Avoiding the ER and arranging a direct admit is not easy

Are emergency departments solely responsible for the bulk of unnecessary tests?

Most would like to believe so, but emergency physician Edwin Leap says that’s not the case.

He cites an instance involving a primary care doctor and hospitalist:

Local physician, who does not admit to the hospital, sees patient in the office. Patient has uncontrolled hypertension and is having some chest pain and shortness of breath. Local physician contacts hospitalist. Hospitalist who could reasonably direct admit patient, says, ‘better send them to the ER first.’

Or this one, involving cardiology tests: “… patient is having outpatient cardiac catheterization or stress test. The test is positive. The patient has a physician, who could be contacted. The cardiologist says, simply, ’send them to the ER.’ Why is this? Why couldn’t they be admitted directly?”

The reason, of course, is that arranging a direct admission and filling out the necessary paperwork takes time. And when primary care doctors are already seeing 30 patients a day, taking additional time to track down and call the consultant and then fill out order forms needed for a direct admission will only put the doctor further behind schedule.

Contrast that option with, “Go to the ER,” and it’s no wonder why this is happening.

Most doctors realize it’s cost effective to avoid the ER, but with the way our health system is structured and incentivized, there’s little reason to do so.

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  • http://www.admc.org Denise Williams

    I would like to know if it is acceptable for and ER physician who does not have admitting privileges to write the admission orders for a patient that is being accepted by our hospitalist?

  • csmith

    I directly admit to the hospital from the office all of the time. I admit to my service. It takes about an extra 5 minutes to write the orders and make arrangements for a reasonably stable patient.

  • http://drpullen.com Edward

    This has been my experience exactly since I moved to an office farther from the hospital and started using hospitalist services. I call the hospitalist, and they usually recommend the ER. I have to say I have had pretty good success with just asking, “Why?” Explaining that the patient is stable, and that I would admit directly if I were still doing inpatient care. As primary care docs we need to challenge this shirking of responsibility of patient care off onto the only docs who cannot say no, i.e. the ER docs.

  • BladeDoc

    Or it could be that the physician feels that the patient needs immediate testing to rapidly rule in/out an acutely life threatening injury/illness. I don’t know how your hospital works but a “direct” admit to my hospital goes though our pre-admission unit. Where paperwork gets shuffled for 1-2 hours. Yes you can get bloodwork but not a stat CXR, an EKG takes about an hour, and CT laughs at you if you order a stat from the PAD unit. AFAIC it is poor patient care to send them to the PAD in my hospital if you are concerned about anything acutely life threatening. YMMV.

  • family practitioner

    Chest pain is not a direct admit.
    Cellulitis is.

  • jsmith

    If the pt is unstable or might have an MI or something, the ER is the place. These days it seems as if most of my admits are unstable, in contrast to, say, 20 years ago. A lot of my pts that would have been hospitalized in 1990 are now treated as outpts.
    This is also an example of supply-induced demand. If the ERs 20 years ago had been as well-staffed with good board-certified docs, as they are now, we probably would have used them more. Build it and they will come.
    Everyone in this game is between a financial and/or time rock and hard place. Society gets the bill.

  • pheski

    The transition between the outpatient world (PCPs in my instance, but this issue is not limited to PCP-hospitalist interactions) and the inpatient world became more fragment and complex with the advent of hospitalists.

    (Let me note up front that the hospitalists I work with are crackerjack – skilled, compassionate, dedicated and well organized. My comments should not be taken as criticism of hospitalists.)

    Picture the healthy child or young adult with a flare of asthma (or the older adult with lare of COPD) who calls after hours or on a weekend. BH I would have met them in the ED, started the evaluation (history, exam, history, selected lab and xray if needed) and drawn on my knowledge of the patient over years and through similar episodes. During this time, treatment would often be started. The patient might be admitted (by me, to me) or kept for a few hours (by me), or discharged for close outpatient followup (by me). In any of these events, the evaluation was done (and billed for) once and detailed information about the patient stayed with the patient through both transitions. I am not at all sure that the 1-2 day savings of hospital days is enough to counterbalance the savings from avoiding duplication (2-3 evaluations and invariably MUCH more lab and xray), or the time lost when I have to schedule an extended amount of time for the follow-up patient because following up on a 7 day hospitalization requires more than reading a 2 page discharge summary and having my nurse update the med list.

    The ED physician rarely calls to discuss the patient during the evaluation or in preparation for discharge, though will sometimes ask the nurse to cal the office for information (allergies, meds, last tetanus) or to schedule a follow-up. Even if I call and speak to the ED doc and specifically ask them to call and discuss the case, it rarely happens. Shift change prevents it some, but I think it is perceived (wrongly) that I am asking them to be my remote agent, rather than a colleague. I’ve gotten ER 2 docs over this, but it took a conversation over dinner and beers on my tab and invitation.

    Now, when I get that call, I mostly send the patient to the ED. The hospitalists won’t see and evaluate them in the ED except for very rare circumstances – they see that as the outpatient world and off limits. The ED will evaluate them, but their mindset is (appropriately) to as much time and money as necessary to prove they don’t need to offer an immediate life-saving intervention (that’s their job) and then simply to determine who will take care of them and how to cover them for the several hours (if admitted) or several days (if discharged).

    Even if it is during office hours and I am seeing them in my office, I can only very rarely get the hospitalists to directly admit. They prefer to have them go through the ED, where lab and xray and IV starts and nursing attention happen much faster than on a medical floor. This also means that the patient has been pre-digested before they start, saving them time and energy.

    These are all skilled, competent, dedicated clinicians doing the best they can in a complex setting that is very fault-intolerant and has some of the most perverse incentives and disincentives one could imagine.


  • http://glasshospital.com John Schumann, M.D.

    I agree that the ER has become the final common pathway (lowest common denominator?) of triage and entry to the hospital, in spite of the fact that it just adds to the ER’s crunch problem.

    This is a quality and patient experience problem for our patients, who wind up waiting much longer and perhaps needlessly. It’s also a shame for our trainees who no longer think through patient admissions but instead recite what’s been done in the ER.

    My lament is here:

    -Dr. John

  • stargirl65

    My hospitalists won’t allow any direct admits. They said they got burned too many times on “stable” patients. These patients would code or crash and burn before they even got to see them on the floor. Sometimes no one would tell the docs that the patients were there and the patient would be languishing on the floor without orders. This could be for hours as the hospitalists are very busy. If they go through the ER they can get triaged, watched, and properly admitted to the correct place on the correct unit.

    • ninguem

      Same here. Same reasons.
      Can’t say as I blame the hospitalists.

    • AmyT

      I am a hospitalist and this is the exact reason I rarely allow direct admits. I work in a small community hospital and specialist care is limited. I may not have the resources to care for that patient. It is much easier to transfer for higher level of care from the ER. For example, I accept a stable direct admit with belly pain and vomiting. They get to the floor and are found to have a gallstone in the common bile duct. This requires ERCP and a gastroenterologist. I do not have these at my hospital and the patient has to be transfered. This can take hours to accomplish on a patient who has already been admitted. It can be done much faster in the ER.

  • joe

    “Patient has uncontrolled hypertension and is having some chest pain and shortness of breath”

    You want to direct admit this guy?

    I too as a former hospitalist was burned one to many times by a clinic doc who described to me a “stable patient” that was anything but stable on evaluation. .

  • ER doc

    If I never hear “my doctor was too busy so he said to go to the ER” for a runny nose again, I’ll take all the “this should have been a direct admit” you can dish out.

  • TrenchDoc

    Another issue are the lack of open hospital beds at certain times of the year. You can’t have a direct admit cellulitis waiting 12 hours to get in a hospital bed and start IV antibiotics.

  • ninguem

    This is a side-effect of the trend of physicians closing their hospital practices. I can direct admit my own patient, from my own office, to my own hospital service. Actually, it’s quite efficient, in that I have the whole H+P and relevant documents in my posession. I just fax them over to the charge nurse.

    A direct admit to a hospitalist service can be a dump. Not always, of course, but often enough that I can understand a “no direct admit” policy across the board.

  • Hospitalist

    Our group often directly admits patients. Even from some specialists’ offices. We have definitely been burned a few times as well, but the majority of the time, a thoughtful conversation is held between the hospitalist and the PCP and a mutually agreed upon decision is reached. All of the above reasons for not directly admitting are valid concerns though.

    Be careful about blaming hospitalists for the breakdown of the good old days of the family doc following the patient everywhere. As someone said above, “build it and they will come”. In my community, as a PCP, you don’t HAVE to give up your priveleges to the hospitalist service. Many choose to though. We can’t recruit fast enough to keep up with the PCP demand.

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