Published in the February 2018 issue of Today’s Hospitalist
WHO GETS TO DECIDE which patients are admitted to the hospital? That’s been a hot topic of debate since the early days of hospital medicine, but as our cover story explains, the conversation is further complicated by the sharp rise in the use of observation care.
On a good day, the decision to admit a patient (or not) can be complex. Emergency physicians face tremendous pressure to dispose of patients quickly and efficiently, but hospitalists don’t want soft admissions dumped on them that they’ll just have to turn around and discharge.
Into that pressure cooker of an environment came the two-midnight rule, which puts a strain on hospitals to avoid admitting patients altogether. The rule can add another twist to admission decisions—and possibly expose patients to a host of unnecessary expenses, particularly if they don’t really need that placement after all. And while hospitalists at many hospitals have the authority to re-evaluate or flat-out reject an admission decision, admission standoffs can be frustrating for everyone, patients included.
Deciding whether patients are admitted, placed in observation or discharged from the ED gets at bigger issues of cooperation and communication. Hospitalists in facilities where those decisions are made collaboratively say it’s important to recognize the different skills and priorities that each specialty brings to patient care.
They also say that when such decisions break down into “us vs. them,” it’s a sign that hospitalists may be burning out—and that they need to sit down with their ED colleagues and hash out some ground rules they can all agree on.
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