Hospitalist pushback on admits. Is it everywhere?

[sluggs]

Here's a cynical picture:
-Look at a place where the hospitalists are on salary.... they will do anything to get out of an admit.
-Look at a place where hospitalists work fee-for-service... they will do anything to get another admit/even observe.

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[Siggy]

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.

I can turn this around, though. Why is the hospitalist and admission the "easy button" dispo?

Too drunk to go home? Meh, we'll admit him for 24 hours (even if clinically sober) instead of letting him ride a hallway gurney for a few hours to sobriety (this is ignoring when the ED decides to baker act/psych hold the drunk because "his drinking is a danger to himself").

ESLD who needs a theraputic tap because it's uncomfortable (and the patient is now being tapped every 2-3 weeks)? Meh, have IR do it and admit to medicine instead of tapping in the ED and discharge when there's zero sign of SBP.

Peritonsilar abscess? Admit to medicine, consult ENT when the patient could be drained in the ED and discharged home.

Patient too psychotic for the psych ward? Ativan and geodon or ketamine to the point where they're barely arousable. Now they get to beat up the medicine ward nursing staff when they wake up instead of being in the lock down unit on the psych side of the hospital.

Medicine is a "team sport," but it shouldn't be up to the inpatient team to make up for the CMG short staffing the ED to make an extra dollar for their stock holders.

As an aside, during the hurricane it was bizarro world helping out in the ED and fighting with the ED attending to do a soft admit. 30 year old chest pain dude with history of surgical excision of a cardiac teratoma isn't going home in the middle of a hurricane. Seriously... just let me admit him to myself and the IM attending.

 

[coachB]

I can turn this around, though. Why is the hospitalist and admission the "easy button" dispo?

Retropharyengeal abscess? Admit to medicine, consult ENT when the patient could be drained in the ED and discharged home.

Really? You think I can drain a retropharyngeal abscess at the bedside? I know what you probably meant to say, but you kind of hurt your credibility with that one.

 

[Siggy]

Really? You think I can drain a retropharyngeal abscess at the bedside? I know what you probably meant to say, but you kind of hurt your credibility with that one.

Sorry, peritonsilar... and yes, I can be an idiot at times.

As an aside, I generally don't complain if it's anything near worthy of admission. I don't expect the ED to do my job for me or be able to practice internal medicine better than me... just like it would be wrong to expect me to manage emergencies in peds/trauma/OB/psych (i.e. EM's job).

Also... House of God law 6...

 

[Psai]

Really? You think I can drain a retropharyngeal abscess at the bedside? I know what you probably meant to say, but you kind of hurt your credibility with that one.

There is no body cavity that cannot be reached with a #14G needle and a good strong arm.

 

[deleted547339]

I can turn this around, though. Why is the hospitalist and admission the "easy button" dispo?

Too drunk to go home? Meh, we'll admit him for 24 hours (even if clinically sober) instead of letting him ride a hallway gurney for a few hours to sobriety (this is ignoring when the ED decides to baker act/psych hold the drunk because "his drinking is a danger to himself").

ESLD who needs a theraputic tap because it's uncomfortable (and the patient is now being tapped every 2-3 weeks)? Meh, have IR do it and admit to medicine instead of tapping in the ED and discharge when there's zero sign of SBP.

Peritonsilar abscess? Admit to medicine, consult ENT when the patient could be drained in the ED and discharged home.

Patient too psychotic for the psych ward? Ativan and geodon or ketamine to the point where they're barely arousable. Now they get to beat up the medicine ward nursing staff when they wake up instead of being in the lock down unit on the psych side of the hospital.

Medicine is a "team sport," but it shouldn't be up to the inpatient team to make up for the CMG short staffing the ED to make an extra dollar for their stock holders.

As an aside, during the hurricane it was bizarro world helping out in the ED and fighting with the ED attending to do a soft admit. 30 year old chest pain dude with history of surgical excision of a cardiac teratoma isn't going home in the middle of a hurricane. Seriously... just let me admit him to myself and the IM attending.

Hey man, we didn't make you pick choose to be a hospitalist...

 

[Siggy]

Hey man, we didn't make you pick choose to be a hospitalist...

Same can be said about emergency medicine, not being forced to choose to be an emergency physician, and BS SNF and primary care physician referrals to the emergency department (see "Insurers not paying for non-emergent care" thread... and at least I agree that PCPs and SNFs shouldn't be transferring BS to the ED).

 

[BJJVP]

I can turn this around, though. Why is the hospitalist and admission the "easy button" dispo?

Too drunk to go home? Meh, we'll admit him for 24 hours (even if clinically sober) instead of letting him ride a hallway gurney for a few hours to sobriety (this is ignoring when the ED decides to baker act/psych hold the drunk because "his drinking is a danger to himself").

ESLD who needs a theraputic tap because it's uncomfortable (and the patient is now being tapped every 2-3 weeks)? Meh, have IR do it and admit to medicine instead of tapping in the ED and discharge when there's zero sign of SBP.

Peritonsilar abscess? Admit to medicine, consult ENT when the patient could be drained in the ED and discharged home.

Patient too psychotic for the psych ward? Ativan and geodon or ketamine to the point where they're barely arousable. Now they get to beat up the medicine ward nursing staff when they wake up instead of being in the lock down unit on the psych side of the hospital.

Medicine is a "team sport," but it shouldn't be up to the inpatient team to make up for the CMG short staffing the ED to make an extra dollar for their stock holders.

As an aside, during the hurricane it was bizarro world helping out in the ED and fighting with the ED attending to do a soft admit. 30 year old chest pain dude with history of surgical excision of a cardiac teratoma isn't going home in the middle of a hurricane. Seriously... just let me admit him to myself and the IM attending.

I can't blame you for the frustration in these cases.

Case #1 - A lot of times, when IR can't squeeze the ascites pts in during the day, the pts complain about having to wait in the ER instead of "getting a bed." The pt's really should be able to have these paracentesis arranged more easily as outpts but it seems that the GI and/or PCP always just tell them to come to the ED. It's BS that you guys get more work just because of our pressures with patient satisfaction and ED length of stays. I don't know what we can do about this.

Case #2 - I don't ever do this. Where I work, our drunks stay in the ED till they sober up in the morning. In fact, I try to get them out before they sober up too much and start withdrawing.

Case #3 - During the day, I call ENT and see if I can send the pt to their office for drainage. In the evening, the ENT will tell me this without even looking at the pt: "It doesn't sound that bad to me. I will see him in the office tomorrow. Unless he has an airway obstruction, I AM NOT coming in. If you think it's bad enough to be admitted, then admit to medicine but I AM NOT admitting this pt." At this point, I can either lie to the ENT and make the pt sound worse, or I will call my friends the hospitalist and see if they will do me the favor. I appreciate their help and I don't take it for granted.

Case #4 - Where I work, we don't do this. Psych pts go to the psych unit. Occasionally, in atypical presentations or weak ODs, I have to admit to medicine for 24 hrs to prove to the psychiatrist that the pt is medically cleared, actually psychotic and not delirious. But this is rare.

I actually think that hospitalists and emergency physicians have a lot more in common than one would think. We are under some of the same pressures from patients, hospital administrators and office PCPs. I actually get along with most of the hospitalists where I work. There are a few that I don't think are that great. But honestly, I don't think the other hospitalists are too crazy about them either. There are a couple of emergency physicians in our group whose sign-out I hate to take. I would wager that the hospitalists hate to hear from those particular physicians as well. I think a lot of our differences have a lot more to do with individual variations in practice patterns and irrational pressures from the medical environment than actual differences between the two fields of medicine.

 

[southerndoc]

Drunks only get admitted where I work if they have significant lab abnormalities (if they are even checked) or if they are drunk enough they smoked a tube. In fact, I've been known to intubate drunks that need a head CT, scan their head, extubate them, then discharge them. Works a lot easier when you see them at the beginning of your shift. If it's toward the end, I usually don't sign out to another ER doc to extubate and discharge the patient.

PTA drainage is within the scope of practice of an ER physician that is trained in emergency medicine. It always baffles my mind why ER docs don't do this. We get transfers all the time for ENT to drain them. Me or my colleagues will drain them in the ER and discharge them. ENT doesn't even come in. Nothing half a pelvic speculum (ours have a built-in LED light, use it as a tongue depressor), Hurricane spray, lidocaine with epi, and a large-bore needle can't fix.

For those that have ENT's that refuse to come in, their ENT's are committing an EMTALA violation. For those that admit to have ENT consult on the patient, if something bad happens, it's an EMTALA violation. There have been numerous hospitals and physicians who have been fined for "admitting for a consultant to see when they likely would have been discharged after consultant has evaluated the patient."

 

[Rendar5]

Drunks stay in the ED until clinically sober. One of my previous jobs had c-suite try to tell me that I had to admit a drunk guy because we needed dispo times under 3 hours. I said uh-huh. Never seen an EP baker act a drunk. Had nonstop,cops baker act them because they don't understand baker acts. Too many to count baker acts by PD that are totally inappropriate. And if someone is too psychotic for psych ed they get zonked with meds. Don't know why it would go to medicine at that point. They're no longer too psychotic for psych.

 

[Nephro critical care]

Hospitalist pushback is somewhat institution based. At my current gig hospitalists have an census 6-14 with average 10-11 with 2-3 admits. They don't cover ICU. Night time coverage is 2 hospitalist + NP and ICU is closed. The night hospitalist get average 5-8 admits. I think they cap around 8-9 admits. Anything that reaches floor after 6 pm / 6 am gets turfed to the night/day team. They get paid decently but no RVUs ( our institution as a policy does not pay per RVUs). There is little pushback from the hospitalist unless there is something grossly wrong i.e pt needs stat surgery or ICU admission and even under those circumstances the hospitalist will sometimes just make those calls themselves. Consultants are generally cordial(have to be as everyone is employed by the big mothership). I can tell you that despite being located in rather rural Midwest 1 hr from a bigger city the hospitalist turnover is very low and they are generally very happy.

At my previous gig hospitalist average census was 18-22 with sometimes numbers reaching up to 25-27. 3 -4 admits . Consultants were nasty and treated the hospitalists just like interns. RVU incentive was about 1-3 K for the year extra if you saw 25 pts rather than 5. Who would be crazy to see 20 extra pts a day to see get an extra 1.5 K for the year ? The night hospitalist did 14-17 admits, cross covered ICU and 150 pts . Any appeals to the hospitalist director were met by " why are u admitting all these pts ? Tell the ED doc to D/c the pt " I think over the last 10 years they have had 40 hospitalists turnover through their system. Everybody stays there for 2-3 years to fix the visa and then leaves. Over there I heard the ED physicians complain all the time about hospitalist pushback.

Hospitalist staffing factors a lot into pushback on admissions.

 

[BJJVP]

PTA drainage is within the scope of practice of an ER physician that is trained in emergency medicine. It always baffles my mind why ER docs don't do this.

Yes, I know it's within my scope but so are many other things that I am sure most EM physicians don't do. A lot of what we do has to do with hospital politics/culture. If I give someone a pneumothorax during a central line insertion, I am fairly confident my chair would back me. I really don't know what the response would be if I injured the carotid or a pt ended up with some other complication after I drained their peritonsillar abscess. I don't think anyone in my group does peritonsillar abscesses. I did only one during residency and it was US guided using the cavitary probe. I have since only worked in places where none of the emergency physicians attempt them.

Are they really that easy to do? I am honestly asking. Maybe I should start doing them. Not doing them hasn't been too much of a problem for us. The ENTs have never asked me to attempt to drain them. LOL, even the hospitalists don't fight me on these admissions.

This thread and the priapism thread have me questioning how similar my practice is with others. Maybe we need a survey/new thread. How many of you tap VP shunts? Suprapubic aspiration of urine when nobody can get a foley? Diagnostic and/or therapeutic paracentesis? What about thoracentesis? Thrombosed hemorrhoids? Burr rust rings? Some of these I don't do because of time constraints. Some of the others are not emergent and can be done later. Just curious what others do.

 

[Nephro critical care]

Kind of hard to have a consultant come in for a non emergent issue if it can wait till the morning. Just so a pt can be discharged rather than admitted at 2:30 in the morning. Most surgeons work long hard hours, in the OR from 6:30 AM to 7:00 pm. It's not shift based work like ED or hospitalist that you may have a busy shifts but you are guaranteed 12 hrs break without pages at the end. I get it if you are calling the surgeon at 8-10 pm but after that come-ins should be strictly for emergent stuff. It's not as if he drives in at 2 am and then gets out of his next day OR schedule. Burnout is real. I guarantee you if a hospital requires all its specialists to come in for non emergent stuff and those consultants are on q2-3 day call soon it will have no consultants in that field.

 

[Rendar5]

Yes, I know it's within my scope but so are many other things that I am sure most EM physicians don't do. A lot of what we do has to do with hospital politics/culture. If I give someone a pneumothorax during a central line insertion, I am fairly confident my chair would back me. I really don't know what the response would be if I injured the carotid or a pt ended up with some other complication after I drained their peritonsillar abscess. I don't think anyone in my group does peritonsillar abscesses. I did only one during residency and it was US guided using the cavitary probe. I have since only worked in places where none of the emergency physicians attempt them.

Are they really that easy to do? I am honestly asking. Maybe I should start doing them. Not doing them hasn't been too much of a problem for us. The ENTs have never asked me to attempt to drain them. LOL, even the hospitalists don't fight me on these admissions.

This thread and the priapism thread have me questioning how similar my practice is with others. Maybe we need a survey/new thread. How many of you tap VP shunts? Suprapubic aspiration of urine when nobody can get a foley? Diagnostic and/or therapeutic paracentesis? What about thoracentesis? Thrombosed hemorrhoids? Burr rust rings? Some of these I don't do because of time constraints. Some of the others are not emergent and can be done later. Just curious what others do.

PTA drainage is easy just use a needle to aspirate instead of incise if you're not sure. And make a guard so you don't go in too deep. That said don't do it if no one does it at your institution. Standard of care is what politics deems appropriate at your facility. At my main hospital I call in ENT. At my satellite ED I do it myself. Same for paracentesis (easy procedure but I don't do it when IR routinely does it for my group). Interestingly I can't give transfusions and discharge do to ED policy so all transfusion requests have to get admitted ( if not pre-arranged through the ambulatory care center) and docs (primary care) around here routinely ignore blood center guidelines and request to transfuse at <8.

 

[shoal007]

Informal community response hospital with all speciality coverage. Most of these I don't do because group standard is no.

PTA no
Paracentesis yes
Thoracentesis yes
Burr no
VP shunt no
Suprapubic no
Priapism no
Thrombosed hemorrhoid yes

Sent from my Pixel using Tapatalk

 

[BoardingDoc]

Yes, I know it's within my scope but so are many other things that I am sure most EM physicians don't do. A lot of what we do has to do with hospital politics/culture. If I give someone a pneumothorax during a central line insertion, I am fairly confident my chair would back me. I really don't know what the response would be if I injured the carotid or a pt ended up with some other complication after I drained their peritonsillar abscess. I don't think anyone in my group does peritonsillar abscesses. I did only one during residency and it was US guided using the cavitary probe. I have since only worked in places where none of the emergency physicians attempt them.

Are they really that easy to do? I am honestly asking. Maybe I should start doing them. Not doing them hasn't been too much of a problem for us. The ENTs have never asked me to attempt to drain them. LOL, even the hospitalists don't fight me on these admissions.

This thread and the priapism thread have me questioning how similar my practice is with others. Maybe we need a survey/new thread. How many of you tap VP shunts? Suprapubic aspiration of urine when nobody can get a foley? Diagnostic and/or therapeutic paracentesis? What about thoracentesis? Thrombosed hemorrhoids? Burr rust rings? Some of these I don't do because of time constraints. Some of the others are not emergent and can be done later. Just curious what others do.

PTA drainage is very easy. The key is to just be safe. I always do a needle aspiration and not a scalpel incision. I also take the cap off of the needle I'm using and then cut 1cm off of the tip of the cap. Cap then goes back on the needle so I effectively have a 1cm long needle. That way if I slip or whatever, it isn't going deep enough to reach the carotid. Then just blast the back of their throat with nebulized lidocaine if you've got it, hurricaine spray if you don't, or just without any anesthesia and you use a small gauge needle as a last resort. Aspirate, abx, dc.

- I've drained 3 priapisms and used neo to get them down. Haven't needed to call uro yet. If it's been up >4-6 hours, I'm calling uro though due to higher risk.

- I never tap shunts as I have not been trained to do so.

- Suprapubic aspiration I've never done and would probably call urology if I have them. If I don't, the patient has a severely distended bladder and we can't get a foley for some reason, I'd probably youtube it and do it. That said, I don't see myself ever being in that exact situation.

- I've done more diagnostic paras than I can count. Stupid easy to do.

- Therapeutic paras I generally admit for as the patient typically needs admission for something anyway, but in the rare cases where they don't, I've done maybe 3 or 4 in the ED. Feel comfortable doing them with a safetycentesis tray

- Thoras I only do for large effusions with significant work of breathing, but I've done them. If you're leaving a catheter in, I find that the pericardiocentesis tray and catheter works very well and makes it a very simple procedure.

- Thrombosed hemorrhoids I see very rarely and have only incised one. Not sure what I'd do for the next one I see.

- Rust rings get nonemergent ophtho followup. I'll flick out a foreign body with a needle, but if there's a significant rust ring there, I'm not using a burr on it due to my own lack of comfort with it.

 

[Angry Birds]

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.

This. And they know it.

 

[gro2001]

Yes, I know it's within my scope but so are many other things that I am sure most EM physicians don't do. A lot of what we do has to do with hospital politics/culture. If I give someone a pneumothorax during a central line insertion, I am fairly confident my chair would back me. I really don't know what the response would be if I injured the carotid or a pt ended up with some other complication after I drained their peritonsillar abscess. I don't think anyone in my group does peritonsillar abscesses. I did only one during residency and it was US guided using the cavitary probe. I have since only worked in places where none of the emergency physicians attempt them.

Are they really that easy to do? I am honestly asking. Maybe I should start doing them. Not doing them hasn't been too much of a problem for us. The ENTs have never asked me to attempt to drain them. LOL, even the hospitalists don't fight me on these admissions.

This thread and the priapism thread have me questioning how similar my practice is with others. Maybe we need a survey/new thread. How many of you tap VP shunts? Suprapubic aspiration of urine when nobody can get a foley? Diagnostic and/or therapeutic paracentesis? What about thoracentesis? Thrombosed hemorrhoids? Burr rust rings? Some of these I don't do because of time constraints. Some of the others are not emergent and can be done later. Just curious what others do.

They are super easy to do, but not 100% of them are going to be successful (sometimes you don't get pus, sometimes they recur). They are very satisfying though, and are one of my favorite procedures (right up there with nurse maid's elbows and shoulder dislocation reductions). Also, when you get a whole bunch of pus out, the patients love the instant relief.

I wouldn't do something that other people at your institution would be surprised at, but maybe consider arranging an interdepartmental meeting between the ENT, EM, and IM folks on figuring out a policy on this? Maybe they can offer some training to the EM group. You might be able to save some admissions, but also build more trust and respect with the IM folks who appreciate that you aren't just reflexively dumping on them because it's in your nature as an ER doc.

About the other procedures:
VP shunts: did a couple under neurosurgery supervision during my neuro ICU rotation in residency, but would never do this in practice as an ER doc.
Suprapubic aspiration of urine when nobody can get a foley: never had to, but would totally do it in the right circumstances.
Diagnostic paracentesis: of course, why wouldn't I?
Therapeutic paracentesis: occasionally, if I think it's going to significantly relieve symptoms, I have time, and the admitting team doesn't
What about thoracentesis: have done both, diagnostic and therapeutic. Sort of surprised people don't do them more.
Thrombosed hemorrhoids: if its definitely thrombosed and very painful, I sometimes do if I can't get them quick follow up. In the right patient, it really helps. But I don't see the right patient very often, like, maybe once a year.
Burr rust rings: never done one, so would not do in practice.

 

[deleted109597]

Therapeutic paracentesis: occasionally, if I think it's going to significantly relieve symptoms, I have time, and the admitting team doesn't
What about thoracentesis: have done both, diagnostic and therapeutic. Sort of surprised people don't do them more.

There are a myriad of reasons I don't do therapeutic ________________ in the ED. The first one is because it's not my job. I don't have a job with a lot of downtime, maybe others do. But I don't have the 30 minutes or longer to sit there and drain fluid. And I don't have medical students or residents to delegate that work to most of the time, and when I do, they also have other **** to do.
Also, therapeutic _____________ typically recur, so they're coming back to the ED because it didn't require pre-auth, waiting for an appointment, or whatever other reason they can't get it as an outpatient.
I mean, where do you stop? Therapeutic LPs for pseudotumor? Transfusions for the chronically anemic? Chemo infusions for people who missed their clinic appointment? Dialysis?
I get the "trying to help the most people the best way I can", but this isn't one of them.

 

[Siggy]

There are a myriad of reasons I don't do therapeutic ________________ in the ED. The first one is because it's not my job. I don't have a job with a lot of downtime, maybe others do. But I don't have the 30 minutes or longer to sit there and drain fluid. And I don't have medical students or residents to delegate that work to most of the time, and when I do, they also have other **** to do.
Also, therapeutic _____________ typically recur, so they're coming back to the ED because it didn't require pre-auth, waiting for an appointment, or whatever other reason they can't get it as an outpatient.

...but why is it an admission then?

 

[VA Hopeful Dr]

...but why is it an admission then?

In my neck of the woods, the ED Physicians will absolutely send home recurrent ascites patients and tell them to follow up outpatient for therapeutic taps.

 

[BJJVP]

...but why is it an admission then?

It's a completely dysfunctional system. There is no appropriate explanation that I can come up with. This, to me, is one of the worst parts of emergency medicine. Just because we are open 24 hours a day, people feel that they can ask for anything, anytime. Patients aren't the only ones to blame for this. Doctors will send patients to the ER specifically for some of the things Dr. McNinja stated above. Yes, I have performed LPs for pseudotumor cerebri. Transfusions for chronic anemia? We do it frequently. Can't get an IV in a nursing home patient? Send them to the ER for a PICC line. Nobody will thank you for sending these patients home. We get caught in the middle all of the time. Unexplained weight loss with normal VS and nl labs usually should not be admitted. But guess what, PCP wanted them to be "directly admitted," through the ER. I hate calling the admitting physicians as much as they hate hearing from me. I only wish they knew how much we have stacked against us when it comes to trying to stonewall these admissions.

 

[deleted109597]

...but why is it an admission then?

It's not. I don't admit them unless they meet admission criteria. "Feeling full" isn't one. Hypoxemia is.

 

[brk81144]

Informal community response hospital with all speciality coverage. Most of these I don't do because group standard is no.

PTA no
Paracentesis yes
Thoracentesis yes
Burr no
VP shunt no
Suprapubic no
Priapism no
Thrombosed hemorrhoid yes

Sent from my Pixel using Tapatalk

Ditto

 

[gro2001]

There are a myriad of reasons I don't do therapeutic ________________ in the ED. The first one is because it's not my job. I don't have a job with a lot of downtime, maybe others do. But I don't have the 30 minutes or longer to sit there and drain fluid. And I don't have medical students or residents to delegate that work to most of the time, and when I do, they also have other **** to do.
Also, therapeutic _____________ typically recur, so they're coming back to the ED because it didn't require pre-auth, waiting for an appointment, or whatever other reason they can't get it as an outpatient.
I mean, where do you stop? Therapeutic LPs for pseudotumor? Transfusions for the chronically anemic? Chemo infusions for people who missed their clinic appointment? Dialysis?
I get the "trying to help the most people the best way I can", but this isn't one of them.

I was thinking more along the lines of:

1) a cirrhotic patient who is getting admitted for some other reason who also has lots of ascites that is either just super uncomfortable or its actually affecting his breathing (not to a dangerous level, but he'd breathe easier without some of the fluid). Sure, I can probably let the admitting team get to it in the morning, but if I have the time (I work at a pretty busy ER too, but sometimes I have time), I'd tap that patient.

or

2) I am admitting a patient for a pneumonia who also has a huge parapneumonic infusion. It's big enough to affect breathing. Maybe not to a dangerous level though and I am not rushing to put a chest tube in. Sure, I could do nothing, but again, if I have time, why not take some of the fluid off? It might buy the patient a day of easier breathing.

 

[jw3600]

If in some bizarre turn of events we get national healthcare or docs actually start getting paid for every patient enough to make it worth their while, it's gonna be hilarious to see all the hospitalists and consultants do a complete 180 overnight.

Hospitalists will be screaming about not admitting such and such based of these "new criteria."

I think that's fine and people should be appropriately reimbursed for their time but it does illustrate how all of these issues are 100% driven by money, like most things.

 

[Psai]

If in some bizarre turn of events we get national healthcare or docs actually start getting paid for every patient enough to make it worth their while, it's gonna be hilarious to see all the hospitalists and consultants do a complete 180 overnight.

Hospitalists will be screaming about not admitting such and such based of these "new criteria."

I think that's fine and people should be appropriately reimbursed for their time but it does illustrate how all of these issues are 100% driven by money, like most things.

What are you talking about? There is always a bed crunch and the census is always insane at least in the institutions that I've been at. People don't fight admissions for no reason.

 

[jw3600]

What are you talking about? There is always a bed crunch and the census is always insane at least in the institutions that I've been at. People don't fight admissions for no reason.

Not my experience at some community hospitals. Probably institution dependent.

 

[Rendar5]

What are you talking about? There is always a bed crunch and the census is always insane at least in the institutions that I've been at. People don't fight admissions for no reason.

Only time census is full here is the holidays and after hurricane Irma hit. Rest of the time there is not usually a crunch.

 

[Psai]

Now I see why you guys are pissed.

 

[chessknt]

If in some bizarre turn of events we get national healthcare or docs actually start getting paid for every patient enough to make it worth their while, it's gonna be hilarious to see all the hospitalists and consultants do a complete 180 overnight.

Hospitalists will be screaming about not admitting such and such based of these "new criteria."

I think that's fine and people should be appropriately reimbursed for their time but it does illustrate how all of these issues are 100% driven by money, like most things.

This isn't true. I worked at a small community hospital where I was the only other doctor in house at night and rarely the ER doc would try to admit someone who would probably need CRRT (which we couldnt do) in a few hours or unstable/new onset epilepsy (we have no overnight EEG or neurologists that round period) or a sick cirrhotic listed for transplant at the major university center an hour away. I had no comfort managing these solo without appropriate subspecialty backup. They would get pissed when I told them to transfer because of all the work they did to get them admitted, but my litmus was to ask myself if I would feel comfortable with my family member getting such subpar care. The hospital admin on the other hand would come down on me because I lost the money for the system.

As mentioned above I never rejected admits I thought were stupid because it created so much drama and they were all very easy. I just kept my mouth shut did the basic (or sometimes no) workup and discharged the next day.

 

[deleted547339]

This isn't true. I worked at a small community hospital where I was the only other doctor in house at night and rarely the ER doc would try to admit someone who would probably need CRRT (which we couldnt do) in a few hours or unstable/new onset epilepsy (we have no overnight EEG or neurologists that round period) or a sick cirrhotic listed for transplant at the major university center an hour away. I had no comfort managing these solo without appropriate subspecialty backup. They would get pissed when I told them to transfer because of all the work they did to get them admitted, but my litmus was to ask myself if I would feel comfortable with my family member getting such subpar care. The hospital admin on the other hand would come down on me because I lost the money for the system.

As mentioned above I never rejected admits I thought were stupid because it created so much drama and they were all very easy. I just kept my mouth shut did the basic (or sometimes no) workup and discharged the next day.

I think there's a big difference in thought process here. I don't care if you don't "do anything" to or for the patients. A lot of the time, I just care that they are monitored for a period of time longer than I can do in the ER.

It's the same problem you see with interns and nurses in the ICU. There are a lot of patients in the ICU that don't need an intensivist, per se, but they do need the ICU nursing staff.

I don't necessarily always need you. A lot of times, I just need your bed.

 

[Janders]

PTA-- Heck yes, love doing these, I do them frequently.
Paracentesis-- frequently. I do therapeutic ones if I can afford the time (if I am solo and there are 12 unseen and the patient isn't in distress, it can wait).
Thoracentesis-- yes, but this don't come up as often.
Burr-- no.
VP shunt-- no, sounds fun to learn though.
Suprapubic-- no, but I did almost once...
Priapism-- yes, but I typically call Uro in parallel
Thrombosed hemorrhoid-- yes

I had a septic chole in a very elderly patient the other day. Had her some 10+ hours while I found somewhere capable of doing a perc chole to accept her in transfer. Tubed, lined, pressor, resus'd, vent repeatedly titrated, abx re-dosed (patted myself on the back for remembering that!), electrolytes repleted. Probably should have done some dvt prophylaxis. But on bedside u/s the GB was MASSIVE and also only about 1cm from skin surface. Believe me, it was tempting to do my own perc chole by the end!

 

[chessknt]

I think there's a big difference in thought process here. I don't care if you don't "do anything" to or for the patients. A lot of the time, I just care that they are monitored for a period of time longer than I can do in the ER.

It's the same problem you see with interns and nurses in the ICU. There are a lot of patients in the ICU that don't need an intensivist, per se, but they do need the ICU nursing staff.

I don't necessarily always need you. A lot of times, I just need your bed.

With all due respect the ER experience is limited to the very short term. When someone leaves the ER I am the responsible physician and it is my job to anticipate the course and potential needs of a patient. Sure the person may not need CRRT or a neurology consult or a liver transplant if they get better but I have seen many times when they dont since I have cared for people with problems like this for days to weeks during the course of my training. I also know the difference in care a specialist in these areas can provide compared to my limited knowledge and whether or not that might matter depending on why they are in the hospital. Why not trust my judgement on this like I trust your judgement that someone needs to be admitted?

 

[Raryn]

I think there's a big difference in thought process here. I don't care if you don't "do anything" to or for the patients. A lot of the time, I just care that they are monitored for a period of time longer than I can do in the ER.

It's the same problem you see with interns and nurses in the ICU. There are a lot of patients in the ICU that don't need an intensivist, per se, but they do need the ICU nursing staff.

I don't necessarily always need you. A lot of times, I just need your bed.

That's a completely different question. If I don't feel that the patient is safe to admit given the resources of the hospital (especially consultants), I will be the first one to decline the admit in favor of an ED to ED transfer.

An inpatient to inpatient transfer is a huge PITA and the delays there can be unsafe besides. More unsafe than the patient boarding in your ED for a couple hours so that the transfer can be arranged. If I think the patients needs say, a neurosurgical consultation, and we don't have one on staff? I won't admit it. Period.

 

[deleted109597]

More unsafe than the patient boarding in your ED for a couple hours so that the transfer can be arranged.

Listen. I'm all for admitting to the right service, and if the patient needs XYZ then they probably shouldn't be admitted to a bed without XYZ. But if they "might" need it, then all bets are off.
Patients don't board for "a couple of hours" waiting to transfer. I've managed ICU patients that have stuck around for over 48 hours. It's more than just a minor inconvenience.

 

[Siggy]

Listen. I'm all for admitting to the right service, and if the patient needs XYZ then they probably shouldn't be admitted to a bed without XYZ. But if they "might" need it, then all bets are off.
Patients don't board for "a couple of hours" waiting to transfer. I've managed ICU patients that have stuck around for over 48 hours. It's more than just a minor inconvenience.

I had a patient that was admitted decided to go into Takosubo with a STEMI presentation after admission. In order to transfer the patient, I needed an accepting cardiologist, accepting interventionalist, accepting intensivist, and an accepting hospitalist. Thankfully, those conversations were basically "I have a STEMI," but I still had to call everyone but the interventionalist (the cardiologist called directly).

How many different specialists do you need to set up an ED to ED STEMI transfer? I'm betting one... the other ED physician.

 

[GeneralVeers]

Listen. I'm all for admitting to the right service, and if the patient needs XYZ then they probably shouldn't be admitted to a bed without XYZ. But if they "might" need it, then all bets are off.
Patients don't board for "a couple of hours" waiting to transfer. I've managed ICU patients that have stuck around for over 48 hours. It's more than just a minor inconvenience.

How have you managed ICU patients for 48 hours? Either they are admitted or transferred. If they are admitted then the ICU doc takes over immediately and I move on to the next patient. Where on Earth do you practice that it takes 48 hours to transfer out an ICU patient? I work in one of the most underserved areas of the countries, and it's 8 hours tops to get a transfer out.

 

[deleted547339]

With all due respect the ER experience is limited to the very short term. When someone leaves the ER I am the responsible physician and it is my job to anticipate the course and potential needs of a patient. Sure the person may not need CRRT or a neurology consult or a liver transplant if they get better but I have seen many times when they dont since I have cared for people with problems like this for days to weeks during the course of my training. I also know the difference in care a specialist in these areas can provide compared to my limited knowledge and whether or not that might matter depending on why they are in the hospital. Why not trust my judgement on this like I trust your judgement that someone needs to be admitted?

My comment wasn't directed towards your statement about patients needing subspecialty services, it was directed at your comment about admitting patients then DCing them without a workup. It's the point that some people don't understand there is utility in keeping some people in house even if you "don't do anything" for them. There are a lot of people who simply need to be monitored. Like I said, its the same thing my interns don't get - a lot of patients need to come to the ICU, not because they are intubated or on pressers, but because they have a high probability of needing something only I can do in the ICU and, if they end up needing it, they will need it right now. It's the same thing with admitting to the hospitalist a lot of the time - it's not that I need them to actively do something, it's that I think they could be too sick to be at home unmonitored.

 

[deleted109597]

How have you managed ICU patients for 48 hours? Either they are admitted or transferred. If they are admitted then the ICU doc takes over immediately and I move on to the next patient. Where on Earth do you practice that it takes 48 hours to transfer out an ICU patient? I work in one of the most underserved areas of the countries, and it's 8 hours tops to get a transfer out.

Me personally, I only managed them for ~24 hours of their debacle.
Other doctors had other shifts.
We had no ICU at this hospital because reasons. So they wouldn't admit. It was almost like a freestanding. But the powers that be would also block almost every attempt at transferring out of system. So they would sit on it. It remains ridiculous, but I don't work there anymore.
We were holding 8 hours for routine patients. Anything requiring specialists was much, much longer.
Unless it's a STEMI or a stroke inside the window getting tPA, or trauma.