In a standoff with the ED?

OVER THE COURSE of his career, Jason Ham, MD, has worked as both an emergency physician and a hospitalist. Dr. Ham also helped design, implement and manage the observation service at the University of Michigan Medical Center in Ann Arbor, which has grown into that center’s highest-volume admitting service of adult ED patients.

“I literally sit at the crossroads between the ED and inpatient admissions for a living,” he says. “I constantly see people frustrated by having multiple admissions of multiple intensities and work-ups of varying quality.” That frustration can boil over into disagreements about whether or not a patient should be admitted.

“The decision to admit,” adds Dr. Ham, “is a very complex communication scenario” where differences in priorities and skill sets between ED doctors and hospitalists can lead to a rough handoff—or even a refused admission. ED doctors may feel slighted when admissions they deem appropriate are blocked, while hospitalists denied any role in admission decisions can feel dumped on and demeaned.

“The decision to admit is a very complex communication scenario.”

~ Jason Ham, MD
University of Michigan Medical Center

So who should have final say in admissions? We spoke to several hospitalists and found a range of how those decisions are handled and why. Some hospitalists can’t refuse admissions, while others have full veto power.

But they all agree that given different times of day, different personalities and levels of clinician experience, how busy the ED or hospitalist services may (or may not) be, a difficult patient or family, and complicated clinical and social factors, the decision to admit can become—as Dr. Ham puts it—”very gray.”

Crouse Hospital, Syracuse, N.Y.:
Giving hospitalists final say
At Crouse Hospital in Syracuse, N.Y., hospitalists have final say on admission decisions. Otherwise, “I think there would be bad feelings,” says hospitalist director James Leyhane, MD. “I think hospitalists would feel they were being abused or subservient.”

When the hospitalists at Crouse think an admission may not be warranted, they’ll do a consult in the ED, and the ED will discharge the patient home. Case managers embedded in the ED can help arrange outpatient follow-up for patients being discharged home, so “that may help sway the ED doc’s decision to admit.” Only rarely will the two specialties continue to disagree about an admission after a consult has taken place.

Case managers embedded in the ED arranging outpatient follow-up “may help sway the ED doc’s decision to admit.”

~ James Leyhane, MD
Crouse Hospital

When that occurs, “the ED doctors will get their department chair involved and then I’ll get involved,” and they’ll usually get a third opinion from another impartial physician, Dr. Leyhane says. “But I can’t remember the last time that happened.”

In a previous hospital where Dr. Leyhane used to work, more disagreements did occur between the hospitalists and the ED, in part because of rapid ED turnover. “Various doctors rotated in and out.”

In that previous position, Dr. Leyhane also saw what doesn’t work: While hospitalists there could decline an admission, that decision was made after patients were sent to the floor. “That was very tough to do because an admission order was often already in the system,” he said. “We used that model only briefly.”

That former hospital also had many more admissions moved down to observation status than his current facility. “The hospitalists bore the brunt of patient complaints about being in observation,” Dr. Leyhane says. Crouse, by comparison, employs an onsite physician to review admission decisions, which cuts down on the number of patients bumped from inpatient to observation.

Westchester Medical Center, Valhalla, N.Y.:
A mandatory phone call
At Westchester Medical Center in Valhalla, N.Y., hospitalist Randy Goldberg, MD, MPH, explains that the ED may not pass a patient to the admitting resident without first speaking to the on-call hospitalist attending. That mandatory call policy was put in place two years ago.

The hospitalist then decides if the patient should be admitted or placed in observation. If the hospitalist doesn’t think the patient should be admitted and can convince the ED doctor, the ED discharges the patient.

“We wanted to reduce the amount of time patients spend in the ED.”

~ Randy Goldberg,MD, MPH
Westchester Medical Center

If the ED doctor isn’t convinced, the hospitalist and admitting resident “admit” the patient (typically an observation placement), evaluate and then discharge if warranted. But—as in Dr. Leyhane’s group—this rarely happens, says Dr. Goldberg.

He also points out that requiring a phone call had nothing to do with not trusting the ED’s admission decisions. Instead, it was designed to speed up throughput.

“We wanted to reduce the amount of time patients spend in the ED and how long it takes to put in an admission order,” he says. “We hoped this would reduce that delay.”

Delays have shrunk, although the center hasn’t yet hit its target time between admission decisions and admission orders. “We were over 200 minutes, and we’re now down to 80 or 90,” Dr. Goldberg says. “We’re aiming for 30.”

And last month, the admission policy was tweaked: Instead of calling the on-call attending, the ED now contacts the hospitalist covering the consult service. “We wanted a faster response.”

Sky Lakes Medical Center, Klamath Falls, Ore.:
Checks and balances
While Westchester’s policy didn’t arise from any conflict between the ED and hospitalists over soft admissions, that may not entirely be the case at Sky Lakes Medical Center in Klamath Falls, Ore. According to Ann Kellogg, DO, the assistant director of the hospitalist program, the hospital’s culture is such that the hospitalists don’t refuse admissions.

However, they do go to the ED and consult on patients, then discharge from the ED as many as 10% of those the ED believes should be admitted. That additional layer of safety and decision-making serves as a check on what can be diagnostic errors in the ED.

Errors arise, Dr. Kellogg says, “because the ED is under time pressures.” Hospital administration, which set the no-refusal policy, assumes the hospitalists have more time to review labs and come to their own admission decisions. She admits that it can “definitely” be awkward when hospitalists decide to discharge patients from either the ED or observation, after the ED has set patients’ expectations up to be admitted.

“Some ED doctors are nervous about discharging patients home, so the onus to do so is put on us.”

~ Ann Kellogg, DO
Sky Lakes Medical Center

A big part of the problem, says Dr. Kellogg, is that ED doctors aren’t trained to know what can be done for patients outside the hospital. That’s not the case for hospitalists, who regularly interact with primary care and outpatient specialists and who routinely discharge complicated patients.

“Some ED doctors are nervous about discharging patients home, so the onus to do so is put on us,” says Dr. Kellogg, who is trained and boarded in family medicine. She gives this example: An ED doctor wants to admit a patient with recurring syncope and have that patient placed on telemetry. She, meanwhile, will discharge the patient from the ED and arrange outpatient follow-up with a Holter monitor.

“We’re a small community,” she explains. “I can send my thoughts to a primary care physician and get reasonable follow-up.”

St. Anthony Hospital, Oklahoma City:
Judgment calls
Outpatient options are also very apparent to Matthew Jared, MD, a hospitalist at St. Anthony Hospi
tal in Oklahoma City. Like Dr. Kellogg, he trained in family medicine. But in addition, Dr. Jared spends an hour every workday seeing three or four outpatients in a clinic

“Sometimes, the ED wants to admit the same kind of patient I’m very comfortable seeing in clinic every two weeks,” he says. When he asks ED doctors why they think hospital care is warranted for such patients, he often hears that they don’t feel medically or legally safe sending patients out unless they have some guarantee that a follow-up plan will actually be followed.

While Dr. Jared understands that hesitation, “it’s very hard to guarantee any treatment plan.” All you can do, he adds, is educate patients and hope they’ll make the right choices in terms of taking medications or showing up for follow-up appointments.

“Do I treat my ED colleague with respect and not throw him or her under the bus? Or do I treat the patient honestly?”

~ Matthew Jared, MD
St. Anthony Hospital

He pushes back against an ED call for an admission “once or twice a week.” When hospitalists don’t accept an admission, they need to get to the ED and do a consult. After that, if they still believe the patient can be sent home, hospitalists will usually do the discharge.

According to Dr. Jared, “I’m wrong about half the time” when he thinks a patient can be easily discharged. “Maybe the ED didn’t have the right data or present the evidence I needed to make a quick decision,” he says.

“Or maybe I didn’t listen carefully enough or ask the right questions.”

But that also means he’s right about half the time. “There are times I walk into observation, see the patient and think, ‘I have to explain this in such a way that you’ll feel you’ve been taken care of but not feel we’ve wasted your time.’ That’s frustrating.” That also has him making tough choices.

“Do I treat my ED colleague with respect and not throw him or her under the bus? Or do I treat the patient honestly?”—particularly if the patient has perhaps incurred an unnecessary observation bill. “That’s where the stress and anxiety for hospitalists comes, making these judgment calls.”

Time and business constraints
University of Michigan’s Dr. Ham also points to this dilemma: Just green-lighting an ED admission decision—even one that sounds soft—and admitting a patient takes about one-third the amount of time it does to question that decision, do a consult and discharge a patient from the ED.

Dr. Jared agrees. If he’s busy with other patients when the ED calls with an admission, he may not take the time to revisit that decision.

And he notes that it’s not easy to forget that you’re practicing fee-for-service medicine. “There’s a financial and personal-security issue related to this, and the system as a whole is pushing us to admit patients,” he says. “When business is slow, there’s a tendency to argue much less with the ED. But when we’re busy and can’t keep up with what we’re doing, those conversations happen much more aggressively and consistently.”

Naval Medical Center, San Diego:
Bypassing residents
Debra Coffey, MD, who heads up the hospital medicine division at the Naval Medical Center in San Diego, also points to competing priorities when it comes to admission decisions.

On one hand, the medical center’s GME mission dictates that residents should be engaged in clinical decision-making, including admissions. But on the other hand, an ED attending with 15 years experience doesn’t appreciate having an admission decision declined by a second-year resident. The contention that results—and the need to then escalate the discussion to include more attendings—can also chew up a lot of time.

To avoid that standoff, particularly when the ED is busy, the ED attending now has the option of calling the hospitalist attending directly to discuss a possible admission, bypassing the admitting resident altogether.

“If the attending declines the admission and the ED physician disagrees, we have to take ownership of that patient and see him or her in the ED within 60 minutes,” Dr. Coffey explains. But hers is another hospital where that rarely happens.

“Normally, we’re able to come to an agreement,” she says. “Just knowing we can use a direct line of communication has been very good for our relationship with the ED overall.” And while it’s vitally important to have both ED and internal medicine residents engaged in discussing admissions, “there are times you need to take out all the middle pieces and just have a direct conversation.”

Changing behaviors
Dr. Coffey’s medical center also tracks the admissions that result from those direct attending-to-attending phone calls. Those data are currently under review.

“We want to know how many patients hit the wards and have an RRT or code blue called within 12 hours to see if patients are being mistriaged to the wrong level of care,” she points out. Also being tracked: how many admitted patients are discharged within 24 hours “to see if patients were admitted unnecessarily.”

ED data are also being used at Oregon’s Sky Lakes Medical Center. The hospital keeps tabs on how many CT scans and ultrasounds ED physicians order, as well as how many admissions they each have. The vice president of medical affairs will then discuss individual doctors with the ED director.

“Some ED doctors order 25% more CT scans or admit 25% more patients than their next colleague, so they’re clearly an outlier,” Dr. Kellogg points out. “Some providers improve once they realize it’s not anecdotal information.”

University of Michigan’s Dr. Ham thinks it would be great to review how many patients are sent home shortly after the ED requests an admission or are discharged within only a few hours if admitted. But the reverse is also true, he adds: Hospitalists should be measured on how many admissions they block when patients end up not going home quickly. Too often, he says, “the ED is a really easy scapegoat” for hospitalists, particularly when hospitalists are starting to burn out. “It should be all about alignment and being on the same team.”

At the same time, he notes, “alternatives to admissions and not admitting patients are becoming much more of the point.” Value-based purchasing and bundled payments may make new medical-home models more robust.

In fact, being able to discharge more patients from the ED and avoid an admission is “an area of hospital medicine that is relatively immature and that, I think, is begging for more clarity and reward,” says Dr. Ham. “We need more support and prioritization in assisting a complex discharge from the ED, and I think this is a ripe area for hospitalists to step up and do more with.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Finding common ground
THE HOSPITALIST PROGRAM at San Diego’s Naval Medical Center was launched just over a year ago, in January 2017. Before then, outpatient physicians and specialists followed inpatients, along with residents.

The ED, meanwhile, was used to handing off admissions to residents, who sometimes declined them. That caused problems, says Debra Coffey, MD, who heads up the center’s new hospital medicine division. To finally hash out how admission decisions should be handled, ED physicians and hospitalists met for months last year in weekly focus groups.

When those sessions began, the ED physicians held that it was their job to determine admissions. But Dr. Coffey and the hospitalists countered that it’s their job to decide whether to accept admissions. “Why should we be forced to take patients who we’re just going to discharge?”

“Why should we be forced to take patients who we’re just going to discharge?”

~ Debra Coffey, MD
Naval Medical Center

The two groups eventually did decide on admission options so that “the emergency physicians don’t feel preempted and we’re not asking them to do something they’re uncomfortable with.” But in addition, the focus groups delivered this big payoff: Both groups learned an eye-popping amount about the other specialty that they didn’t know before.

Dr. Coffey, for instance, learned how much pride her ED colleagues take in their ability to triage patients and decide who should be admitted. She also didn’t know that, as one ED physician told her, he’s legally liable for not only every patient in the emergency department, but everyone in the triage area as well, when he’s on service. “That’s why they want to move patients through as quickly as possible.”

For their part, the ED doctors admitted to being annoyed when asked to get more tests or labs in the ED for a patient being admitted. Why can’t the hospitalists just order those from the floor themselves?

“I said, ‘Because your STAT trumps our STAT,’ ” Dr. Coffey points out. The ED physicians had no idea that a lab or image they can get in less than 30 minutes “can take four to six hours to turn around upstairs.”

The ED doctors also didn’t realize that while they can grab ready-mixed bags of antibiotics, “we have to call the pharmacy to have those mixed and sent to us,” she points out. Now, when an ED doctor calls with an admission, it’s not unusual for him or her to ask: “Do you want me to hang the antibiotics?”

She also came away with a better sense of how differently the two groups view individual patient encounters. “To an ED physician, a patient is in the ED because his or her primary care has failed in most cases,” she says. “ED docs see this as their one opportunity to see the patient and intervene.” She, on the other hand, “looks at a patient as a general internist. I see someone who is going to have follow-up and get plugged into the system.”