Precautions to be taken during night pager call for hospitalist?

[GIDOC85]

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[deleted480308]

My wife takes night pager call at a local hospital as a hospitalist. It is a small hospital with 30 beds. She takes calls for cross cover stuff and for admission orders ( 2-4 admissions per night). What (general) precautions should she take to avoid malpractice issues? Also, is it ok to give admission orders on a patient that she is not gonna see physically ( she takes only night pager call) as day time hospitalist will she those patients? Any input is appreciated.

I would advise your wife start an account here if she has concerns

 

[GIDOC85]

I would advise your wife start an account here if she has concerns

Can you answer the question I posted? Lately the forum has become obnoxious. Random people make unnecessary comments rather than helping people out. Shameful!!

 

[deleted480308]

Can you answer the question I posted? Lately the forum has become obnoxious. Random people make unnecessary comments rather than helping people out. Shameful!!

You asked for imput and you got it. Carry on

 

[GIDOC85]

You asked for imput and you got it. Carry on

Shameful!!! Selfish!! Ridiculous!! Stop bullying people on the forum who have genuine questions. If you cannot help at least stay out of it.

 

[deleted480308]

Shameful!!! Selfish!! Ridiculous!! Stop bullying people on the forum who have genuine questions. If you cannot help at least stay out of it.

If you're going to troll well, you need to practice the slow burn. Subtlety. Learn it. You have to draw people into the facade

 

[michaelrack]

Yes, it's okay to give admission orders....the main precaution is that she needs to be prepared to go to the hospital in the middle of the night for unstable patients

 

[AdmiralChz]

My wife takes night pager call at a local hospital as a hospitalist. It is a small hospital with 30 beds. She takes calls for cross cover stuff and for admission orders ( 2-4 admissions per night). What (general) precautions should she take to avoid malpractice issues? Also, is it ok to give admission orders on a patient that she is not gonna see physically ( she takes only night pager call) as day time hospitalist will she those patients? Any input is appreciated.

I'll give you the benefit of the doubt, I guess.

I think somewhere in the terms of service in this site that if you agree to post on behalf of yourself only, or something along those lines. Not sure, but your wife should definitely come here and ask herself.

Moving on, who is admitting these patients? You claim she is, but on who's authority? The ER physician? A surgeon for medical admission? The day hospitalist? Hospital transfer? Magic 8 ball? Any hospitalist/surgeon/internist/etc will tell you how important it is to confirm exam findings and the diagnosis before admission to the hospital! A major part of an admission H&P is, by definition, physical exam. If you haven't seen the actual patient and done one, and then go ahead and admit and document an exam it's probably fraud. A physician or physician extender needs to see an admitted patient, period.

I have no input for malpractice coverage, she needs to discuss this with the hospital she is moonlighting at.

 

[GIDOC85]

I'll give you the benefit of the doubt, I guess.

I think somewhere in the terms of service in this site that if you agree to post on behalf of yourself only, or something along those lines. Not sure, but your wife should definitely come here and ask herself.

Moving on, who is admitting these patients? You claim she is, but on who's authority? The ER physician? A surgeon for medical admission? The day hospitalist? Hospital transfer? Magic 8 ball? Any hospitalist/surgeon/internist/etc will tell you how important it is to confirm exam findings and the diagnosis before admission to the hospital! A major part of an admission H&P is, by definition, physical exam. If you haven't seen the actual patient and done one, and then go ahead and admit and document an exam it's probably fraud. A physician or physician extender needs to see an admitted patient, period.

I have no input for malpractice coverage, she needs to discuss this with the hospital she is moonlighting at.

She does not do H&P or any documentation other than just giving admit orders based on the history obtained from ER>.

 

[deleted480308]

She does not do H&P or any documentation other than just giving admit orders based on the history obtained from ER>.

That would not at all be acceptable at the hospitals I've rotated

 

[rokshana]

My wife takes night pager call at a local hospital as a hospitalist. It is a small hospital with 30 beds. She takes calls for cross cover stuff and for admission orders ( 2-4 admissions per night). What (general) precautions should she take to avoid malpractice issues? Also, is it ok to give admission orders on a patient that she is not gonna see physically ( she takes only night pager call) as day time hospitalist will she those patients? Any input is appreciated.

Is she admitting these pts under her name and no seeing them? Or is there a mid level in house seeing the pt and then discussing the pt with her? If so why is she having to put in orders? Cantvthr mid level do it?
If it's the former , it does open her up to significant liability if she hasn't seen that pt...
pts get admitted (or there are attempts to admit) pts that aren't appropriate for the floor or, depending on subspecialty support, or even the hospital and the end all responsiblity will be the physician of record. I , personally, am not willing to take on that responsibility if I haven't seen that pt and made a medical assessment that I will be able to defend if called to do so.

 

[rokshana]

She does not do H&P or any documentation other than just giving admit orders based on the history obtained from ER>.

Smh

 

[VA Hopeful Dr]

She does not do H&P or any documentation other than just giving admit orders based on the history obtained from ER>.

This scenario is fraught with problems. I would absolutely not do that kind of thing myself.

If the orders are in your name then you are legally and ethically responsible for what happens to the patient.

 

[AdmiralChz]

She does not do H&P or any documentation other than just giving admit orders based on the history obtained from ER>.

Well, then to more directly answer your question she will need a HUGE amount of malpractice coverage because, well, this sounds like an easy argument for malpractice and direct negligence. Sounds like she should be taking in-house call if this happens.

Can you imagine if a surgeon just takes a patient to the OR based solely on the ER doctor's assessment? Or a pulmonologist does a diagnostic bronch on the recommendation of a hospitalist? Or a nephrologist starting dialysis just because an intensivist asked?

I hope this isn't a real situation.

 

[Winged Scapula]

This *does* happen but as others have noted, it is fraught with liability.

When I was a resident and fellow, doing moonlighting, I sometimes would get consulted at a small community hospital for surgical issues. The consult came from the internist/GI who had admitted the patient from the ED. On many many occasions, I would look for the H&P from the admitting physician to find none existed. After casually asking about this on a few of those occasions, I found it was common that when patients came in after hours, they (the ED Physician) would call the relevant physician for admission, who would give orders over the phone and not see the patient until the next morning. It always struck me as odd.

Now that Im in practice, I would never take the word of someone else, especially someone not trained in my speciality, and as others have pointed out, this is ripe for liability if you miss something. I'm not an attorney, but I cannot imagine it would be defensible if your wife had to admit that she never saw or examined the patient. Mistakes can still happen if she did, but this sounds like a nightmare to me. She should definitely get up and go in and see patients she is admitting.

And yes, your wife should register her own account. Its free and easy and reduces confusion.

 

[hamstergang]

I thought this was standard practice since getting in-house overnight coverage isn't always feasible -- based on the ED evaluation and then a discussion with you, you would give orders for admission and the patient would be seen the next day. You don't do anything crazy with these overnight orders.

 

[Winged Scapula]

I thought this was standard practice since getting in-house overnight coverage isn't always feasible -- based on the ED evaluation and then a discussion with you, you would give orders for admission and the patient would be seen the next day. You don't do anything crazy with these overnight orders.

I agree with you; it is not uncommon outside of larger academic and hospital centers with residents.

However, I don't think any of us think its good medical practice or helps the OP's wife escape liability. It is not defensible to say, "I didn't know <x>; the ED doc didn't tell me!" If she is admitting that patient and her name is on the chart, she is responsible.

As far as "not doing anything crazy", sure but does that mean that the patient has been adequately assessed by an internist, to assess the level of care and kind of care they need? Daily I find mistakes/ommissions on patient's medical records; I'm sure if others were reviewing mine, they'd find the same. I am personally not comfortable admitting a patient to my service/my liability/my responsibility on the word of someone else, especially someone not in my group or specialty. Would you be?

 

[Gastrapathy]

I know someone for whom this practice went bad. The patient had a fall in the ED after admission (probably during transport to the floor). Head bleed. Bad outcome. No doctor knew. ED physician eventually was let off the hook. Admitting doc sleeping at home, not so much.

 

[rokshana]

I thought this was standard practice since getting in-house overnight coverage isn't always feasible -- based on the ED evaluation and then a discussion with you, you would give orders for admission and the patient would be seen the next day. You don't do anything crazy with these overnight orders.

I don't think this is standard practice (at least on the east coast) there may be only one nocturnist or mid level doing the admission but at least someone has seen the pt but I have yet to see a place where the admitting person isn't in house...as a consultant sure that happens all the time but they are not the primary attending of record.

She needs to rethink that job.

 

[FutureInternist]

She does not do H&P or any documentation other than just giving admit orders based on the history obtained from ER>.

Our triage docs do this to get the pt a bed and have some orders for IVFs, diet etc and then we do formal orders once we have seen the pt which could be up to 10 hours later.

 

[mvenus929]

A major part of an admission H&P is, by definition, physical exam. If you haven't seen the actual patient and done one, and then go ahead and admit and document an exam it's probably fraud. A physician or physician extender needs to see an admitted patient, period.

Technically speaking, an H&P needs to be on the chart within 24 hours of admission, not as soon as the patient is admitted. Admission consists of orders, doing the H&P can technically be done the following morning. While it may not be best medical practice, it's not against the law or uncommon.

[While very different circumstances, infants are admitted to the newborn nursery all the time without the pediatricians coming in to see them at all hours of the night. In fact, in the hospitals I've worked in, the nurses even put in the orders under the attending's name, who then cosigns them in the morning.]

 

[AdmiralChz]

Technically speaking, an H&P needs to be on the chart within 24 hours of admission, not as soon as the patient is admitted. Admission consists of orders, doing the H&P can technically be done the following morning. While it may not be best medical practice, it's not against the law or uncommon.

[While very different circumstances, infants are admitted to the newborn nursery all the time without the pediatricians coming in to see them at all hours of the night. In fact, in the hospitals I've worked in, the nurses even put in the orders under the attending's name, who then cosigns them in the morning.]

Have you worked in a hospital where one specialty admitted to another? Without any checks? Sounds questionable, and potentially dangerous.

I moonlight at an ED in town on the weekends, I'd never even consider doing something like this. There is an overnight in-house internist (also a moonlighter, on the weekends) who handles the admission, including the H&P, and signs the patient out to the hospitalist in the morning. This gig should be in-house, not home call, if you are responsible for new admits and there is no one else there to see them.

 

[mvenus929]

Have you worked in a hospital where one specialty admitted to another? Without any checks? Sounds questionable, and potentially dangerous.

I moonlight at an ED in town on the weekends, I'd never even consider doing something like this. There is an overnight in-house internist (also a moonlighter, on the weekends) who handles the admission, including the H&P, and signs the patient out to the hospitalist in the morning. This gig should be in-house, not home call, if you are responsible for new admits and there is no one else there to see them.

I'm fairly certain some of our orthopedic docs admit overnight without seeing the patient. Patient needs surgery, they've looked at the films at home, but patient hasn't been NPO long enough, so they chill in the hospital for a few hours until the morning when the surgeon can come in and fix it.

Beyond my experience in the nursery, no one would think to do this because the only admissions to a pediatric service that can happen in our town is at the academic hospital, where except for 48 hours in November every year, there are always residents in house. So it's never come up personally for me. I'm just saying that it's not illegal. I wouldn't feel comfortable admitting someone from the ED without someone else laying eyes on the kid, but it's not illegal.

 

[gutonc]

Can you answer the question I posted? Lately the forum has become obnoxious. Random people make unnecessary comments rather than helping people out. Shameful!!

Says the guy who's been here for 3 months and has half his posts in this thread.

To answer your question, as has been stated above, this is a horrible idea and is very high risk for s*** going very badly.

When I take home call (in a sub-specialty) and I get called to admit a patient (at one of the 7 hospitals that I cover), I ask them to admit to the hospitalist service and have them call me to discuss (all 7 of these places have 24/7 hospitalist coverage). I honestly don't even care if they write the H&P (although they usually do, because you can't get paid for it if you don't), but my take is that, if they need to be admitted to the hospital in the middle of the night, it's because they need a doctor there to evaluate them. And I'm not there...but there's 1-6 docs already there that can do it.

We'll often take over from the hospitalists in the morning if they ask.

 

[rokshana]

I'm fairly certain some of our orthopedic docs admit overnight without seeing the patient. Patient needs surgery, they've looked at the films at home, but patient hasn't been NPO long enough, so they chill in the hospital for a few hours until the morning when the surgeon can come in and fix it.

Beyond my experience in the nursery, no one would think to do this because the only admissions to a pediatric service that can happen in our town is at the academic hospital, where except for 48 hours in November every year, there are always residents in house. So it's never come up personally for me. I'm just saying that it's not illegal. I wouldn't feel comfortable admitting someone from the ED without someone else laying eyes on the kid, but it's not illegal.

your ortho admit to their OWN service??
I have yet to work in a hospital that ortho admits to their service before surgery...usually it goes to the hospitalist service.

 

[Crayola227]

I think it really depends on the specialty, setting, and patient, even just going off what I've read in this thread, it seems like in some situations (uncomplicated vaginal delivery, simple orthopedic issue, some psych admits after being "medically cleared") putting in admit orders and then seeing in the AM might be appropriate, and other times it wouldn't

 

[Soccer171983]

The answer depends on hospital policy/group policy. I know at our location you have 4 hours to see an admission. Some people just stay at the hospital to play it safe and other group the calls so that once they are 3-4 patients behind they come in and clean up. Putting a bridging stabilizing order prior to see them with the intent to seem them is different than just putting in orders and not seeing the patient. Obviously an unstable patient despite certain policies would probably be best seen asap as opposed to waiting the alloted time one has. Common sense usually prevails.

 

[ThoracicGuy]

My wife takes night pager call at a local hospital as a hospitalist. It is a small hospital with 30 beds. She takes calls for cross cover stuff and for admission orders ( 2-4 admissions per night). What (general) precautions should she take to avoid malpractice issues? Also, is it ok to give admission orders on a patient that she is not gonna see physically ( she takes only night pager call) as day time hospitalist will she those patients? Any input is appreciated.

Can you answer the question I posted? Lately the forum has become obnoxious. Random people make unnecessary comments rather than helping people out. Shameful!!

Shameful!!! Selfish!! Ridiculous!! Stop bullying people on the forum who have genuine questions. If you cannot help at least stay out of it.

 

[mvenus929]

your ortho admit to their OWN service??
I have yet to work in a hospital that ortho admits to their service before surgery...usually it goes to the hospitalist service.

Not always, but yes. It's typically the uncomplicated broken bone, rather than the septic joint/osteo that they take on their service. Hospitalist (or a subspecialty service) manages the actual medicine.

 

[Raryn]

your ortho admit to their OWN service??
I have yet to work in a hospital that ortho admits to their service before surgery...usually it goes to the hospitalist service.

M-F, if it's an uncomplicated younger patient, yes.

Their PAs don't work weekends though, so anyone admitted after 5pm on Friday is inevitably too medically complex for the Ortho service.

 

[PlutoBoy]

Sounds like a recipe for disaster.

 

[Psai]

Can you answer the question I posted? Lately the forum has become obnoxious. Random people make unnecessary comments rather than helping people out. Shameful!!

I like the part where you came crawling begging for help and thought the best thing to do was to sling insults

 

[GIDOC85]

I like the part where you came crawling begging for help and thought the best thing to do was to sling insults

Your account is on hold and u r pointing fingers at me? LOL

 

[Winged Scapula]

Please keep on topic and keep the personal comments under wraps

 

[VA Hopeful Dr]

Your account is on hold and u r pointing fingers at me? LOL

It's not actually on hold, it's a joke by the poster.

 

[AdmiralChz]

I like the part where you came crawling begging for help and thought the best thing to do was to sling insults

Yeah, this is just a rapidly moving version of the classic SDN advice thread:

Poster: "Here is this idea, what do you guys thing need honest opinions."
SDN: "Really bad idea for X, Y and Z concrete reasons"
Poster: "WHAT DO YOU KNOW YOURE MEAN IM DOING IT ANYWAYS"
SDN: "*sigh*"

 

[Winged Scapula]

Yeah, this is just a rapidly moving version of the classic SDN advice thread:

Poster: "Here is this idea, what do you guys thing need honest opinions."
SDN: "Really bad idea for X, Y and Z concrete reasons"
Poster: "WHAT DO YOU KNOW YOURE MEAN IM DOING IT ANYWAYS"
SDN: "*sigh*"

You missed the part where the OP comes back to call other users profane names (deleted by one of the Mod staff).

 

[gutonc]

You missed the part where the OP comes back to call other users profane names (deleted by one of the Mod staff).

No he didn't...he edited it out of his reply.

But yes, that's usually part of the process.

 

[GIDOC85]

Stupid useless forum

 

[Psai]

Remember the time you were a valuable contributor to this forum? Yeah me neither. Parasite.

 

[gutonc]

Stupid useless forum

You actually got some really good answers to your question.

Sorry (not sorry) you didn't like them. But that doesn't make them stupid or useless.

 

[VA Hopeful Dr]

You actually got some really good answers to your question.

Sorry (not sorry) you didn't like them. But that doesn't make them stupid or useless.

Come on, you've been around long enough to know that we're always the problem. It's never the original poster who is the problem. They are perfect in every way and we're a bunch of jerks who don't know anything

 

[ThoracicGuy]

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You do realize all your posts were quoted, so erasing this doesn't do anything.