ASK HOSPITALISTS about what happens when the ED wants to admit patients, and you’ll get an earful. ED physicians, they say, regularly make end runs around them with admission requests, first calling specialists who invariably recommend that the patient be admitted to internal medicine.
Or ED doctors click their electronic decision-to-admit button, time-stamping that decision, before they even talk to an admitting provider. Or the ED requests an admission before it has any of the labs or tests back that hospitalists need to decide if the patient should go to the ICU or not.
Ann Kellogg, DO, assistant director of the hospitalist program at Sky Lakes Medical Center in Klamath Falls, Ore., describes how admission requests play out at her hospital: Hospitalists end up discharging from the ED about 10% of the patients that emergency physicians think should be admitted. And “the ED mislabels between 15% and 20% of admissions, due to patient severity, and we routinely have to do a significant amount of work-up after the ED signs out,” Dr. Kellogg says. “We have to be very proactive to make sure patients aren’t sent to the wrong floor.”
“The ED mislabels between 15% and 20% of admissions, due to patient severity.”
~ Ann Kellogg, DO
Sky Lakes Medical Center
Such scenarios highlight a longstanding tension between the ED and hospital medicine. All too often, the ED wants to identify patients too sick to go home—and let hospitalists figure out where in the hospital those patients need to go.
But in recent years, that tension has been stoked by different metrics being used for ED physicians and hospitalists. For several years, a portion of the reimbursement of many ED physicians has been pegged to several time measures that include patients’ door to diagnostic evaluation time and admission-decision time (typically, when the ED requests an admission) to ED departure time for admitted patients.
ED departure time has a lot to do with when an admitting provider (usually a hospitalist) puts in an admission order. As a result, EDs are pressuring their colleagues on the receiving end of admissions. Hospitalists complain that some EDs even cut corners—with inadequate work-ups, for instance— to make their own times look better.
For now, most hospitalists aren’t being incentivized on how long it takes them to file admission orders on requests. But with ED clinicians watching the clock and hospital administrators pushing ED throughput, hospitalists are under growing pressure to reduce the time they spend evaluating potential admissions and filing admission orders.
How long should orders take?
Another cause of the tension with the ED is that ED doctors often identify hospitalists as the path of least resistance in terms of admissions that should instead go to other specialties. ”I often hear that hospitalists should have ‘a culture of yes’ and that we should just take on any patient or transfer,” says Kendall Rogers, MD, division chief of hospital medicine at the University of New Mexico Hospital in Albuquerque. But besides not serving the best interests of patients who would be better cared forby another service, he says, that approach is “an incredible danger to professional satisfaction in hospital medicine.”
“I’ve pushed back with a 60-to-90 minute window.”
~ Karri Vesey, RN
Before requesting an admission, Dr. Rogers says he expects the ED to complete a work-up to determine not only that the patient should be admitted, but what the appropriate admitting service and level of care should be. In addition, for urgent conditions like sepsis, he expects the ED to start initial treatment, like antibiotics and fluids.
But “we have variable success” nationwide in having EDs make those determinations, he points out. “Too often, hospitalists have to do the primary work-up to make those decisions, and that greatly increases how much time it takes between the request for admission and the admission order.”
Because work-up delays are so common, many hospitalist groups object when EDs push to speed up admission orders. At Billings Clinic in Billings, Mont., for instance, Karri Vesey, RN, the hospitalist department program manager, says the ED wants hospitalists to place admission orders within 30 to 60 minutes. “But I’ve pushed back with a 60-to-90 minute window, and I feel that’s fair,” she says.
Ms. Vesey also tracks how long it takes between admission requests and admission orders. “I always look at how many of our providers are outliers and why,” she adds. “When we get three admission requests five minutes before an ED doctor goes off shift, the time it takes to get to admission orders shouldn’t be on us.”
Still, hospitalists are working hard to process potential admissions faster—sometimes with unintended consequences.
“We’re seen as the easier admission option.”
~ Brian McGillen, MD
Penn State Health Milton S. Hershey Medical Center
At Penn State Health Milton S. Hershey Medical Center in Hershey, Pa., hospitalist Brian McGillen, MD, says that his group began collaborating with its ED in 2017 to help the ED find an accepting service faster. They put in place this workflow change: If the ED calls a particular service with an admission and that service doesn’t feel it should admit that patient, that service—not the ED, whose primary job it had been previously—is now responsible for calling the department it believes is more appropriate.
The good news is that the time between admission request and admission order has fallen from a median of 90 minutes to 68.
The bad news: The hospitalists were immediately identified as “the service most likely to get patients in quickly, and the ED now calls us for admissions that may be better suited for other services,” Dr. McGillen says. That’s left the hospitalists stuck calling different services, then admitting patients themselves when other departments say no.
“Our higher census bears that out, and it hasn’t boosted our morale,” he says. “What was supposed to be a collaboration has shifted work to us because we’re seen as the easier admission option.”
A screening role
At the University of Virginia in Charlottesville, the ED likewise complained about delays in admission orders, particularly when resident teams were called to admit. The ED also had to spend time figuring out which of several general medicine admitting teams they should call.
“Some of these times are dropping just through competition.”
~ Sheryl L. Williams, MD
Baptist St. Anthony Hospital
To solve those problems, the hospitalists in 2016 created a new position: that of admissions and throughput coordinator (ATC). The ATC hospitalist takes all ED admission requests, as well as all requests for direct admissions and transfers.
“The ATC serves as a filter for obvious mistakes,” deflecting admission requests that should go to other services, explains hospitalist director George Hoke, MD. The ATC has helped the group shave significant time off its median time to admission orders.
But when the ATC refuses an admission request, who’s supposed to call the next service line to admit? Unlike at Hershey Medical Center, Dr. Hoke says, that responsibility reverts back to the ED—most of the time.
“If I know there are certain magic words that need to be said to get cardiology to accept that admission, I may make that call myself,” he says. And if the ED calls cardiology and cardiology refuses the admission?
At that point, “if a cardiologist saw the patient in the ED and is still refusing to admit, hospital medicine will take that patient,” he says. “Everyone is tired of waiting.” But if he believes a department is refusing an admission due to some misunderstanding, “I’ll call the attending and discuss. Sometimes, you have to cut out the layers and go to the top.”
According to Dr. Hoke, only half the hospitalists in his group rotate through the ATC role.
“Sometimes, you have to cut out the layers and go to the top.”
~ George Hoke, MD
University of Virginia
“You need some institutional knowledge and that takes years to build, plus you need to know who’s sick enough for the ICU,” he says. “That can be hard for a novice doctor.” And because services get in admission stand-offs, “we’re often asked to mediate and decide where the patient would get the safest care.”
At Hershey Medical Center, Dr. McGillen says the hospitalists and the ED, as well as all the other service lines, are in “sustained discussions” to figure out how to shift more admissions away from hospital medicine and to a more appropriate service. In the meantime, he’s sat down with both the cardiology and orthopedic departments and hammered out admission guidelines for the ED to use.
“We’ve said, ‘Here are the conditions under which you should call this particular service,’ ” he notes. “That’s helped.” It’s also helped to have utilization management nurses embedded in the ED who point out when patients don’t meet admission criteria and steer those patients to observation instead.
But at Billings Clinic, the hospitalists realized they had an admission bottleneck due to legacy care management-utilization management practices. As Ms. Vesey points out, the ED used to not be able to request a bed for an admission, even after a hospitalist or specialist agreed to accept that patient.
“Care managers in the ED used to have to look over all admission orders, and it wasn’t until you got their blessing that you could request a bed,” she says. “Sometimes, that could take time.” Now, the ED can put in preliminary bed requests as long as the admitting service (usually the hospitalists) agrees the patient needs to be admitted. “That gets the ball rolling in bed board and on the floor.”
To improve median times to admission orders, groups are also green-lighting ways to place orders sooner for slam-dunk admissions, even before hospitalists evaluate patients in the ED. At the University of Virginia, for instance, “the ED can request a ‘fast-track’ evaluation” for a patient it considers a straightforward admission, says Dr. Hoke.
“When you’re past capacity, the rapid admission is not your most important throughput metric.”
~ Kendall Rogers, MD
University of New Mexico Hospital
In such cases, the ATC OKs the fast-track admission over the phone and allows the ED to put an admission order in, even before calling the resident or hospitalist admitter to go see the patient.
At Baptist St. Anthony Hospital in Amarillo, Texas, hospitalist Sheryl L. Williams, MD, the hospital’s medical director of quality, baselined the hospitalists’ data on their median time to admission order earlier this year. She found it was between 60 and 70 minutes.
“So we thought, ‘How can we make this time shorter?’ ” she says. She and many of her fellow admitters—and in Dr. Williams’ group, admitters do only admissions and don’t rotate between admitting and rounding—have started putting in single admission orders on patients they consider slam-dunks.
“We do this before we walk in the door to evaluate the patient,” she says, “and the order specifies the admitting physician, the attending and the level of care required.” That order allows for early bed assignment and preparation for transfer. It has also “cut anywhere from 15 to 45 minutes off our time clock.” A full set of orders can then be placed as patients are prepared for and transported to their destination floor.
What’s also worked is making a chart every month out of individual hospitalists’ median times to admission orders, color-coding it green, yellow and red, and posting it on the wall of the hospitalists’ office.
“It’s in a locked office so we’re the only ones who see it,” she says. “Some of these times are dropping just through competition.”
The case for full staffing
At the University of New Mexico, Dr. Rogers says that several initiatives now being discussed or implemented should help speed up admissions.
For one, the hospitalists plan to start staffing a 24-hour ED triage role. They are also about to implement having all admission requests be communicated between ED and hospitalist attendings, not residents.
And a new position at his medical center with 80% protected time begins this month: an executive director of patient flow. Dr. Rogers says that physician, a family medicine hospitalist who’s worked at the center for years, will “help further develop admission guidelines, evaluate different chokepoints in the admission process and intervene when admitting services disagree.”
Dr. Rogers also points to other factors that he believes are lost in the rush to beat the clock.
“When you’re past capacity, the rapid admission is not your most important throughput metric,” he says, adding that his center is almost always over 100% capacity. “Anytime you have ED boarders, your most important metrics are being able to dispo patients out of the hospital and prevent unnecessary admissions.” To that end, his hospital medicine division just got the approval it needed to hire significantly more FTEs. Many will be devoted to day coverage.
“You can’t put all your resources upfront and not be clearing beds,” he points out. “To facilitate throughput, we need full staffing upstairs first.”
Ramping up observation
Dr. Rogers says he’d also like to see standardization nationally of ED observation.
“In some institutions, ED observation is used for only a small, defined number of conditions,” he says. Some hospitals, however, are placing patients in ED observation as soon as ED physicians can’t make a definite admission decision about patients after initial studies come back or when they need to wait hours for test results. “That use of ED obs status can have a big impact on reported metrics.”
We also need, Dr. Rogers adds, agreement on when the time stamp for “decision to admit” occurs. “Once you have a complete work-up that determines the need for admission and the appropriate service and level of care, that’s the time you can make a decision to admit.” Further, “that time should be mutually agreed upon by both ED and hospitalist attendings.”
And despite hospitalists’ frustration with the ED, Dr. Williams counsels taking a collegial—and interdisciplinary—approach.
“We have a whole bunch of buckets: the door-to-doc bucket, the doc-to-admit bucket, the decision-to-admit-to-admission-order bucket,” she points out. “All the doctors involved know how to game their own buckets—and then we all dump on the nurses who are charged with actually getting the patients out of the ED.”
Instead, “we should all be looking at the entire length of stay in the ED,” says Dr. Williams, “not trying to offload time on one another.”
Admission orders and quality incentives
HOW CLOSELY ARE hospitalists being tracked on how long they take to put in admission orders after the ED requests an admission? And should hospitalists be incentivized for that time as part of a group—or even individual—quality bonus?
At Penn State Health’s Milton S. Hershey Medical Center in Hershey, Pa., hospitalist Brian McGillen, MD, notes that his group’s times are measured and reported every week.
Interested in more about hospitalist incentive plans? See What’s in your incentive plan
But “it’s a service-line only measurement,” he notes, adding that the data are shared among only the inpatient service leadership. “The data go down to the physician level, but we tend to not pull out names.” And while his institution hasn’t suggested making the metric part of hospitalists’ quality bonus, he says he “would have pushed back hard” against any such effort.
“There are too many factors at play that an individual hospitalist doesn’t control,” says Dr. McGillen, adding that he worries that the “right” admission is being sacrificed for the “fast.”
But at Sky Lakes Medical Center in Klamath Falls, Ore., the hospitalists several years ago did include a 90-minute window between admission request and order as one of several metrics that made up their quality bonus. The group got rid of that metric last year, says Ann Kellogg, DO, assistant director of the hospitalist service, because “we were all largely meeting it.”
“We have a residency program separate from our hospitalist service and we work with residents at night,” Dr. Kellogg says. “They routinely aren’t able to get that time under 90 minutes, but the hospitalists had no problem.”
And at Baptist St. Anthony Hospital in Amarillo, Texas, Sheryl L. Williams, MD, the medical director of quality for the hospital, says that she and the hospitalist medical director are considering making the metric part of the hospitalists’ quality bonus, beginning next year. They haven’t yet decided whether to make it a group or individual metric.
But before such an incentive could be put in place, everyone would need to agree on certain ground rules. Chief among them: What constitutes a true outlier?
“Say the ED first tries to get the surgeons to admit, but the surgeons refuse and then the ED asks another service and then another,” Dr. Williams says. “Finally, the hospitalists—because we are at the bottom of the hill—admit the patient.” That all adds up to a three-hour delay that hospital medicine shouldn’t be dinged for. “There needs to be a legitimate way to scrub out the outliers.”
Published in the August 2019 issue of Today’s Hospitalist