Denying ER Admissions

[BigSib]

I still struggle with those "soft admissions" from the ER and whether or not certain patients warrant or meet criteria for inpatient care. Often times the ER doc says they've "been here for X# hours and they're still ..." vomiting or having 10/10 pain, but when I see the patient they're resting comfortably in no distress with only a few minor physical or diagnostic abnormalities. Other times the primary problem is more related to social or placement issues. Regardless, as a PGY2 I don't feel comfortable denying any admission.

How do you deal with these situations? Have you ever denied an admission? What are some obvious things I should look for (e.g., should be admitted to another group, capped, etc.)? Does your program have a policy? What can I do to better convince the ER and my attending (who may have to visit the patient) if I feel the patient should go home?

There are a number of threads out there related to this, but I didn't feel they adequately addressed the topic. I don't want to discuss why these soft admissions are coming (risk v. benefit, finances, etc.), complaints about them (near sign-out time or too many), or the politics involved - I want to hear how you deal with the situation. For example, knowing the indication for admission for a specific diagnosis.

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[MedicineMan99]

Residents can't deny admissions. Only attendings can. And even then- there are institutional policies.

At my hospital, for instance, which is a Level-1 Trauma center, an ER attending can admit a patient for any reason they see fit. They then have to call the admitting attending before they call the resident. Now, if the admitting attending disagrees with the ER attending about the admission, he or she has to personally appear in the ER and discharge that patient in order for them not to be admitted. In other words, this transfers the liability off of the ER attending. The attending has no ability to deny any admission.

I'd say about half of the admissions I did as a resident could have been dealt with as an outpatient with close follow up. But I still had to admit them because I was the resident- just cheap labor working under an attending. That's what I hated about being a resident- you really have no authority. But, at the very worst the patients are just discharged home the next day. The day team always likes easy discharges.

 

[Raryn]

I make them obs and let the attending kick them to the curb when the patient is staffed, frequently as early as 4-5 hrs later. We can't block an admission without calling our attending in, and it's not worth it. Combine that with a policy we don't have to do a discharge summary for obs patients there <2 days (i.e. everyone not converted to an admit), and I just do the H&P for the complete BS and move on.

 

[nlax30]

Yea we can't deny admissions. ED doc makes decision and calls admitting attending, at that point the attending can argue if they want but it usually ends up with the ED doc telling them to come down to the ER to discharge them if they want.... Which we've done maybe twice.

 

[nlax30]

That being said, when I go down to the ER I will talk with the doc if I feels it's an obvious bogus admit and on a couple occasions they've sent the patient home. I think one was a 20-something guy found to have a minor distal superficial thrombophlebitis they wanted to admit for anticoagulation. When I mentioned all we were going to do was throw him on ASA and send him home in the morning he sent the kid home.

 

[KnuxNole]

If approved by the attendings(sometimes they don't even have to talk to any if there isn't appropriate coverage like for acute stroke or complicated kid), residents here can deny admissions, and they either get transferred from the ED/admitted to someone else or they get discharged by the resident without ever leaving the ED.

 

[Hellothere111]

In my hospital as well, a level 1 trauma center, the ER attending decides when the patient goes up and a separate office decides whether the patient meets criteria for observation or inpatient admission.
It's a much tougher job than I thought and at my ER, they only send up 12-15% of the patients and discharge the rest, eventually.

 

[styphon]

In my residency program only the attending could refuse admissions - which was very rare. BUT sometimes we would go to the ER, do the H&P get additional labs/studies and send the pt home before they even got a bed. We also rounded in a specific nursing home - and occasionally could get social admissions transferred there instead of being admitted.

 

[AStark]

At my centre we get consulted directly by ERPs (who have no ability to admit anyone). There is no obligation to admit or discharge, as these are considered consultations rather than admission H&Ps. If I don't think a patient needs to be admitted (whether covering cardio or medicine), then I always review with staff first. I suppose my centre might be something of an exception as its smaller (still the tertiary referral centre for the whole province), and we are quite used to calling staff overnight and they're very used to talking to us. On occasion we may say that there's no indication for medicine or cardiology admission, but that we are not "discharging" the patient, i.e. we hand back to emerg to make the call. It's easier to do this on cardio where they might not be a good story, or the patient might be better served with an outpatient stress, sometimes within the next day or so. We also have a system called "community emergency" where we deny admission for purely "social" reasons, and let emerg deal with them.

Anyway, if someone doesn't need admission, they shouldn't be admitted. You can still have "soft" admissions, but last night I had a guy with probable dementia with Lewy bodies (a new diagnosis), but the family needed to get that assessed and he needed some workup. They were perfectly willing and able to take him home and come back for an outpatient CT. I think reviewing with staff is important for both medicolegal and, crucially, supervisory purposes.

 

[Psyche Estrelle]

It's very hospital dependent. Where I did my residency (medium-sized community hospital, not a level 1 trauma center or academic center), if the resident felt that the patient didn't have to be admitted (especially if it was our own clinic patient we knew well) and the attending agreed, the resident was able to discharge the patient from the ER him/herself. To be honest, for the float it was pretty much took the same amount of work, since we still would write an H+P-like note that would justify why the patient could be discharged, with clear followup instructions/ER precautions. If the patient suffered a poor outcome, it was completely on us, which IMO was completely fair.

 

[QofQuimica]

How do you deal with these situations? Have you ever denied an admission? What are some obvious things I should look for (e.g., should be admitted to another group, capped, etc.)? Does your program have a policy? What can I do to better convince the ER and my attending (who may have to visit the patient) if I feel the patient should go home?

As a PGY2, don't try to convince the ER attending of anything. Don't argue with them that the admission is unwarranted. Don't give your opinion at all unless someone explicitly asks or you think doing the admission will somehow harm the patient. In all other cases, just admit the patient and move on with your life. The faster you get them admitted, the faster you can go do something else.

I make them obs and let the attending kick them to the curb when the patient is staffed, frequently as early as 4-5 hrs later. We can't block an admission without calling our attending in, and it's not worth it. Combine that with a policy we don't have to do a discharge summary for obs patients there <2 days (i.e. everyone not converted to an admit), and I just do the H&P for the complete BS and move on.

Basically this. What would be great is if every ER had an obs unit where the borderline patients that don't need admission but that the ER docs want to watch for a while could be kept overnight and then dispo'ed in the morning.

 

[PTPoeny]

At my centre we get consulted directly by ERPs (who have no ability to admit anyone). There is no obligation to admit or discharge.

I'm at an academic level 1 trauma center and this is basically how it works at my residency too. We get a consult, see the patient and then we staff the consult by phone with attending. The tricky thing about our set up is that we staff the discharges with the outpatient attending but we staff the admits with the hospitalist. Occasionally they disagree with each other, but once we've called both, they will usually talk to each other. As residents we cannot block an admit our attending wants but we have a lot of control over the process.

 

[brosef]

As an ER resident, I struggle with calling for these soft admissions. (being off service makes you appreciate not getting a soft admit at 3 in the morning). If I were on the admitting team, I would wonder wtf these ED attendings are thinking. But, im just a resident, I havent seen enough patients to be so cocky not to. Ive had many patients that presented looking healthy/stable that have gone south really fast, anywhere from the waiting room to fast track... where I wouldve felt really crappy if I sent them home. Everyone always says 'do what's right for the patient and no one can fault you'

No big deal though, soft admits are usually easily managed. The IM residents love them bc it caps their census and the hospitalists have to take the rest of the admits. I just do what im told, learn what I can, and the rest of the BS is just part of daily / residency life

 

[brotherman]

agreed, it's easier to just do the admission than to fight it, in most cases. This is true, even as an attending.

 

[atomi]

When I was a busy overworked intern, I always greatly preferred the soft admits, especially towards the end of the day. Which would you rather have, an admit that takes you less than an hour and put you at the bottom of the algorithm or one that's going to push all of your other work to the end of the day and keep you there to midnight? Would you prefer an unstable admit that's going to be a total pain to sign out and may or may not be stable when you show up the next morning or one that you can preround on and write a soap note on in 5 minutes?

 

[mvenus929]

When I was a busy overworked intern, I always greatly preferred the soft admits, especially towards the end of the day. Which would you rather have, an admit that takes you less than an hour and put you at the bottom of the algorithm or one that's going to push all of your other work to the end of the day and keep you there to midnight? Would you prefer an unstable admit that's going to be a total pain to sign out and may or may not be stable when you show up the next morning or one that you can preround on and write a soap note on in 5 minutes?

When you're being slammed with admissions, and residents basically do them all (not the IM style where teams cap at a certain number and faculty take on the rest), the 'soft' admissions are annoying because you actually have to do something rather than sending them home from the ED. And if you do have one of those unstable patients on the floor, you're trying to sort that out while getting paged by the ED/floor nurses for orders for the admit.

 

[rokshana]

When you're being slammed with admissions, and residents basically do them all (not the IM style where teams cap at a certain number and faculty take on the rest), the 'soft' admissions are annoying because you actually have to do something rather than sending them home from the ED. And if you do have one of those unstable patients on the floor, you're trying to sort that out while getting paged by the ED/floor nurses for orders for the admit.

i don't know about the IM at your place, but where i trained, if the interns capped and there were admissions…the residents did them and admitted to the next team…and on night float, the resident did all the admissions overnight 1 or (my personal record 11…)… you COULD call in back up(at 14 total)…but that was still a resident, not faculty .

 

[hamstergang]

When I was a busy overworked intern, I always greatly preferred the soft admits, especially towards the end of the day. Which would you rather have, an admit that takes you less than an hour and put you at the bottom of the algorithm or one that's going to push all of your other work to the end of the day and keep you there to midnight? Would you prefer an unstable admit that's going to be a total pain to sign out and may or may not be stable when you show up the next morning or one that you can preround on and write a soap note on in 5 minutes?

I like my work to be useful and not a waste of resources, so soft admits bothered me more than a patient that actually needed me. I don't mind doing work if it's actually necessary.

 

[TooMuchResearch]

As an ER resident, I struggle with calling for these soft admissions. (being off service makes you appreciate not getting a soft admit at 3 in the morning). If I were on the admitting team, I would wonder wtf these ED attendings are thinking. But, im just a resident, I havent seen enough patients to be so cocky not to. Ive had many patients that presented looking healthy/stable that have gone south really fast, anywhere from the waiting room to fast track... where I wouldve felt really crappy if I sent them home. Everyone always says 'do what's right for the patient and no one can fault you'

No big deal though, soft admits are usually easily managed. The IM residents love them bc it caps their census and the hospitalists have to take the rest of the admits. I just do what im told, learn what I can, and the rest of the BS is just part of daily / residency life

From the off service side: Soft admits are like CYA consults... quick and easy. See the patient, write orders, write a note, and your attending gets paid.

Easy.

 

[Siggy]

i don't know about the IM at your place, but where i trained, if the interns capped and there were admissions…the residents did them and admitted to the next team…and on night float, the resident did all the admissions overnight 1 or (my personal record 11…)… you COULD call in back up(at 14 total)…but that was still a resident, not faculty .

That's pretty much how my house works. All of the IM admission teams but 2 are resident run (we also have 2 NP run teams for the long term ABx or placement rocks). The 2 non-resident teams take admissions during the middle of the day (7am-3pm) so the primary teams can do didactics, morning report, and round. Anything outside of that is admitted by the resident teams with patient either being put on the call or night float team's list or redistributed to one of the other IM teams (including the non-resident teams).

Capped admissions? No. Such. Thing. The closest is rolling over late admissions to the next team.

 

[gutonc]

agreed, it's easier to just do the admission than to fight it, in most cases. This is true, even as an attending.

It's even more true as an attending. BS Admit = Boat Payment.

 

[Raryn]

That's pretty much how my house works. All of the IM admission teams but 2 are resident run (we also have 2 NP run teams for the long term ABx or placement rocks). The 2 non-resident teams take admissions during the middle of the day (7am-3pm) so the primary teams can do didactics, morning report, and round. Anything outside of that is admitted by the resident teams with patient either being put on the call or night float team's list or redistributed to one of the other IM teams (including the non-resident teams).

Capped admissions? No. Such. Thing. The closest is rolling over late admissions to the next team.

Here it varies from hospital to hospital. At the VA where there are no academic services, the only cap is the ACGME mandated hard cap that a senior resident can't do more than 10 admissions. If I get 10 during the course of a call day, I don't admit anyone until the other night senior comes in and then they take over admitting. If I go over the team cap of 20, the remainder just roll over onto a different team in the morning.

At the other hospital where there's a mix of academic and non-academic services, we admit until the team hits it's cap of 20. After that, all patients just go to the non-academic services.

In the ICU where (obviously) the patients are critically ill, we admit however many we get. In the winter, going over cap is pretty common. Theoretically if the teams cap out the fellows are supposed to pitch in and see patients on their own, but that's highly fellow dependent and can't really be counted on most of the time.

 

[FutureInternist]

That's pretty much how my house works. All of the IM admission teams but 2 are resident run (we also have 2 NP run teams for the long term ABx or placement rocks). The 2 non-resident teams take admissions during the middle of the day (7am-3pm) so the primary teams can do didactics, morning report, and round. Anything outside of that is admitted by the resident teams with patient either being put on the call or night float team's list or redistributed to one of the other IM teams (including the non-resident teams).

Capped admissions? No. Such. Thing. The closest is rolling over late admissions to the next team.

I think.......
Interns can only admit up to 5 pts + 2 in house transfers
Residents can admit up to 10 pts

Hard cap for team w/ 1 intern - 16, if 2 interns then 20

Double check if still true & if so, mention it on the ACGME survey

 

[Siggy]

I think.......
Interns can only admit up to 5 pts + 2 in house transfers
Residents can admit up to 10 pts

Hard cap for team w/ 1 intern - 16, if 2 interns then 20

Double check if still true & if so, mention it on the ACGME survey

Well, until this year, my hospital's IM program was AOA only, now there's an AOA and an ACGME rotation. This is also probably why we now have attending IM coverage 24/7 with the students who do admissions presenting to the attending (granted, the senior resident is still writing out the admission orders and verifying as needed).

Also, all of our teams have 2 interns and, up until this year, one senior. Now about half of the teams have 2 seniors. Our old cap was 30 patient's per team, but I'm not sure if that still applies to the AOA teams (granted, we aren't nearly as busy as we were last year and the year before when I was a med student).

 

[FutureInternist]

Well, until this year, my hospital's IM program was AOA only, now there's an AOA and an ACGME rotation. This is also probably why we now have attending IM coverage 24/7 with the students who do admissions presenting to the attending (granted, the senior resident is still writing out the admission orders and verifying as needed).

Also, all of our teams have 2 interns and, up until this year, one senior. Now about half of the teams have 2 seniors. Our old cap was 30 patient's per team, but I'm not sure if that still applies to the AOA teams (granted, we aren't nearly as busy as we were last year and the year before when I was a med student).

Yet another reason to not to AOA residency

 

[rokshana]

I think.......
Interns can only admit up to 5 pts + 2 in house transfers
Residents can admit up to 10 pts

Hard cap for team w/ 1 intern - 16, if 2 interns then 20

Double check if still true & if so, mention it on the ACGME survey

to your team…ACGME is fuzzy about admitting to other teams (other than non teaching teams…that's a no-no)...

 

[FutureInternist]

to your team…ACGME is fuzzy about admitting to other teams (other than non teaching teams…that's a no-no)...

Any PDs around...I thought the cap didn't mention which teams, jut the max an intern or resident can admit

 

[mvenus929]

i don't know about the IM at your place, but where i trained, if the interns capped and there were admissions…the residents did them and admitted to the next team…and on night float, the resident did all the admissions overnight 1 or (my personal record 11…)… you COULD call in back up(at 14 total)…but that was still a resident, not faculty .

At my med school, if the teams were capped, all the admissions went through the hospitalist, rather than the resident teams, who would do his/her own admissions. We had a total of 8 wards teams (consisting of 1-2 interns and a senior), and two would be on at any given time, but once those teams capped (even before their sister team capped), all admissions went through hospitalist until the night team came in.

 

[dsh1234]

I still struggle with those "soft admissions" from the ER and whether or not certain patients warrant or meet criteria for inpatient care. Often times the ER doc says they've "been here for X# hours and they're still ..." vomiting or having 10/10 pain, but when I see the patient they're resting comfortably in no distress with only a few minor physical or diagnostic abnormalities. Other times the primary problem is more related to social or placement issues. Regardless, as a PGY2 I don't feel comfortable denying any admission.

How do you deal with these situations? Have you ever denied an admission? What are some obvious things I should look for (e.g., should be admitted to another group, capped, etc.)? Does your program have a policy? What can I do to better convince the ER and my attending (who may have to visit the patient) if I feel the patient should go home?

There are a number of threads out there related to this, but I didn't feel they adequately addressed the topic. I don't want to discuss why these soft admissions are coming (risk v. benefit, finances, etc.), complaints about them (near sign-out time or too many), or the politics involved - I want to hear how you deal with the situation. For example, knowing the indication for admission for a specific diagnosis.

Something you should understand.... this fight between the ED and the rest of the inpatient hospital services is as old as medicine itself, especially in academic centers. It's why every other specialty essentially hates the ED, for right or wrong. You can throw all kinds of generic suggestions out there - create a dialogue with the ED attending and explain why inpatient is not appropriate, get your attending to talk to their attending, its easier to admit and d/c than to fight, get the patient convinced he doesn't need to come in and then tell the ED the patient doesn't wanna come in either, etc etc. The fact remains that nothing is really gonna change and everyone has to deal with the soft admit on essentially a DAILY basis.

Also, you need to realize that the community hospitals it's a completely different environment. When you order an echo at the community hospital I rotated at as a resident, a menu pops up first asking you which cardiology group with privileges at that hospital you want to read your echo (aka which group is gonna be getting to read and get paid for the echo). If a group consistently doesn't read you 4pm echos, and the other one always gets it back to you in 3 hours no matter how late in the day, which one are you going to go with next time? Also, if the hospital isn't small, the ED can choose to call any one of the multiple hospitalist groups based out of that hospital to call for the admission. If you complain, give attitude, and give the ED a hard time about admissions they are just gonna call the next guy. Now, that's not to say that if someone TRULY felt a patient could be outpatient (ex - the superficial thrombophlebitis young guy above that just needed aspirin) that they wouldn't recommend D/C home, you still gotta do right by the patient. However, when you're the hospitalist in that setting soft admits are never gonna be a problem for you anyways because you LOVE soft admits. You're salary depends on them and the RVU's that they generate (RVU = how you get paid). Do you want to round on 20 complicated patients and leave at 10pm, or do you want 20 easy patients that give you no stress/anxiety and leave on time? Same goes with specialist consulting services. At private hospitals they get sad when you don't consult them, and wonder what they did to wrong you and will even come up and ask you if they disappointed you. Consultants putting in their own orders is the rule not the exception. I consulted pulmonology on basically every COPD I admitted during that rotation and the only order I had to put in was the discharge. Compared that to the crap you get at an academic center, where the Cards fellow gives a big sigh every time you consult for a little trop leak, and say "You really think this needs to be a consult?".

 

[Shikima]

I wonder if you incentivized resident pay with a pseudo-RVU model, that enthusiasm would increase for any kind of consult or admit (soft or not)?

 

[Crayola227]

My only 2 cents is that for residents, at least IM there are not only admit caps but also transfer caps, discharge caps, some of the rules are a bit convuluted with time windows on those, so it can be hard to tell, but it's all pretty black and white.

Residents should read the ACGME rules, and aside from work hour rules which you could lie on I guess to "help" the program out, and the program can expect to do and get away with it, and those lies could fly well with ACGME unless it was really bad, whistle was blown, EHR audited to see if it supported what residents reported (remember those notes and orders have your name and time stamp), patient cap rules should be followed.

It's the one time you can legit ask the program not to stomp on you, because it's dangerous for patient care, and the ACGME will be less forgiving about that if something bad happens and they can easily see what's going on with caps. You can easily make the case this is for the benefit of the program.

Work hour violations can get the program heat and probation, I've heard the ACGME has much less tolerance for patient overload and/or bad outcome related to that, and programs getting shut down faster if this happens.

Most old time docs don't seem to believe the work hours make a difference to patient error (I'm not one of them), and maybe that's true, but being overloaded with patients and transfers/hand offs are a real problem and shouldn't be ignored IMHO.

 

[Crayola227]

Not to mention me doing a 100 work week, the extra hours alone could be any degree of hard/easy, but going over caps is legit more work and I hate it.

So that's where I draw the line and I'm a big believer in never crossing the program.

 

[Deep Sea]

At my institute, we residents can request (as a courtesy of the ER physicians) a non-urgent admission to be called at a later time when labs are available or some clinical notes are in the system. I have personally found it useful to ask them if the patient agrees to the admission since many times I have done all the preliminary investigations and to find out the patient refused to be admitted.

 

[filhodeinferno]

I still struggle with those "soft admissions" from the ER and whether or not certain patients warrant or meet criteria for inpatient care. Often times the ER doc says they've "been here for X# hours and they're still ..." vomiting or having 10/10 pain, but when I see the patient they're resting comfortably in no distress with only a few minor physical or diagnostic abnormalities. Other times the primary problem is more related to social or placement issues. Regardless, as a PGY2 I don't feel comfortable denying any admission.

How do you deal with these situations? Have you ever denied an admission? What are some obvious things I should look for (e.g., should be admitted to another group, capped, etc.)? Does your program have a policy? What can I do to better convince the ER and my attending (who may have to visit the patient) if I feel the patient should go home?

There are a number of threads out there related to this, but I didn't feel they adequately addressed the topic. I don't want to discuss why these soft admissions are coming (risk v. benefit, finances, etc.), complaints about them (near sign-out time or too many), or the politics involved - I want to hear how you deal with the situation. For example, knowing the indication for admission for a specific diagnosis.

As an EM resident, I struggle with these "soft admissions" too. Nothing worse than calling report on a patient who you know is going to piss off the residents upstairs. Sometimes these patients are such a social nightmare that they can't go home, but they also can't stay in the ED. Sometimes your staff just wants them upstairs, but leaves you to do the rationalization of this plan to the floor docs.

However, when I've rotated on the floor as a resident I didn't mind those soft admissions. Like the above posters said, they cap your census, and they are a breeze to deal with for a day or two. The irony was that sometimes I was getting soft admits as the EM resident from the IM resident rotating down in the ED. It happens.

 

[ThoracicGuy]

As an EM resident, I struggle with these "soft admissions" too. Nothing worse than calling report on a patient who you know is going to piss off the residents upstairs. Sometimes these patients are such a social nightmare that they can't go home, but they also can't stay in the ED. Sometimes your staff just wants them upstairs, but leaves you to do the rationalization of this plan to the floor docs.

However, when I've rotated on the floor as a resident I didn't mind those soft admissions. Like the above posters said, they cap your census, and they are a breeze to deal with for a day or two. The irony was that sometimes I was getting soft admits as the EM resident from the IM resident rotating down in the ED. It happens.

They don't cap a surgery census and just add to the stuff to round on with a typically already busy service...

 

[Arcan57]

They don't cap a surgery census and just add to the stuff to round on with a typically already busy service...

While there are definitely things to tighten up about EM/surgery communication and workflow, I would suggest soft admissions are pretty uncommon to a surgical service.

 

[ThoracicGuy]

While there are definitely things to tighten up about EM/surgery communication and workflow, I would suggest soft admissions are pretty uncommon to a surgical service.

The thing that I always got that was the worst was getting called to "lay the hands" on someone with belly pain. Even if they had no findings on CT scan or whatever, it was always that call. We ended up having to bring them in at least overnight more times than I wanted to count. Soft admissions, unfortunately, were numerous enough to make morning rounds longer than they should be. Then, of course, is all the paperwork to discharge them in addition to all the other daily work.

 

[filhodeinferno]

While there are definitely things to tighten up about EM/surgery communication and workflow, I would suggest soft admissions are pretty uncommon to a surgical service.

Exactly. Nothing is going there unless they let it. Those guys dump on the medical GPU if it is at all a soft admission.

 

[Arcan57]

The thing that I always got that was the worst was getting called to "lay the hands" on someone with belly pain. Even if they had no findings on CT scan or whatever, it was always that call. We ended up having to bring them in at least overnight more times than I wanted to count. Soft admissions, unfortunately, were numerous enough to make morning rounds longer than they should be. Then, of course, is all the paperwork to discharge them in addition to all the other daily work.

Hmm, standard practice at our shop was for surgery resident to staff with attending and write note saying nothing surgical. That pretty much ended any admission discussion to that service.

 

[Doctor4Life1769]

Hmm, standard practice at our shop was for surgery resident to staff with attending and write note saying nothing surgical. That pretty much ended any admission discussion to that service.

Followed by the ED admitting the patient to medicine.

 

[Arcan57]

Followed by the ED admitting the patient to medicine.

Or sending home. We do that sometimes

 

[Neuronix]

"Doc are you SURE I need admission for this? I don't have insurance."

My thoughts as an intern: "No."
ED attending's thoughts: "Just get them out of the ED."
Attending's thoughts: "Just admit and discharge in the morning, I'm not fighting with the ED." or "I'm too busy to do the discharge now."

Ever encouraged a patient to sign out AMA? I thought about it, but pretty sure my resident and/or attending would have killed me if they found out. I really regret convincing these people to come into the hospital.

 

[DrDrummer]

Ever encouraged a patient to sign out AMA? I thought about it, but pretty sure my resident and/or attending would have killed me if they found out. I really regret convincing these people to come into the hospital.

Unless you're planning on lying when/if the patient bounces back and tells the ED that you encouraged them to sign out AMA, that's not a good idea. I've seen this happen before, no bueno. Makes you look lazy and/or discriminatory if it looks like a funding/socially complicated reason and there's a bad outcome.

 

[link2swim06]

That's why it's really nice to have an ED obs unit. You can just put the people that are in between there.

 

[turkeyjerky]

The thing that I always got that was the worst was getting called to "lay the hands" on someone with belly pain. Even if they had no findings on CT scan or whatever, it was always that call. We ended up having to bring them in at least overnight more times than I wanted to count. Soft admissions, unfortunately, were numerous enough to make morning rounds longer than they should be. Then, of course, is all the paperwork to discharge them in addition to all the other daily work.

So, you're complaining that, frequently after being asked to consult on a patient in the ED, you would recommend admission for obs/pain control/serial exams, etc? I understand bitching about the extra work , but how exactly can you blame the ED doc for this?

I'm not exactly happy when new patients come in at 4 in the morning, but I don't blame my triage nurse for refusing to register them. These are patients who need to be seen, just like the ones you are complaining about need (by your own acknowledgement) to be admitted (for whatever reason).

 

[Raryn]

So, you're complaining that, frequently after being asked to consult on a patient in the ED, you would recommend admission for obs/pain control/serial exams, etc? I understand bitching about the extra work , but how exactly can you blame the ED doc for this?

I'm not exactly happy when new patients come in at 4 in the morning, but I don't blame my triage nurse for refusing to register them. These are patients who need to be seen, just like the ones you are complaining about need (by your own acknowledgement) to be admitted (for whatever reason).

The complaint is that even though the consult is often absurd, we (admitted services) have to bring them in because A) The patient has been told they'll be admitted and insist on it B) We can't turn down an admission without waking up our attendings and making them come in C) The argument is more work than the admission itself or D) some combination of the above. I don't get it for abdominal pain, but I frequently get it for things like a troponin of 0.08->0.09 (where the normal range at that hospital is <0.15 and the troponin had no indication to be checked in the first place) or vasovagal syncope in an otherwise healthy young man with no EKG abnormalities. (Both cases I admitted last week)

The ED docs are "blamable" because the patient in these cases could have been sent home, but through their actions we have no choice but to take them into the hospital overnight without making a huge stink out of it. I don't *really* think admission is recommended, but with careful phrasing I manage to take them in before I send them home 8 hours later. If I was an attending who got paid per patient, I might still admit the patient... but the BS isn't exactly intellectually satisfying.

 

[ThoracicGuy]

So, you're complaining that, frequently after being asked to consult on a patient in the ED, you would recommend admission for obs/pain control/serial exams, etc? I understand bitching about the extra work , but how exactly can you blame the ED doc for this?

I'm not exactly happy when new patients come in at 4 in the morning, but I don't blame my triage nurse for refusing to register them. These are patients who need to be seen, just like the ones you are complaining about need (by your own acknowledgement) to be admitted (for whatever reason).

As a resident, I didn't have the option. My staff said to bring them in to watch them. Nevermind that the staff was either not the one that the patient was admitted to or didn't really care because all the paperwork was done by their resident. I don't blame the ER. They just want the patient out of the ER, but sometimes they seemed to just not have any clue of what an appropriate consult was. I could generally guess which of the staff was in charge of the resident calling with these patients as well...

 

[turkeyjerky]

As a resident, I didn't have the option. My staff said to bring them in to watch them. Nevermind that the staff was either not the one that the patient was admitted to or didn't really care because all the paperwork was done by their resident. I don't blame the ER. They just want the patient out of the ER, but sometimes they seemed to just not have any clue of what an appropriate consult was. I could generally guess which of the staff was in charge of the resident calling with these patients as well...

No, you are blaming the ER--you're blaming them for the fact that your attending doesn't agree with your assessment and instead recommends admission. If someone calls you and asks you to "lay hands on" a patient, and after doing so you (in this case your attending, after staffing it on the phone) recommend admission, it's ludicrous to blame the requesting physician. They requested a CYA consult and you (your attending) recommended a CYA admission.

@Raryn
I sympathize with you about the BS admissions (and I know here are a hell of a lot of those) but that's really a different situation.

 

[mvenus929]

They don't cap a surgery census and just add to the stuff to round on with a typically already busy service...

Peds doesn't have caps in place either.

The thing that I always got that was the worst was getting called to "lay the hands" on someone with belly pain. Even if they had no findings on CT scan or whatever, it was always that call. We ended up having to bring them in at least overnight more times than I wanted to count. Soft admissions, unfortunately, were numerous enough to make morning rounds longer than they should be. Then, of course, is all the paperwork to discharge them in addition to all the other daily work.

I get the frustration with soft admissions. What makes me mad is when a surgical service (usually ENT or Urology at my hospital, but occasionally Peds Surg) feels that a patient needs to be admitted, but doesn't want to admit to their service. Or when the patient clearly has a surgical problem (post-op bleeding, vomiting, etc, or in a case I had recently, appendicitis), but the surgeons decide to admit to a different team, do most of the management themselves, and then leave the primary team to do all the paperwork. If the patient doesn't clearly have a surgical problem and surgery doesn't want to admit, I have no problem admitting to hospitalist for serial abdominal exams with surgery consulted.

 

[Arcan57]

Peds doesn't have caps in place either.



I get the frustration with soft admissions. What makes me mad is when a surgical service (usually ENT or Urology at my hospital, but occasionally Peds Surg) feels that a patient needs to be admitted, but doesn't want to admit to their service. Or when the patient clearly has a surgical problem (post-op bleeding, vomiting, etc, or in a case I had recently, appendicitis), but the surgeons decide to admit to a different team, do most of the management themselves, and then leave the primary team to do all the paperwork. If the patient doesn't clearly have a surgical problem and surgery doesn't want to admit, I have no problem admitting to hospitalist for serial abdominal exams with surgery consulted.

That's going to be an interesting and ugly fight as reimbursement trends change. Right now a lot of admits for specialty services goes to the hospitalist because of convenience such as meeting bylaws requiring patients to be seen by an attending within 4 hrs of admission.

If the payors move to global payment for docs per episode of hospital care, every additional doc is siphoning off some portion of the payment. Does it suddenly become cheaper to hire a PA or suck up the pain of coming in at 2am to avoid paying a doc to tuck in or babysit your patient? Will hospitalists take on more potential legal risk because of the real risk of losing the majority of their revenue to a loaded boat of consultants?