Published in the November 2012 issue of Today’s Hospitalist
IT’S A BUSY FRIDAY NIGHT when the ED doctor calls about a 40-year-old patient in the ED with nausea. The woman, despite being given fluids, Zofran, Pepcid and Maalox, still can’t tolerate PO fluids. She has no fever or other complaints, her belly is benign, and the rest of the exam is unremarkable.
When the hospitalist asks for a diagnosis, the ED doctor has this smug reply: “intractable vomiting.” The hospitalist comes back with, “That’s a symptom, not a diagnosis!” To which, the ED doc fires back: “We’re not going to get the diagnosis in the ER. She needs to come in for IV fluids, and you can continue the workup upstairs.”
Sound familiar? This type of standoff, which is depicted in one of a series of short videos, is all too common between hospitalists and ED doctors, say the two “actors” in the series, hospitalist Kenneth Epstein, MD, and emergency physician Kenneth Heinrich, MD. Dr. Epstein is chief medical officer of Hospitalist Consultants Inc., while Dr. Heinrich is regional director of Emergency Consultants Inc. Both companies are part of ECI Healthcare Partners, which is based in Traverse City, Mich. The companies staff and manage programs in 120 hospitals in 25 states “and in many facilities, they manage both the ED and hospitalist programs.
Each two-minute video depicts a split-screen phone conversation between the two doctors. The videos are part of a year-old initiative to get conflict out in the open and improve care coordination. To date, they have been shown to joint ED physician-hospitalist audiences and hospital administrators in both small and large group sessions. They were also presented at the ECI Healthcare Partners’ annual meeting. (The videos are online under “ED and Hospitalist Collaboration.”)
“We want everyone to see the videos and feel the resentment brewing,” says Dr. Heinrich. The big lesson he and Dr. Epstein have learned from the initiative is that, “ED doctors and hospitalists are accustomed to butting heads because we’ve been doing it for so long, but everybody wants it to change. We want to work together, and we need to learn how to bridge that gap.”
Different pressures, metrics
Improving hospitalist-ED relations is critically important, says Dr. Epstein, given the push from the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission to reduce readmissions and cut costs.
“But to improve care, both hospitalists and ED physicians have to understand each other’s pressures and metrics,” he says. He thinks that lack of understanding is behind most of the conflict.
For starters, Dr. Heinrich explains, ED physicians are under constant pressure to “move the room. That’s a big driving force behind a lot of what we do. If we don’t, patients build up, and people end up really sick and not being seen.”
Those pressures have heated up with two high-profile metrics that the CMS has been measuring since the first of this year “and that have ED doctors sweating. The first is door-to-floor time for all admitted patients, which is the median time from ED arrival to the patient being transferred to an inpatient bed. The second is patients who leave without being seen, which happens often and wreaks havoc on both patient satisfaction and liability.
“Some of these are metrics hospitalists hadn’t really thought about,” says Dr. Epstein. While Medicare is holding only the ED accountable for those measures, he notes that the ED can’t really address them without hospitalist buy-in and help.
Hospitalists, meanwhile, have their own set of pressures, particularly when admitting “borderline” patients. Such admissions mean that beds won’t be available for perhaps sicker patients later.
And both hospitalists and hospitals are increasingly held accountable to justify admissions. “Case management comes up the next day and asks, ‘Why did you admit that patient? She doesn’t meet admission criteria,'” Dr. Epstein says. “Our answer is: ‘Because the ED called and said, We have a patient downstairs who needs to come up. We didn’t have a choice.’ ”
While the ED obsesses about discharges that should have been admitted, Dr. Heinrich notes that ED physicians aren’t really taught to think about whether an admission is covered by insurance. That mindset, however, is changing.
A few of the videos hint at training differences between ED doctors and hospitalists, which become apparent when tempers flare. ED physicians are taught to focus on identifying and stabilizing an emergent condition, while hospitalists learn to fix their sights on the diagnosis.
In the ED, Dr. Heinrich explains, “sometimes we don’t make the right diagnosis.” That’s not “because we’re stupid,” but because ED doctors are trying to answer a different question: “Can this patient go home and get worked up later, or do they need to stay here?”
Another common flashpoint is the “undesirable” timing of admission requests. The ED physician wants a patient admitted at 9:30 a.m. and doesn’t understand why a hospitalist wants to hold off.
“That’s often a quiet time in the ED,” Dr. Epstein explains, “but hospitalists are being pressured to get patients discharged by 11 a.m., so things are crazy for us.” One solution is for the hospitalist to explain to the ED doctor that he must get several patients discharged to make room for the afternoon ED admissions; then, he will be able to admit the patient. But too often, an argument ensues. “That’s what we’re looking at in these videos: how to stop fighting and collaborate to find a solution,” says Dr. Epstein. “That’s often what comes up in the discussion afterward.”
In another video, the doctors start yelling about a patient who’s being admitted but needs a CT scan. The ED doctor wants the patient off his books, while the hospitalist knows that ordering a CT upstairs could result in a longer length of stay.
“As a hospitalist, I can get a stat emergency CT scan if the patient is in the ED,” says Dr. Epstein, “but once the patient comes upstairs, it may be 12 hours.” Both parties come to realize that the solution is not to keep the patient in the ED.
“The solution is to meet with radiology and say, ‘If we accept patients quicker, can we put hospitalist-admission CTs as a priority and solve this?'” he says. “We’ve ended up doing this at a few of our hospitals.”
In another video, the two doctors argue over a patient who lands in the ED at night and likely needs surgery. The surgeon wants medicine to admit the patient and take care of things until the next morning, but that makes the hospitalist uncomfortable.
“The ED physician is caught in the middle,” says Dr. Epstein. “We’re misplacing our frustration by being angry at the ED.”
One solution, which came out of a post-video discussion, would be requiring surgeons to commit to a certain window in which they’ll arrive.
“If ED physicians and hospitalists see ourselves as being on the same team,” Dr. Heinrich maintains, “we can solve many of these issues.”
Bonnie Darves is a freelance health care writer based in Seattle.