Responsibility for Admitted Patients

[joeDO2]

In the case where a patient is in the ED, admitted, seen by the hospitalist, but then waits in the department for a bed, who is responsible? What are the responsibilities of the ED doc both legally and ethically? If someone has chest pain and the admitting doc does not come promptly is it your responsibility to initiate work up and treatment? What if a patient is nauseous and asks a nurse for some zofran? Are you willing to write for it? I've seen quite a spread of opinions on this in the different places I've been.

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[TrumpetDoc]

If they are in "your department" you own 'em. Period. This is one of many reasons ED boarding is such an issue.
Two friends of mine can attest to the legal ramifications of this fact.


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[Groove]

What irks me is that I have to write bridging orders for our hospitalists. It expedites the pt moving out of the ED and up into a bed, but they sit in limbo until the hospitalist sees them. My bridging orders don't technically expire for 10 hours. Can you believe that? I've often wondered what strange sort of limbo medmal situation I'm in while they are out of the ED but haven't been seen by a hospitalist and are being managed by my bridging orders during the interim. The best I've been able to do is place a notify physician and nursing communication order to alert the accepting physician on arrival to the floor to review current bridging orders and approve/amend with a request to immediate evaluate the pt at bedside. I've noticed that most of the nurses cancel with a reason of "no longer needed", or perhaps they are ignored, or perhaps they are even followed. Who knows, but I've covered myself as best as I can. I hate the policy but otherwise the pt's will sit in the ED forever.

 

[southerndoc]

I've also heard that legally they're still ED patients until they get upstairs. What's interesting is if an orthopedic patient is admitted to the neurology floor, the neurologists aren't responsible for the patient (even if they're in-house a few rooms down rounding on patients).

 

[dotcb]

Once the inpatient team has written orders, they assume care of the patient. Unless you become re-involved in the patient's care. This is the best reason to field any care questions on ED boarders to their inpatient team and do not continue involvement or get re-involved unless the patient becomes critical.

 

[Beth_W737]

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[Siggy]

Once the inpatient team has written orders, they assume care of the patient. Unless you become re-involved in the patient's care. This is the best reason to field any care questions on ED boarders to their inpatient team and do not continue involvement or get re-involved unless the patient becomes critical.

This is what the attendings at my hospital has instructed the residents to do. Zofran/pain/diet orders? Call the primary team. Patient actively trying to die? Page the primary team and start working the problem.

 

[styphon]

-In our hospital once the hospitalist saw the pt, they would be considered a hospitalist pt. When I was a resident on inpt service sometimes the ER was so backed up(>24hours for a bed) we would do H&P/tests/and d/c before the pt ever had a bed upstairs. Problem is you are using ER nurses who have other ER patients to do floor work/labs/treatments.

 

[Birdstrike]

You're most likely jointly responsible. If the hospitalist has written orders, he's on the case and legally liable. If you're in the ED and the patient is still in the ED you could be held liable, too. Especially if the nurse is documenting things like, "ED doc notified of vital signs..." The only exception would be if you documented something like, "Admitting doctor at bedside. Signed off case and transferred care at time:..." But remember, it all comes down to whether a jury (of non-medical people) decides you're no longer responsible or not. Then reality is that there's no black or white answer and they can decide whatever they want on each case.

 

[alpinism]

Interesting to read about the different hospital cultures on here.

For us its the when the admitting team has written orders. After that they're responsible for any patient issues.

Per Birdstrike's post above this is likely why both the ED nurses and attendings always document when the admitting team sees the patient.

 

[BoardingDoc]

I'm amazed there are so many variations here. Trumpetdoc has the same situation that I do and one I expected was the same everywhere. Is the patient in the ED? They are your patient. They stop being your patient once they leave the ED. I can't imagine it working any other way. Are the hospitalists generally sitting around in other peoples' ED all the time? If so, then having them take over for you once they accept the patient makes sense, but if they're up on the floor and the patient is waiting to go up and starts vomiting, I don't know why I would expect the hospitalist to come down to give them some zofran.

 

[Arcan57]

I'm amazed there are so many variations here. Trumpetdoc has the same situation that I do and one I expected was the same everywhere. Is the patient in the ED? They are your patient. They stop being your patient once they leave the ED. I can't imagine it working any other way. Are the hospitalists generally sitting around in other peoples' ED all the time? If so, then having them take over for you once they accept the patient makes sense, but if they're up on the floor and the patient is waiting to go up and starts vomiting, I don't know why I would expect the hospitalist to come down to give them some zofran.

We have joint responsibility until the admitting doc has seen the patient in the ED or the patient gets up to the floor. After that we're just responsible if the patient codes. If a patient starts vomiting while holding, one of two scenarios should play out.

1) Admitting doc knew patient's condition was likely to lead to vomiting and ordered something PRN already.

2) Admitting doc had no idea patient would start vomiting and thus needs to be informed of the patient's change in condition.

Interrupting my workflow so I can place a CPOE order helps neither of those situations.

 

[DreamingTheLive]

At our very large university hospital, they're yours until they're tucked-in upstairs. Can be quite problematic at times as there is really no rush on the admitting residents side of things....haha, no rush at all....