Home On the Wards Making nice with the ED

Making nice with the ED

July 2011

Published in the July 2011 issue of Today’s Hospitalist

"I CAN’T BELIEVE HE’S ADMITTING A GI BLEEDER and can’t even tell me what the patient’s hemoglobin is."

"If the patient is that low-risk and the chest pain is reproduced by palpation, why can’t you just send her home with a script for Motrin?"

"Did the ED have to give that much morphine? I can’t even take a history."

The ED doesn’t really have it in for hospitalists; it just seems that way sometimes. Part of the problem is that we “more than any other non-emergency specialty “spend more time in the ED, and we share many of the same problems.

Sometimes, it seems like working together is the surest path to a nervous breakdown. But learning more about why and how the ED works can pay off in many ways.

What motivates them
Most ED doctors are under contract to the hospital, which in these days of cost control produces a whole new kind of performance anxiety.

Quality improvement managers and committees like having numbers to look at, and for the ED, those tend to be door-to-needle time for strokes and MIs, patient satisfaction and "throughput." Electronic systems now track arrival times, nurse visits, order writing and when a doctor first sees the patient. A physician with unsatisfactory response times may be asked to take fewer shifts.

You’ll hear the term "dispo" a lot. Patient disposition may mean discharge home, hospital admission or holding for more tests. What this means to you is that once a patient meets admission criteria, the ED is under pressure to call whoever is admitting and record the disposition as quickly as possible. That old lady with hematochezia, the pyelonephritis patient whose vomiting can’t be controlled “no argument, they need to come in. The doctor calls before he’s even seen the CBC result.

But "soft" admissions “people who really don’t need inpatient care “are often the result of this pressure. Hence, you’ll see the asthmatic who could go home with a couple more nebulizer treatments or the teenager with witnessed syncope who just needs a fluid bolus.

Rather than chewing out someone in the ED about these patients, it’s quicker to discharge the patients yourself, as long as they have good follow-up. If the asthmatic has no insurance and lives with a smoker, however, admitting her may be less trouble than being called again four hours later when she’s back in the ED.

Different job, different rules
There was a time when "emergency physician" just meant "any doctor willing to work there" “moonlighting residents in almost any specialty or local docs looking for extra income. But since 1988, the American Board of Emergency Medicine has required residency training in the field to even take the certifying examination, which covers just about all branches of medicine.

While ED docs know something about everything, they are not experts in any one field. So the cardiologists point to subtle EKG changes that were missed, pediatricians worry that developmental problems are not taken
into account … and the ED doc gets very little respect. On the other hand, emergency nurses are far higher on the hospital totem pole than their counterparts elsewhere. Their job requires more initiative in evaluating patients and making decisions, and they have clinical skills that take months to instill in med students.

The ED is probably the only part of the hospital where you will hear a nurse tell a doctor what to do. That nurse was there when the ambulance brought the patient in and may have learned far more from family members than the doctor did. If the patient’s physical findings change, the ED doc may be somewhere suturing a laceration, and it’s the nurse’s job to make him get back to Mr. Chest Pain before the aneurysm dissects further.

Word to the wise: You need these people whether they’re nurses, EMTs or doctors. Treat them with respect.

Red flags
Still, some situations indicate that the ED has a serious problem, one that may require outside help. Health care reform has not addressed the shortage of primary care doctors, so patients can be expected to continue to fill the ED needing care that they could (and should) receive as outpatients.

But before you complain about ED care, look around while you’re there. Is every room full? Do the nurses have trouble keeping up? How many patients who arrived in the last two hours have CPR in progress?

If this is unusual, let it go. But if every time you’re in the ED, the place is on the verge of meltdown, somebody needs to get busy. The hospital’s chief of emergency medicine may have been trying for months to get more staff or funding, and adding your group’s voice to his or hers may help get the administration’s attention.

Changes to make

  • Hold regular meetings with ED staff. If you’re lucky, these will include a nursing representative. Regular sit-downs will let you look at trends, explain admission criteria, request access to ED software and handle problems after everyone has cooled down.

    Bring other hospitalists to these meetings, even those in competing groups. These meetings are the best place to discuss changes you both can make, and you may be surprised to learn that some of your habits are slowing their care down too.

  • Don’t grumble. Rather than griping about "doing the ED doctor’s job," help out when you can. Our hospital recently had so much trouble with downcoding that a case manager now reviews all ED admissions to be sure they were properly assigned to ICU, observation or inpatient admission.

    If you multiply three minutes per phone call times the number of patients admitted per shift, you can imagine how happy the ED guys were when we offered to take over those case manager calls for our own admissions. The same goes for admission orders on patients you can’t see immediately. Talking to the nurse and giving phone orders will free the ED doctor for other chores.

  • Criticize behaviors, not people. If an ED staff member seems to be causing problems, find out if anyone else has noticed, just to be sure it’s consistent. If you must criticize, focus on specific actions and areas where ED physicians need to improve.

You know how long it takes to break in a new hospitalist. Well, ED doctors deal with the entire medical staff, so training a replacement for one who "knows the territory" is much harder than getting someone to change their practice.

Hospitalists and ED staff face many of the same pressures, from 24/7 availability to increasingly limited re- sources. Talking over shared problems and finding out what you can do to support each other is the best way to build not just a relationship but an alliance to improve patient care.

Stella Fitzgibbons, MD, did a one-year fellowship in emergency medicine and worked at a number of EDs in the Houston area before realizing how much better suited she is for hospitalist work.