Home Cover Story Sprinting past the ED: When are direct admissions a good idea?

Sprinting past the ED: When are direct admissions a good idea?

Hospitalists find ways to streamline the direct-admission process

April 2016

Published in the April 2016 issue of Today’s Hospitalist

FOR YEARS, the process of directly admitting patients at White River Medical Center in Batesville, Ark., was a challenge. As a result, Miguel Villagra, MD, medical director of hospital medicine, and his team began working to improve patient access and enhance their working relationship with local primary care physicians.

They realized that no practice guidelines existed for direct admissions, which led to inconsistencies in the process. Patients were experiencing admission delays—and referring doctors received conflicting information about criteria for direct admissions vs. referral to the emergency department.

After assuring local physicians that the center wanted to retain their referrals, Dr. Villagra developed guidelines based on clinical best practices that spelled out who should—and should not—be directly admitted. A primary care doctor who determines that a patient seen in his or her clinic is not doing well on oral antibiotics can refer that patient for direct admission.

“Having guidelines makes it easier for me to know if the patient should go to the ED.”


 ~ Miguel Villagra, MD, White River Medical Center 

But patients presenting to a clinic with unstable angina or acute neurologic symptoms need to be referred instead to the ED for immediate evaluation. Further, group guidelines now point out that any patient being considered for direct admission has to be evaluated by a primary care provider that day.

“We work together to discuss the best plan of action with the shared goal of doing what is best for the patient,” says Dr. Villagra. “Communication is key.”

A reduced number of direct admits
In hospitals around the country, it’s no wonder the direct-admission process can become divisive. Fewer hospitalists, after all, have outpatient experience, so they may not see the advantages of direct admissions. Instead, they worry about the risks of making quick decisions in a unit not designed for the task.

And one bad experience can color a program’s entire perspective. Dr. Villagra, for example, talked to one hospitalist from another medical center whose group stopped taking direct admissions after one malpractice case, which involved a direct admit, cited delayed care.

A perspective published online in November 2015 by the Journal of Hospital Medicine (JHM) found that the number of direct admissions in U.S. hospitals had dropped by 1.6 million between 2003 and 2009. Lead author JoAnna K. Leyenaar, MD, MPH, MSc, a pediatric hospitalist at Tufts Medical Center in Boston, thinks that decline is linked to the rise of hospital medicine.

That’s because the specialty “creates purposeful discontinuity between the inpatient and outpatient setting,” Dr. Leyenaar says—and direct admissions particularly suffer from that lapse in communication.

And given the lack of continuity between the outpatient and inpatient settings, “hospitalists may be concerned about the quality and safety of direct admissions,” she adds. “They are most comfortable with established triage procedures, and bypassing the ED means bypassing those procedures as well.” She notes, however, that preliminary data don’t show any link between direct admissions and readmission rates or ICU transfers.

In a study published in the September 2014 issue of JAMA Pediatrics, Dr. Leyenaar and her colleagues found that more than one-third (36%) of pediatric patients with pneumonia were admitted directly. Further, while 2% of those patients ended up in the ICU within 12 hours (about the same percentage as for similar patients admitted through the ED), direct admissions did reduce costs.

Improving the process
Instead of pointing to disconnects as a reason to avoid direct admissions, Dr. Leyenaar urges hospitalists to find ways to enhance communication. “We propose,” she and her colleagues wrote in their JHM article, “that transitions of care research and quality improvement, historically focused on hospital-to-home transitions, be expanded to address transitions into the hospital.”

In Arkansas, Dr. Villagra’s group shared its guidelines—including a cover page with hospitalists’ contact information and photos—with local primary care providers.

Those providers can now call a direct-admissions hotline where a registered nurse who’s with the hospital medicine department takes patient information and then discusses each case with a hospitalist.

Dr. Villagra expects to have hard data on the revised process by this summer. But he already notes that direct-admission patients are in beds faster and that outpatient doctors have fewer complaints.

“They know it’s not just, ‘Dr. X doesn’t want my patient,’ ” he says. “We’re doing the best we can to evaluate each patient’s condition.”

Small vs. large hospitals
According to Dr. Villagra, deciding if and how to accept direct admissions depends on location, the size of the hospital or health care system, and whether primary care doctors are part of the same system.

The 235-bed White River Medical Center, for example, is the nearest hospital for some rural clinics and providers that prefer to send patients to a hospitalist to avoid long waits in the ED. “We have a duty to respond and help them,” he notes. “Having guidelines makes it easier for me to know if the patient should go to the ED.”

When James W. Leyhane, MD, worked at the 99bed Auburn Memorial Hospital in Auburn, N.Y., direct admissions were banned because too many patients presented differently than expected. People sent for heart failure might arrive with other medical issues, for instance. One direct admit with renal failure had to be transferred to a hospital a half hour away because Auburn didn’t have the ability to perform dialysis.

But larger hospitals don’t have those limitations, nor the malpractice risks such factors pose. When Dr. Leyhane moved to the 450-bed St. Joseph’s Hospital in Syracuse, N.Y., where he is now hospitalist service director, he knew direct admissions would be different because physicians have access to specialists and equipment. Hospitalists, for instance, can immediately call an invasive cardiologist for a patient presenting with an acute coronary syndrome.

And circumstances at the new hospital also have driven more direct admissions: The hospital saw a jump in patient volume after opening a new ED in 2013.

“There was a big push to unclog the ED,” says Dr. Leyhane, “so we were asked to start accepting more direct admissions.” The hospitalists have increased the number of direct admits from zero or one a day to about four. (The group admits about 40 patients a day.)

Right and wrong approaches
But some hospitalists find that direct-admission volume can be overwhelming. Joseph Messina, DO, MBA, is managing director of Coastal Medical Group, based in Isle of Palms, S.C. A traveling hospitalist, Dr. Messina says his group staffs start-up programs until permanent physicians are in place.

He recalls working at one hospital where he felt “trapped in the middle” when pushed to directly admit more patients to help raise the hospital census. Because the facility had lost some cardiologists, hospital administration was encouraging outpatient physicians to have their patients bypass the ED—inappropriately, Dr. Messina believes—and wait for hours to be seen in the ICU by a hospitalist instead.

“We were getting calls for direct admits for unstable patients with a blood pressure of 220 systolic because primary care physicians said they were told by the hospital CEO to do so,” he says. “I thought that was wrong to direct admit to the ICU.” Dr. Messina says he stopped working at that hospital before the issue was resolved.

At St. Joseph’s, meanwhile, Dr. Leyhane was given the go-ahead to develop his own protocols.

He talked to primary care doctors in person and explained those guidelines. He also handed out cards listing direct-admission criteria, the phone number to call and details of how to arrange a direct admission. If a patient is denied admission, the hospitalist turning the admission down must notify Dr. Leyhane or his assistant, who then reviews the decision.

According to Dr. Leyhane, early signs have been encouraging. ED volume is holding at about 200 patients a day, despite the fact that the hospital now has a larger catchment area due to smaller hospitals in the area looking actively for larger hospital partners. And while he doesn’t have data on diagnosis codes of patients who have been directly admitted, he believes those patients have had a lower length of stay.

The benefit of outpatient experience
Implementing protocols doesn’t have to be a formal process. Matthew George, MD, medical director of the hospitalist service at the 400-bed Mississippi Baptist Medical Center in Jackson, Miss., takes an informal approach by drawing on his own six years of outpatient experience. “I can put myself in that referring physician’s shoes,” he says. “Is this a patient I would normally admit from my clinic?”

Dr. George notes, however, that this strategy will not hold up as hospital medicine matures. “We have fewer hospitalists who have practiced traditional outpatient and inpatient medicine,” he says. “They seem to have a much higher aversion to direct admits than physicians with experience in both settings.”

At the same time, Dr. George notes that his center has re-engineered its direct-admission process. Previously, a medical officer of the day would handle calls requesting a direct admission. While that strategy made sense, transferring information to hospitalists taking those patients was problematic.

“The person taking the admission was at the mercy of the memory of the medical officer of the day,” he says.

Today, Mississippi Baptist still uses that model to handle direct admissions, but it has made some changes. When a request comes in, the medical officer now enters the details on a shared computerized spreadsheet. That information includes the time of the call, the referring physician’s name, the patient’s name and age, a brief clinical history, and a plan of action for when the patient arrives.

The medical officer also verifies that the patient is stable enough for a direct admission. On an average day, Dr. George notes, the medical officer fields about three calls for direct admissions (and several more for transfers). To further reduce patient wait times, the medical officer of the day also requests subspecialty consults before patients arrive and can place preliminary orders.

And to speed the process even further, once direct admissions have been cleared, patients go directly to the floor to be seen by the hospitalist who is up for the next admission. Previously, says Dr. George, direct admissions used to be first assigned to the medical officer of the day.

A physician access line
For direct admissions, the hospitalists at the 853-bed Wake Forest Baptist Medical Center in Winston-Salem, N.C., have for several years used a 24-hour physician access line.

An attending physician, who can be a hospitalist (for general medicine patients) or a subspecialist, answers that line. If a patient is accepted, the transferring physician is asked to send progress notes and images (if available) and to call if the patient’s clinical status changes.

As hospitalist Pankaj Kumar, MD, explains, acceptance triggers a call to the nurse in charge of the patient’s accepting floor. This creates continuity of care and decreases errors in patient handoffs during transition.

The line also allows for conference calls. “We can hold a three-way conversation, for instance, if we need a neurologist’s opinion to create a broader plan for the patient and maintain continuity of care,” Dr. Kumar says.

At Primary Children’s Hospital in Salt Lake City, asking for a direct admission used to trigger a haphazard phone tree that typically started with an admitting resident. However, the hospital, which is owned by Intermountain Healthcare, launched a revised direct-admission system in 2007, prompted by calls from the ED to increase efficiency and patient safety.

Today, the call—which is recorded for safety and liability reasons—goes to a dedicated call line. An Intermountain dispatcher contacts the hospitalist while others are conferenced in, such as the nursing supervisor
and admitting resident, a surgeon or surgical fellow.

“When I was a community physician looking at a child in my office who I believed should be admitted, it was strange to justify that to a resident,” says pediatric hospitalist Laura N. Hodo MD, MSC. “An attending-to-attending conversation is a better way to go.”

“The decision to directly admit is mainly left to the discretion of the referring provider who we feel has better knowledge of the patient, although all those involved in the call are encouraged to give their input,” says Jeff Van Blarcom, MD, also a hospitalist at Primary Children’s. Dr. Van Blarcom was the lead author of an article in the March 2014 issue of Hospital Pediatrics describing the system’s development and implementation. He also points out that direct admissions now comprise 15% of all admissions.

At the same time, the hospital continues to improve the process. It has, for instance, added a direct-admission module to its existing patient-tracking computer program to make sure direct admissions are not inadvertently diverted to the ED.

Expect surprises
While protocols and dedicated phone lines help, Mississippi Baptist’s Dr. George warns that even the best-laid plans can go awry. A patient may deteriorate en route or may not have been accurately assessed before being sent. To prepare for such contingencies, a nurse at his medical center makes sure direct admissions are stable when physicians can’t see them immediately.

And when patients aren’t quite as sick as expected, they can be placed in observation status. To avoid contradicting the referring physician, Dr. George says something like: “Thankfully, the test came out looking pretty good. It looks like you can go home tomorrow.”

Hospitalist researcher Dr. Leyenaar agrees that hospitalists need to handle direct-admission surprises. However, she hopes that physicians will not only “be aware of those experiences, but have a conversation about improving the triage system and standardizing assessments to share with PCPs,” she says. “Don’t just say ‘no’ to direct admissions.”

Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.

When are direct admissions OK?

WHEN SHOULD YOU green-light a direct admission, and when should it be denied? We asked that question of the hospitalists interviewed for this article. Here’s a summary of patients they would—and wouldn’t—approve for a direct admission.

Patients with the following should be OK:

  • COPD exacerbation;
n cellulitis with failed outpatient therapy;
  • recurring pancreatitis;
  • mild heart failure;
  • UTI with stable vital signs; and
  • routine pneumonia with stable vital signs.But according to our sources, requests would likely be denied for patients who require rapid imaging, those in decline but who have no further details available, or patients who haven’t seen their primary care physician within the past 24 or 48 hours.Matthew George, MD, hospitalist medical director of Mississippi Baptist Medical Center in Jackson, Miss., says he recently received a call requesting a direct admission from an outside clinic for a patient having abdominal pain. That patient had had gallstones on a previous ultrasound.But it turned out the patient hadn’t been seen by his physician in a week. Without a recent office visit, says Dr. George, “We advised that we wouldn’t take this as a direct admission.”Here are other conditions where sources say patients would be sent to the ED instead of admitted directly:
  • sepsis;
  • acute coronary syndrome;
  • undiagnosed chest pain;
  • diabetic ketoacidosis;
  • syncope;
  • dehydration;
  • unstable vital signs;
  • hypoxia;
  • hypotension;
  • active GI hemorrhage; and
  • new neurological symptoms.
  • Pediatric direct admissions
    BECAUSE OF 24/7 staffing, a robust 30-hospitalist pediatric staff and a number of patients who come from long distances, the criteria for pediatric direct admissions include virtually no restrictions at the 289-bed Primary Children’s Hospital in Salt Lake City, says hospitalist Laura Hodo MD, MSC. Primary Children’s, which is owned by Intermountain Healthcare, is a tertiary-care pediatric hospital for Utah, Wyoming, Idaho, Montana and Nevada.

    Appropriate conditions include asthma, pneumonia, failure to thrive, nausea, vomiting and diarrhea. Excluded conditions include overdoses, psychiatric conditions and patients who need urgent surgical consults, “because the floor doesn’t have the same access to crisis evaluation as the ED,” Dr. Hodo says.

    JoAnna K. Leyenaar, MD, MPH, a pediatric hospitalist at Tufts Medical Center in Boston, who has published on the intersection of direct admissions and pediatrics, says that children with complex chronic health conditions who are familiar to the health care team or being readmitted for the same diagnosis are appropriate for direct admissions.Primary Children’s in Salt Lake uses its own direct admission computer program (based on a sign-out tool for residents and nurses) where doctors can click boxes for special instructions to indicate if the patient needs telemetry, respiratory isolation or TB precautions.