Hospitalist pushback on admits. Is it everywhere?

[sonofva]

I'm an Em2 at a community program. The wards are split days run by IM contractors and fm residents 25/75%. The im folks are pretty good about admits. I work for the army and almost everyone can get reliable close followup and many people can be command directed to return if need be, so we have very few "soft admits" in my opinion. Granted, we dont have a lot of subspecialty backup where i work (or any at all sometimes)...

The IM folks are great, take people easily, and block really only if someone is genuinely too sick to stay. If they do block, they usully come hash it out and we make a shared decision about dispo.

The fm folks, however, give pushback on nearly all patients. I feel like im taking crazy pills. Things i consider slam dunk admits get blocked by these people and i just say screw you and transfer, or the fm service freaks and admits to icu...

It is physically exhausting having these battles if i have a high acuitu shift. I hate to sound whiny but im starting to get burnt out being a hard patient advocate all the time.

Is it like this everywhere? Do things get easier?

Sent from my SM-G930V using Tapatalk

---

Members don't see this ad.

 

[Mad Jack]

I'm an Em2 at a community program. The wards are split days run by IM contractors and fm residents 25/75%. The im folks are pretty good about admits. I work for the army and almost everyone can get reliable close followup and many people can be command directed to return if need be, so we have very few "soft admits" in my opinion. Granted, we dont have a lot of subspecialty backup where i work (or any at all sometimes)...

The IM folks are great, take people easily, and block really only if someone is genuinely too sick to stay. If they do block, they usully come hash it out and we make a shared decision about dispo.

The fm folks, however, give pushback on nearly all patients. I feel like im taking crazy pills. Things i consider slam dunk admits get blocked by these people and i just say screw you and transfer, or the fm service freaks and admits to icu...

It is physically exhausting having these battles if i have a high acuitu shift. I hate to sound whiny but im starting to get burnt out being a hard patient advocate all the time.

Is it like this everywhere? Do things get easier?

Sent from my SM-G930V using Tapatalk

I dunno, hospitalist vs EM seems like a pretty universal thing, you've basically got opposing goals much of the time. That your IM peeps tend to be better than your FM is more of a quirk than a normal feature.

 

[Choledocholithiasis]

Fm residents don't get paid extra for extra consults, IM attendings do get paid more for consults at most places, it could just be the difference bw attending and residents responses to extra work

 

[Apollyon]

True hospitalists are kin to EM. Residents, no matter what stripe, will object to everything.

Remember that "fish stinks from the head on down". If the FM residents are giving you heartburn, their leadership is poor. Either the command is not aware (bad), or IS aware, and supports this blocking (which would be quizzical, because more patients means more learning) (MUCH worse).

Best thing? Go to your command, and share your concerns. Frame it as education. Sprinkle patient satisfaction liberally.

However, just stand up a little straighter, and tell yourself (not anyone else) that you are doing the right thing for these patients.

 

[emergentmd]

The hospitalists are testing you. Why do you need to battle this? Let the attending battle it or atleast get their go ahead.

If a Hospitalists ever refuses admission, I just ask them to do a consult in the ED and discharge if they disagree. They are REQUIRED to consult in the ED, no different than an on call specialists required to consult in the ED or Inpatient.

I am sure a hospitalists would not like a surgeon to tell them they will not consult. I am also sure they would not like it if I told them that I would not intubate one of their patients or put in a central line for them.

Its not your battle, but a department head battle. Get the department head to end this turf crap. An easy way is just tell them they are consulted to see the pt in the ED and get the pt off ur hands.

 

[Tenk]

This is 100% a location and cultural thing. I trained in an area where it was always a fight. I work in an area where there is almost no pushback. The difference still blows my mind.

 

[Raryn]

When I work as an admitting hospitalist, it's almost as much work for me to go see the patient and not admit them as it is to see the patient and admit them. Given the latter has significantly less drama, I just admit them. They can always be discharged the next day if needed, no skin off my nose.

As a resident, if an admit was inappropriate I still wouldn't block it unless it was truly inappropriate and it was between the hours of 9 and 4, as we had a policy that the attending themselves had to go down and see the patient before they could be discharged without admission. I did that a grand total of twice in three years, both with the same attending, who was the chief of medicine at our VA and was going on a crusade to decrease the # of what were felt to be inappropriate admissions (and our VA ED was staffed with internists anyway). Otherwise, we (as residents) would bitch and moan about the ED physicians to each other, and otherwise just do our damn jobs.

 

[GeneralVeers]

Once in practice you should have no pushback. I let the night hospitalist sleep all night and then call him at the end of my shift with the list of admits. He appreciates the sleep, but also trusts that I won't admit nonsense. Obviously I wake him up for anyone really sick.

 

[justaregularmed]

Context is also important, pushback is common at academic programs but it's not the rule. It's not uncommon for the hospitalist service not to make money and require a stipend. This has lead to some more bizarre behavior in the age of the CMG in my opinion, but it all depends on admin pressure and local setup.

 

[Rendar5]

I get pushback from 4-5 doctors on soft admits if I dont phrase things correctly. I get pushback from 1 idiot in obvious cases (e.g. I had a patient with an obvious stroke and he wouldn't accept it until a neurologist came in, saw the patient, confirmed the clinical diagnosis and then spoke with him on the phone to tell him it needed to be admitted). I get no pushback from the other 99 docs I admit to.

 

[VA Hopeful Dr]

I get pushback from 4-5 doctors on soft admits if I dont phrase things correctly. I get pushback from 1 idiot in obvious cases (e.g. I had a patient with an obvious stroke and he wouldn't accept it until a neurologist came in, saw the patient, confirmed the clinical diagnosis and then spoke with him on the phone to tell him it needed to be admitted). I get no pushback from the other 99 docs I admit to.

Something to consider as well is how the hospitalists are paid. Production based will rarely ever fight you, salaried is much more likely to.

Not a great example of professional ethics, but it is what it is.

 

[Raryn]

Something to consider as well is how the hospitalists are paid. Production based will rarely ever fight you, salaried is much more likely to.

Not a great example of professional ethics, but it is what it is.

Eh. I'm paid per hour when I admit. Any phone calls are literally just extra work when I could be sleeping. It's still more trouble than it's worth to argue.

 

[Psai]

Maybe it's because they had bad experiences in the past. Can't discharge without an attending so a patient that looks amazing but has "multifocal pneumonia" gets a nice bill for an useless overnight inpatient stay or "r/o MI" in a patient with no chest pain but has several decades of rotator cuff issues presenting with shoulder pain. It makes it hard to give the ED the benefit of the doubt.

 

[deleted547339]

Maybe it's because they had bad experiences in the past. Can't discharge without an attending so a patient that looks amazing but has "multifocal pneumonia" gets a nice bill for an useless overnight inpatient stay or "r/o MI" in a patient with no chest pain but has several decades of rotator cuff issues presenting with shoulder pain. It makes it hard to give the ED the benefit of the doubt.

Uh, really? You've never seen someone with a marginal story rule in, or a patient that looks ok but had a bad cxr crump? Seems like some bias....

 

[Venko]

I choose to believe that pushback is a defense mechanism that comes from an imbalance of reward and fear.

I tend to experience pushback when the admitting physicians knowledge base is not sufficient for at least some of the patient outcomes, and they don't see enough potential benefit to taking the patient anyway.

In my theory, a resident is more likely to feel that fear that they are not able to care for the patient and not likely to see much of any benefit from admitting the patient.

What can I do? Well, often, if I anticipate that the admitting service will be fearful of the patient, I try to hedge the fear off early:

- alert the ICU team of the patient and see if they are happy to be a resource for the floor team. They invariably say of course.
- if a Subspecialist may be useful but not in the ED, I will call them and ask them to assist the floor team
- if they won't know how to treat something, I write the plan and doses in the chart
- sometimes I call the floor attending before the resident to see what I can do to help their team with the patient. Then the resident is kinda stuck.
- I highlight the great opportunity for learning and achieving comfort by taking the patient and gaining experience.

Anything I can do within reason to provide comfort I will.


Sent from my iPhone using SDN mobile

 

[Angry Birds]

Hospitalist pushback on admits. Is it everywhere?

Yes.

 

[hello1234!]

I choose to believe that pushback is a defense mechanism that comes from an imbalance of reward and fear.

I tend to experience pushback when the admitting physicians knowledge base is not sufficient for at least some of the patient outcomes, and they don't see enough potential benefit to taking the patient anyway.

In my theory, a resident is more likely to feel that fear that they are not able to care for the patient and not likely to see much of any benefit from admitting the patient.

What can I do? Well, often, if I anticipate that the admitting service will be fearful of the patient, I try to hedge the fear off early:

- alert the ICU team of the patient and see if they are happy to be a resource for the floor team. They invariably say of course.
- if a Subspecialist may be useful but not in the ED, I will call them and ask them to assist the floor team
- if they won't know how to treat something, I write the plan and doses in the chart
- sometimes I call the floor attending before the resident to see what I can do to help their team with the patient. Then the resident is kinda stuck.
- I highlight the great opportunity for learning and achieving comfort by taking the patient and gaining experience.

Anything I can do within reason to provide comfort I will.


Sent from my iPhone using SDN mobile

Wow, that is above and beyond the call of duty, I can't believe you have to go to those lengths with all of those phone calls to avoid push-back.

 

[GeneralVeers]

Wow, that is above and beyond the call of duty, I can't believe you have to go to those lengths with all of those phone calls to avoid push-back.

Yes, especially when a simple "come see the patient if you disagree with the admission" will suffice in 99% of cases.

 

[Psai]

Yes, especially when a simple "come see the patient if you disagree with the admission" will suffice in 99% of cases.

I have to admit that there have been a few patients where they sounded like bs on paper because the phone call was sparsely detailed. Then I see the patient and wonder why they called the floor instead of the icu

 

[Venko]

Wow, that is above and beyond the call of duty, I can't believe you have to go to those lengths with all of those phone calls to avoid push-back.

Yes, especially when a simple "come see the patient if you disagree with the admission" will suffice in 99% of cases.

It's actually not much work for me. We are blessed to have a closed unit and full admitting privileges. I would not want to slow the admission process up by having another doc come down to the ED. Also, if I as the staff doc would like the admission, I don't really prefer to have the resident in a primary care specialty come and make a decision for me...especially to discharge when I feel they need admission.

The calls I'm talking about are really easy to make because I am mobilizing a team of folks to help an inpatient resident who is scared.

If they come down and ask me for more testing or more ED consultations, etc and still feel uncomfortable about the admission...it's a lot of time and energy for a person who is stable for inpatient care in my determination.

It's my style I guess.




Sent from my iPhone using SDN mobile

 

[Nephro critical care]

As a night hospitalist I would fight all the time with the ED docs. Our ED shifts were oddly stacked so there was 3 or 4 ED docs who were all working evening shifts and leaving between 9 and 12 pm. And these guys would all keep all their admits till the end of the shifts so every day as the standalone night guy I would invariably get called with 8-12 admits between 9 and 12 pm.
And we had a bunch of chest pain guys who had real coronary artery disease but had become drug seekers along the route and would come in with chest pain every other night. When I had 8 admits and get called about these 2 pts who were going to be ruled out for MI for the 100th time this year I was almost ready to bite the ED physicians head off. The smart ED docs soon learnt to start these pts on heparin gtts ( for supposed unstable angina ) so I wouldn't tell them to do a 2nd troponin and street these folks.

 

[emergentmd]

I work at two places. One where admitting is rarely ever challenged. I text my admission, they disappear without even a conversation.
The other, I will get made up reasons not to admit. This requires alittle more finesse but I almost always get my way without resorting to "come see the pt and discharge them if you like".

Chest pain - Classic Angina story
Pneumonia - Pt can barely walk to the bathroom
abdominal pain - pt has intractable pain and vomiting.

By the time they go upstairs, the hospitalist wont care anyhow b/c they just gonna pass it along in the am.

 

[Nephro critical care]

As a night hospitalist I have never been able to sleep at night so I'd rather do admits rather than sit around twiddling my fingers. This is despite I have no RVU incentive so doesn't matter I do 1 admit or 15. But obviously nobody wants 15 admits together at the same time.
For PNA admits we used the CURB-65 guidelines (confusion, RR>30,BUN>19,SBP<90,DBP<60,age>65). If score >1 admit.
The problem is that this score will sometimes give you admits that don't need admission i.e a 88 yr old with baseline dementia with a tiny sliver of PNA , RR of 12 and stiff arteries with baseline BP 120/48 , and CKD with baseline BUN 22 creat 1.2 will get a score of 4 . Per CURB-65 he should be admitted preferably to ICU. In reality if he has reliable family and is also keeping food down he could go home on levaquin.

 

[Apollyon]

As a night hospitalist I have never been able to sleep at night so I'd rather do admits rather than sit around twiddling my fingers. This is despite I have no RVU incentive so doesn't matter I do 1 admit or 15. But obviously nobody wants 15 admits together at the same time.
For PNA admits we used the CURB-65 guidelines (confusion, RR>30,BUN>19,SBP<90,DBP<60,age>65). If score >1 admit.
The problem is that this score will sometimes give you admits that don't need admission i.e a 88 yr old with baseline dementia... In reality if he has reliable family and is also keeping food down he could go home on levaquin.

You would give a demented 88 year old a quinolone? I mean, don't you worry about delirium?

 

[Birdstrike]

I'm an Em2 at a community program. The wards are split days run by IM contractors and fm residents 25/75%. The im folks are pretty good about admits. I work for the army and almost everyone can get reliable close followup and many people can be command directed to return if need be, so we have very few "soft admits" in my opinion. Granted, we dont have a lot of subspecialty backup where i work (or any at all sometimes)...

The IM folks are great, take people easily, and block really only if someone is genuinely too sick to stay. If they do block, they usully come hash it out and we make a shared decision about dispo.

The fm folks, however, give pushback on nearly all patients. I feel like im taking crazy pills. Things i consider slam dunk admits get blocked by these people and i just say screw you and transfer, or the fm service freaks and admits to icu...

It is physically exhausting having these battles if i have a high acuitu shift. I hate to sound whiny but im starting to get burnt out being a hard patient advocate all the time.

Is it like this everywhere? Do things get easier?

Sent from my SM-G930V using Tapatalk

My two cents, for what it's worth, are this:

From the sound of it, it seems you're getting more pushback than what I'd expect as the norm and that maybe the setting you're currently working shifts in is on the more painful side of the bell curve. Some residency programs are like this including the one I was trained at, which had terrible pushback and made admitting people torture. When you're getting to the breaking point feeling that the pushback is so bad you're taking "crazy pills," it sounds like there may be something systemic going on, such as overwhelmed hospitalists, burned out consultations, or just a miserable and negative hospital culture (midpoint through residency can feel like this).

However, allowing for the fact that pushback from admitting physicians certainly will vary from job to job, hospital to hospital and specialty to specialty, some amount of pushback to the emergency physician from those being consulted for admission or consultation is as much part and parcel of Emergency Medicine as is shift work, working some amount of nights/weekends/holidays, seeing critical patients and dealing with a whole lot of non-emergencies.

 

[Nephro critical care]

You would give a demented 88 year old a quinolone? I mean, don't you worry about delirium?

It's kind of a rare cause of delirium. Maybe it's there but underreported . I bet there is at least 1 million elderly pts in the USA who got levofloxacin or Avelox last year.

 

[Apollyon]

It's kind of a rare cause of delirium. Maybe it's there but underreported . I bet there is at least 1 million elderly pts in the USA who got levofloxacin or Avelox last year.

I've had two geriatricians tell me to avoid them, and that works for me. Seeing it once with Cipro scared me enough.

 

[VA Hopeful Dr]

I've had two geriatricians tell me to avoid them, and that works for me. Seeing it once with Cipro scared me enough.

That and snapping all their tendons...

 

[barnacle]

For residents on the job search this a great topic to bring up when interviewing. How many phone calls do you have to make to get a person admitted? How much push back do you get? Do your consultants back you up? I have worked at a places where consultants always push back and offer no help when s*** hits the fan. You don't need extra stress in your life. Don't work at these places.

 

[barnacle]

As a night hospitalist I would fight all the time with the ED docs. This was in Massachusetts. Our ED shifts were oddly stacked so there was 3 or 4 ED docs who were all working evening shifts and leaving between 9 and 12 pm. And these guys would all keep all their admits till the end of the shifts so every day as the standalone night guy I would invariably get called with 8-12 admits between 9 and 12 pm.
And we had a bunch of chest pain guys who had real coronary artery disease but had become drug seekers along the route and would come in with chest pain every other night. When I had 8 admits and get called about these 2 pts who were going to be ruled out for MI for the 100th time this year I was almost ready to bite the ED physicians head off. The smart ED docs soon learnt to start these pts on heparin gtts ( for supposed unstable angina ) so I wouldn't tell them to do a 2nd troponin and street these folks.

Why do you fight with your ED docs? These are your colleagues. We appreciate what you do and how hard you work. And just like you, the ED docs require others help to do their job. Your ED is likely not oddly staffed. Most EDs staff according to average volume. Peak hours = most coverage. Unfortunately I notice this is rarely done on the hospitalist side. Stacked day team till 7pm and lone man/woman after 7pm. Most EDs have a surge of pts in the evening, thus surge in admits. The ED docs have no control over your staffing model. If the ED docs are truly holding their admits this is a problem on ED side & warrants a discussion w/ ED mgmt. If you don't like CP r/o's (I don't think anyone does) suggest to hospital to create an obs unit and have someone else run it. If admits aren't warranted discuss alternative plans & educate the ED docs you might be surprised how receptive they are. I know the frustrations of working short staffed all too well, it's not fun, however your ED docs are trying to survive their shift just like you. Medicine is a team sport.

 

[Nephro critical care]

Why do you fight with your ED docs? These are your colleagues. We appreciate what you do and how hard you work. And just like you, the ED docs require others help to do their job. Your ED is likely not oddly staffed. Most EDs staff according to average volume. Peak hours = most coverage. Unfortunately I notice this is rarely done on the hospitalist side. Stacked day team till 7pm and lone man/woman after 7pm. Most EDs have a surge of pts in the evening, thus surge in admits. The ED docs have no control over your staffing model. If the ED docs are truly holding their admits this is a problem on ED side & warrants a discussion w/ ED mgmt. If you don't like CP r/o's (I don't think anyone does) suggest to hospital to create an obs unit and have someone else run it. If admits aren't warranted discuss alternative plans & educate the ED docs you might be surprised how receptive they are. I know the frustrations of working short staffed all too well, it's not fun, however your ED docs are trying to survive their shift just like you. Medicine is a team sport.

You are right my friend. But people are on a visa or doing a waiver and there is a reason my hospital hardly ever had an AMG in the hospitalist program other than the hospitalist director and one lady who clashed with the director and then left/ was let go. I have talked to my director about the number of admits and rather than getting extra help he just told me why I was taking so many admits. When he gets called for admits his first reaction is to tell the ED physician " f''' you " , some pleasantries are exchanged and then the pt is usually shunted to one of the non- medicine services or kept in the ED for additional testing like MRCP, pan MRI spine etc. As you could probably figure out none of the ED physicians like to call our director with admits and the newer ones always wait till he is not carrying the pager. And because that's what he teaches all the other hospitalist to do as well no wonder the ED/hospitalist relations aren't great. Obs unit is good but the ED and hospitalist director have to buy in.
I have seen pts come to the ED at 9 am and still having w/u in the ED at 3 am the next morning i.e CT enterography. By then they are either well enough to go home or I will have mercy on pt/ ED staff and admit the pt.There is a good reason our ED hallways are always packed with pts on stretchers.

 

[BoardingDoc]

You are right my friend. But people are on a visa or doing a waiver and there is a reason my hospital hardly ever had an AMG in the hospitalist program other than the hospitalist director and one lady who clashed with the director and then left/ was let go. I have talked to my director about the number of admits and rather than getting extra help he just told me why I was taking so many admits. When he gets called for admits his first reaction is to tell the ED physician " f''' you " , some pleasantries are exchanged and then the pt is usually shunted to one of the non- medicine services or kept in the ED for additional testing like MRCP, pan MRI spine etc. As you could probably figure out none of the ED physicians like to call our director with admits and the newer ones always wait till he is not carrying the pager. And because that's what he teaches all the other hospitalist to do as well no wonder the ED/hospitalist relations aren't great. Obs unit is good but the ED and hospitalist director have to buy in.
I have seen pts come to the ED at 9 am and still having w/u in the ED at 3 am the next morning i.e CT enterography. By then they are either well enough to go home or I will have mercy on pt/ ED staff and admit the pt.There is a good reason our ED hallways are always packed with pts on stretchers.

That is completely insane and utterly unprofessional. I don't know why this hasn't been dealt with at the hospital level already, but even at the individual provider level I'm not sure why this happens. If someone is refusing to admit until I perform an MRCP or a CT enterography in the ED, I'm going to ask that they either come admit or come DC the patient as those tests are in absolutely no way part of an ED workup. If they refuse to do either, I would simply transfer the patient another facility and document exactly why I am doing so.

 

[carbonizedeyesockets]

I'm counting my blessings. 2 months into my attending job and I have gotten push back maybe twice. And they were both pretty weak push backs.

 

[deleted859535]

That is completely insane and utterly unprofessional. I don't know why this hasn't been dealt with at the hospital level already, but even at the individual provider level I'm not sure why this happens. If someone is refusing to admit until I perform an MRCP or a CT enterography in the ED, I'm going to ask that they either come admit or come DC the patient as those tests are in absolutely no way part of an ED workup. If they refuse to do either, I would simply transfer the patient another facility and document exactly why I am doing so.

This right here. In no world would I ever put up with that bull****.

 

[Nephro critical care]

This right here. In no world would I ever put up with that bull****.

Well, though you also have to look at it from the perspective of the person fielding your calls. For us the problem is that some of ED physicians are no better than triage nurses. Their only focus is on whether the patient needs to be admitted or discharged. If the patient is going to be discharged then maybe they will focus on what the patient's diagnosis really is but if he needs admission some of them don't try at all to figure out what's actually going on. I get all these calls about " I have this patient who I think is having a PNA and a COPD exacerbation and a CHF excerbation. I gave him levaquin / solumedrol / lasix / duoneb and put him on bipap . And then he dropped his pressures so I gave a 500 cc fluid bolus and started him on 2 mcg dopamine " Me: What access does he have ? Oh he has a 24 gauge in his rt foot and the ED charge nurse put an I/O. And I evaluate the patient and find his BP is 79/24 and find he has been complaining of back pain for the last day and his real problem is an aortic dissection.
If I have an intensivist on then at least I can turf some of these to him. But if I don't have intensivist backup and I am getting 2 or 3 of these every night it's not hard to figure out why you sometimes get pushback from the night hospitalist.

 

[KGflyboy]

Well, though you also have to look at it from the perspective of the person fielding your calls. For us the problem is that some of ED physicians are no better than triage nurses. Their only focus is on whether the patient needs to be admitted or discharged. If the patient is going to be discharged then maybe they will focus on what the patient's diagnosis really is but if he needs admission some of them don't try at all to figure out what's actually going on. I get all these calls about " I have this patient who I think is having a PNA and a COPD exacerbation and a CHF excerbation. I gave him levaquin / solumedrol / lasix / duoneb and put him on bipap . And then he dropped his pressures so I gave a 500 cc fluid bolus and started him on 2 mcg dopamine " Me: What access does he have ? Oh he has a 24 gauge in his rt foot and the ED charge nurse put an I/O. And I evaluate the patient and find his BP is 79/24 and find he has been complaining of back pain for the last day and his real problem is an aortic dissection.
If I have an intensivist on then at least I can turf some of these to him. But if I don't have intensivist backup and I am getting 2 or 3 of these every night it's not hard to figure out why you sometimes get pushback from the night hospitalist.

Although I agree your hypothetical scenario sounds like the patient did not receive a good workup or appropriate treatment, I think most ER doctors would fundamentally disagree with the first part of your post. You implied that it is the ER's job to diagnose the patient. That's incorrect. Our job is to stabilize the emergent patient if needed and get them admitted for definitive diagnosis and treatment. Sometimes we can make the diagnosis in the ER, and that's icing on the cake. That is not the ultimate goal or responsibility of the ER.

If the patient has been resuscitated and an appropriate workup initiated, there is no reason to keep a patient in the ER pending a final diagnosis.

 

[Nephro critical care]

Although I agree your hypothetical scenario sounds like the patient did not receive a good workup or appropriate treatment, I think most ER doctors would fundamentally disagree with the first part of your post. You implied that it is the ER's job to diagnose the patient. That's incorrect. Our job is to stabilize the emergent patient if needed and get them admitted for definitive diagnosis and treatment. Sometimes we can make the diagnosis in the ER, and that's icing on the cake. That is not the ultimate goal or responsibility of the ER.

Sent from my ONEPLUS A5000 using Tapatalk

Nope. It is your job to make all life-threatening diagnosis. If I get 6 admits at the same time, I am not going to get to all of them at once. I am not asking you to diagnose mitochondrial depletion syndrome but I should not have to diagnose bacterial meningitis, STEMI and acute mesentric ischemia and I do that almost every shift I work. And a 22 gauge thumb IV is not adequate for resuscitation either.

 

[KGflyboy]

Nope. It is your job to make all life-threatening diagnosis. If I get 6 admits at the same time, I am not going to get to all of them at once. I am not asking you to diagnose mitochondrial depletion syndrome but I should not have to diagnose bacterial meningitis, STEMI and acute mesentric ischemia and I do that almost every shift I work. And a 22 gauge thumb IV is not adequate for resuscitation either.

If you are admitting people and subsequently diagnosing stemi or bacterial meningitis routinely, your hospital is in serious trouble. That is not right. However, the examples you give seem to be hyperbolic. The fact that a patient would get admitted with a 22 in the hand indicates the patient did not have one of the "life threatening" diagnoses you mentioned. If that happens to you routinely, your ER is flat out incompetent and negligent.

Sent from my ONEPLUS A5000 using Tapatalk

 

[Nephro critical care]

If you are admitting people and subsequently diagnosing stemi or bacterial meningitis routinely, your hospital is in serious trouble. That is not right. However, the examples you give seem to be hyperbolic. The fact that a patient would get admitted with a 22 in the hand indicates the patient did not have one of the "life threatening" diagnoses you mentioned. If that happens to you routinely, your ER is flat out incompetent and negligent.

Sent from my ONEPLUS A5000 using Tapatalk

ED physicians come in different flavors. We have 1 who saw about 1.5 pts / hr . His w/u were thorough seemed liked he picked up the sick ones. Whenever I got an admit from him I knew what he said was gospel. Unfortunately the ED didn't like him and they let him go although the hospitalists loved him. Unfortunately there are a few who run about 3 pts an hour . If they are all on together and I come on , I know my night is s'''''' .

 

[Nephro critical care]

My examples are not hyperbolic they happen every night. I will grant that some of them come from smaller EDs and I don't know if the physicians are board certified ED docs.

 

[deleted547339]

My examples are not hyperbolic they happen every night. I will grant that some of them come from smaller EDs and I don't know if the physicians are board certified ED docs.

Some EM docs are lazy, others think they should be sending off IM workups. Neither help the hospital. A good EPs jobs is to first triage appropriately, second stabilize anything that could be a life threat, third dispo - any further diagnostics and management can usually be left up to the admitting doc. The ED isn't the place to tease out intricacies of patient complaints.

 

[gro2001]

I have to admit that there have been a few patients where they sounded like bs on paper because the phone call was sparsely detailed. Then I see the patient and wonder why they called the floor instead of the icu

Ah, the classic example of a patient moving instantaneously from the "too healthy to admit" to "to sick to go to the floor" group. This is the only phenomenon in the observable universe that has been observed to occur faster than the speed of light. Occasionally, the patient will seem to occupy a quantum superposition state, and the ED will be reamed out for both a soft admit and not calling the ICU at the same time.

 

[Psai]

Ah, the classic example of a patient moving instantaneously from the "too healthy to admit" to "to sick to go to the floor" group. This is the only phenomenon in the observable universe that has been observed to occur faster than the speed of light. Occasionally, the patient will seem to occupy a quantum superposition state, and the ED will be reamed out for both a soft admit and not calling the ICU at the same time.

You can't really blame others if both your presentation and disposition abilities leave something to be desired

 

[e30ftw]

Pushback is much less common in the community than in academics but still occurs.

Sometimes you just have to sigh and realize that you're doing the best thing for the patient and that's the only thing that matters.

Yesterday one of our hospitalists made some condescending remarks about why a patient would need admission for pneumonia.

The patient was 95 years old, had a LLL infiltrate, was not improving on outpatient zithromax, had new onset pulm edema, a trop 0.06, lateral ST depression/twi, a Cr of 3.5 and BUN of > 60, was traveling through to escape Irma so had no follow up.. etc.

Hospitalist asked why he needed to be admitted because he wasn't "retracting" and "his sat is 97 on room air".

Smile and nod fellas.. smile and nod.

 

[deleted109597]

You can't really blame others if both your presentation and disposition abilities leave something to be desired

This is a universal problem. It's much more prominent in residency. But I would argue it isn't on the presentation or disposition. It's the other person wanting it not to be their problem, either at home or on a different floor.

 

[Raryn]

Pushback is much less common in the community than in academics but still occurs.

Sometimes you just have to sigh and realize that you're doing the best thing for the patient and that's the only thing that matters.

Yesterday one of our hospitalists made some condescending remarks about why a patient would need admission for pneumonia.

The patient was 95 years old, had a LLL infiltrate, was not improving on outpatient zithromax, had new onset pulm edema, a trop 0.06, lateral ST depression/twi, a Cr of 3.5 and BUN of > 60, was traveling through to escape Irma so had no follow up.. etc.

Hospitalist asked why he needed to be admitted because he wasn't "retracting" and "his sat is 97 on room air".

Smile and nod fellas.. smile and nod.

I don't get it. That's an easy admission that takes under 30 minutes to do. You have a diagnosis. Put him on IV abx, decide what to do with his home meds, ask him for his code status, and move on. Why argue?

 

[deleted547339]

I don't get it. That's an easy admission that takes under 30 minutes to do. You have a diagnosis. Put him on IV abx, decide what to do with his home meds, ask him for his code status, and move on. Why argue?

Because some people just suck and hate life.

 

[Psai]

Pushback is much less common in the community than in academics but still occurs.

Sometimes you just have to sigh and realize that you're doing the best thing for the patient and that's the only thing that matters.

Yesterday one of our hospitalists made some condescending remarks about why a patient would need admission for pneumonia.

The patient was 95 years old, had a LLL infiltrate, was not improving on outpatient zithromax, had new onset pulm edema, a trop 0.06, lateral ST depression/twi, a Cr of 3.5 and BUN of > 60, was traveling through to escape Irma so had no follow up.. etc.

Hospitalist asked why he needed to be admitted because he wasn't "retracting" and "his sat is 97 on room air".

Smile and nod fellas.. smile and nod.

Okay that's pretty bad. Every single one of those problems warrant admission.

 

[Birdstrike]

Because some people just suck and hate life.

Miserable people tend not to like to be the only one miserable, and will work hard to ensure that you join them. It's like the old saying, "Misery loves company."

 

[HooliganSnail]

Once in practice you should have no pushback. I let the night hospitalist sleep all night and then call him at the end of my shift with the list of admits. He appreciates the sleep, but also trusts that I won't admit nonsense. Obviously I wake him up for anyone really sick.

I find this to be incredible important, especially since I work in rural places.

When you get to know the other docs, and your specialists, and start to establish a reputation for no-nonsense, then you get respect. After that, its kinda a breeze, especially when you need to use up brownie points on a softer admit (everyone needs to admit some soft stuff in an old person once in awhile).

It also matters what kind of PCP follow up people in the area have. When I'm in places where most people seem to have a decent relationship with their doctor, it makes discharge with strict return precautions alot easier.