity is added as doctors from different services sometimes fight not to admit the patient to their roster of patients.

Contesting an admission might occur with good intentions, but one thing is for certain: it delays getting the patient out of the ER and up to a hospital ward, which compounds the problem of ER backup and overcrowding.

Monday morning quarterbacking occurs in hospitals on a daily basis. ”If this patient had been admitted to the Intensive Care Unit (ICU) in the first place, a lot of these mishaps could have been avoided,” is a frequent refrain heard the morning after a very sick patient has been admitted.

In teaching hospitals, admitting and triage decisions take longer, since the resident doctors, both in the ER and the ones working on the hospital floors are learning the skills of triage. There’s a subtle (and not-s0-subtle) dance that goes on to choose the service and the location. Most of the time it’s very straightforward. The few times that it’s not can lead to major worry on the part of everyone.

Patients admitted to general medical services from the ER usually come in two varieties:

1. Completely undifferentiated illness, with a first time presentation. For example: new onset shortness of breath. There are myriad possibilities, and a deft ER will help sort our which are most likely.

2. An acute exacerbation (heightening) of a chronic medical condition. Of the two presentations, this is the far more common. In an aging population with a preponderance of chronic illness (diabetes, hypertension, survivable cancers, strokes, and cardiac conditions), patients can have a perturbation of their bodily balance (e.g. a salty food binge) that can result in acute on top of chronic illness.

We’ve moved away from the direct admission.

This occurs when a doctor evaluates a patient in the office, and determines that there’s a variety #2 going on–an acute flare of a chronic condition.

Such a patient does not likely need an extensive workup to determine the nature of the illness, since it’s long ago been defined. The patient requires a titration of medication in a supervised fashion (many of these medicines alter the body chemistry, and can upset the heart or kidneys) to alter the physiology back toward balance, and then the patient can be discharged.

Yet since we’ve become so reliant on the ER to triage everyone, we’ve fallen into a predictable pattern of sending all patients destined for admission to the ER.

“Let the ER sort it out,” is the oft-thought, rarely-spoken mantra of a busy office physician.

Is it any wonder the ER is so crowded when on top of having people use the ER as a medical home, we have doctors shunting patients through the ER as a portal of entry?

The hospital’s admitting office does not want to receive and then admit patients who might be “unstable.” At the hospital at which I work, if a patient even has an IV placed (customary for a patient admitted to a general medical service) they are deemed too “unstable” to wait in the admitting area.

Something has to give.

It would be nice for patients if they could be admitted to their hospital bed as quickly as possible. The patient is relatively powerless to decide how they get into the hospital.

There’s a real opportunity for the place that figures out how to transition people who are sick from the outside world to the inside-hospital world in a more seamless fashion.

In a world of medical consumerism, that’d be something to boast about.

John Schumann is an internal medicine physician at the University of Chicago who blogs at GlassHospital.

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Comments

ninguem
That ER visit will pay the ER doc far more than I would for the hospital admission.
stargirl65
I use a hospitalist. I cannot direct admit. They insist on all patients going through the ER. They got burned on a few patients directly admitted to the floor that crashed and burned before they got to round on them. Now they all go through the ER.
family practitioner
I admit my own patients, but agree with stargirl65: direct admissions are discouraged for “quality” reasons.
http://glasshospital.com John Schumann, M.D.
I think from the admitting physician’s viewpoint, it’s a lot easier if all patients are “standardized” [labs, IV, xrays, antibiotics hanging] via the ER portal of entry.
Of course, from the patient’s viewpoint, this is lousy customer service much of the time. Also, our residents don’t get to think the cases through as much after the patients have been “packaged” by the ER.
http://drpullen.com Edward Pullen MD
I’ve been on both ends of this, admitting my own patients until about 18 months ago, now using hospitalists. I admit, far more patients got direct admissions when I admitted my own patients. I used the office as a place to “triage” sick patients, and decide, much as the ER does now but with far fewer tools. Now when I see the patient in the office, want to get the hospitalist to admit them, and call to arrange this, I feel like I did when I was the ER resident pleading with the on call resident for medicine to accept an admission. Except now it is much easier for the hospitalist to dump the work on the ER. I have worked hard at developing a trust with the hospitalists to trust my opinion that the patient is stable enough to go to the floor and be managed there. I still often find the plea to send them to the ER often. When admitting to hospitals other than my local community hospital, I essentially always am forced to just send the patient to the ER. I can tell you, patients hate it. If I felt like I could afford to go back to attending my own inpatients, I’d do it in a minute. I can earn about $4:$1 for time spent on outpatient care vs. inpatient care, and life is so much better. My wife would go to court to declare me insane if I went back to live at the hospital.
ninguem
For years, I’ve seen organized Family Medicine lose battle after battle after battle in hospitals. No ICU work. No ER work. No operating room privileges. No endoscopy. No C-sections. No pediatric/nursery privileges. No obstetrical privileges.
Family physicians are not smart enough to do anything in hospitals unless it it not remunerative, or it’s time-consuming, or it’s in the middle of the night, when family physicians suddenly become real smart.
So fine, the primary care docs finally decided to live with it. So………now it’s a problem when no one wants to do primary hospital work.
I know I could see three, four, five patients in the time it would take to see a patient in the hospital when you consider travel. Dollars and cents, not even close for me. Tired of hospital petty politics. The ER doc can see the patient and do the workup, and get paid twice what I would get for the same workup. So…….fine. I don’t begrudge them the money. Let them do it. I’ll be glad to send office reports.
“Then you’re no better than the nurse practitioners”. Heck, fine. We already DO have 100% nurse-practitioner-run clinics in our area, our state allows it. They are paid presicely the same as I’m paid, and no one chides them for not following their patients in the hospital.
In fact, when I DID do hospital work, when on call, I would be responsible for admits from those same nurse-practitioner clinics. And the hospital-owned docs would provide the physician fig leaf of “supervision” to an independent NP-run clinic, which enhanced their reimbursement.
So the hospital supported my competition. And when on-call, I was forced to support my competition. So don’t mind me, I’ll stay in the clinic, and visit the patient socially, let the hospitalists do the work.
http://www.epmonthly.com/whitecoat WhiteCoat
Good overview of how an emergency department should work contrasted with how an emergency department often does work.
I sometimes find it frustrating when we get calls from staff physicians the following day, after all the inpatient testing has been completed, chastising us for not making some obscure diagnosis sooner or for misreading a chest x-ray that everyone else needed a CT scan of the chest to properly interpret.
Comes with the territory, I guess.
As for ninguem, if you don’t “begrudge” the emergency physicians their pay, then why are you so fixated on how much you think we make?
FYI, a vast majority of emergency physicians get paid hourly, so whether you send three dumps or six dumps to the ED so you can get out of office hours early, most of us still get paid the same.
Not so much fun when someone makes overbroad misinformed generalizations about your specialty, is it?
family practitioner
I agree with WhiteCoat; let’s not blame the ER docs; if anything, they are negatively impacted by this because they have to see these patients in the ER.
The system is dysfunctional, so therefore, the “solutions” are dysfunctional as well, be they hospitalists, urgi-cares, midlevels, etc. The bottom line is that primary care is overworked and undervalued; that should be fixed. All these other “solutions” are just stop gap measures that ultimately will not fix anything and become their own source of problems.
Evinx
So if the ER is really the main portal of hospital admits, then how does health care reform (Obamacare 2.0 or Ryan’s Roadmap Plan or Coburn’s plan) resolve this problem of overuse of the most expensive hospital doorway?
pcare doc
I know not every emergency doc will agree with the ACEP, but it appears–ironically–that your professional organization _wants_ every patient to be triaged in the ED rather than in a tooled-up primary care office (i.e., medical home).
Check it out:
http://www.acep.org/practres.aspx?id=42740
The ACEP is actually scared that medical homes might just eliminate unnecessary ED visits. Unreal.
ninguem
>>Not so much fun when someone makes overbroad misinformed generalizations about your specialty, is it?
That’s just bizarre. Do you always take offense when someone says you earn your pay?
I don’t know what your problem is White Coat, but the income figures are public knowledge from the specialty organizations, recruitment firms and all that.
Specifically, I know the billing codes for E+M services, I can look up the codes for the work, ER services, hospital admission, that sort of thing. I get the fee schedules from the insurers and Medicare. I also know the overhead figures for a primary care practice. Boy, do I know that. I’m paying to keep an office open when I’m in the hospital. So….yeah, about twice for that admit. I know full well you’ve got a nonpaying customer somewhere else, I’m talking about that one particular admit.
What you can’t do is read my mind. I don’t begrudge anything. I’m not blaming you for anything. I’m saying you earn your pay. But if it makes you feel better, I’ll stipulate that pay is 100% equal. Feel better?
Nothing else I wrote changes. Over the last decade or so, FP’s lost battle after battle after battle with privileges. You’re not seeing the FP’s in the hospital anymore because they were pushed out. Then many of them decided they liked it that way. I know I do. So I make social visits to my patients but don’t bill anything. Money-wise, it works out, I see more patients in the office in the time I would spend seeing one patient in the hospital.
Please forgive us for making lemonade out of lemons.
From what I see from my own hospital, the ER is the workup portal because the hospitalists are insisting on the workup there, before accepting the patient on the medical floor. But that may be a local matter.
Primary Care Internist
ER docs I’ve dealt with earn their pay and more (double probably). Same is true for most docs, certainly FPs and IMs. All of us do lots of charity care (esp ER docs who are essentially forced to, unlike us).
My first patient as an intern was a direct admission to my floor, literally on like the 2nd or 3rd day of internship to a busy NYC hospital with a new 2nd-year resident “supervising” me. I worked up and admitted an elderly woman in florid CHF, respiratory distress, hypoxic etc. She was sent to the floor a few hours earlier from her PMDs office and looked really bad. She was full code, had no IV line or bloods drawn, no meds given despite orders sent with her from her PMD hours earlier. No CXR. Her primary showed up a couple of hours after we admitted her and “gee guys, i don’t think she’s gonna make it”. She died that evening. I think she just had bloods drawn and got some IV lasix an hour before dying.
So to me, that is the point of admitting thru the ER. As primary care docs, particularly moving toward and outpatient-only model based on economics, we NEED the ER and its staff (particularly good nursing care compared to med-surg floors) to start the treatment that the patient would otherwise destabilize without getting quickly. There’s no point telling ourselves that a particular patient is sick enough to be admitted but can wait for workup/treatment for 12 hours or more.
I understand from an ER doc or nurses perspective, lots of non-urgent stuff is seen in the ER and that can be frustrating. But also sometimes the primary knows the patient and feels they aren’t at baseline, and a quick workup in the ER can be reassuring to both patient and doctor.
http://www.edwinleap.com/blog Edwin Leap
When I talk to residents or medical students, I say that in the emergency department, our job is to make one main decision: really sick or not really sick. The rest stems from that point. I think that, because we do it so often, we do it fairly well. And so, on some level, it makes a sense for us to be the ‘port of entry.’ the problem is it becomes all too easy; the patient from cardiology with the positive outpatient stress test gets sent to the ER, because either their own primary doc or the internist needs them ‘checked out’ first. Of course, they were checked out. And the cardiologist won’t admit them! Or, the primary care doc knows the problem, knows the need for admission (dka for instance), and although they have seen them in the office, wants them ‘stabilized’ (despite being stable) while they wait on a bed, or the hospitalist, (always overwhelmed) sees the ER as a place to ‘get the workup started.’ I understand the financial and even logistical imperatives from their standpoints. But it does rather clog up the department and add more hay through which to search for needles. And of course, we’re accused of costing too much, but just try to admit a patient to a hospitalist,for anything, without liver function tests, cbc, urinalysis, drug screen, etc., etc. Can’t be done!
We’re all in a mess, aren’t we? I don’t hold any particular animosity toward any group. But I find the emergency department just feels overwhelmed all the time; and this is part of the reason. It’s why my partner calls emergency medicine ‘the residency that never ends.’
Edwin Leap
family practitioner
Three basic rules of direct admissions:
1. definite diagnosis, ie cellulitis
2. definite treatment, ie antibiotic choice for cellulitis
3. NOT potentially acutely life threatening; this rules out many things including the most stable chest pain patient and chf. If it is acute enough to admit, it should go through the ER.
jsmith
Good comments all. Our hospitalists will accept direct admissions for stable pts so I feel fortunate about that. Ninguem is correct that a family doc who follows his or her own pts in the hospital is basically either a fool or a saint. Our group just stopped doing this January 1 of this year. Wow, quite an eye-opener. It would be hard to go back.
The ER docs do get dumped on. I feel bad about that. They have hard jobs and earn their pay.
JustADoc
I guess I am in a fairly ideal situation. I can walk to the hospital from my office in under 5 minutes. Hospital billing codes pay comparable to a outpt. 3.5(if such a thing existed) on average and that is no incremental overhead time if it is done before you’d have patients in the clinic anyway. Now if you live 20 minutes from the hospital and then it’s 15 minutes to your practice that is a different story. But if right next door it is still very financially viable. Well, at least no less so than FP/IM already.
anonymous
i wonder if the specialty type makes a difference when considering the opportunity cost of seeing patients in the hospital? if a busy fp might see 4 patients in an hour and a busy internist might see 2, does it cost more for the fp to see the inpatients and forego the hour in the clinic?

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