Admission Presentations...

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EMCC

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Hey! I was reading in an other thread that some EM residents don't actually talk to the admitting teams. Does this mean that you don't ever present the patient to a resident/attending/hospitalist/surgeon/podiatrist/orthopedist/etc, etc, etc. over the phone?? Just strikes me as odd. Just wanted to find out the info on that procedure...

Perhaps that causes some angst between us and consultants?? If a unit clerk calls a surgeon and says there is an urgent belly to be seen (and the clerk doesn't know the details), won't the surgeon be upset? I know that personally I would be...

I am not trying to rile people up; I just wanted to find out more about this trend (if it can even be called that).

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For our medicine admissions, we dictate a patient signout into a voicemail system. The admitting team is paged that they have an admission. The page includes the patients name, medical record unit number (MRUN), what floor the patient is going to, and the ED resident's name and Spectralink phone number. If they have any questions, they are encouraged to call the ED resident. We receive calls on maybe 15% requesting clarification or suggesting additional tests for things we may have missed or not thought about. This is part of a study that will be published in the coming months.

For all patients with private attendings, we discuss the admission with them first (even if they have an agreement to admit to our private hospitalist service). For clinic patients or those without a physician, they are simply booked without a discussion with an attending or resident. Even if the private attending is the attending of record, it may still be assigned to a hospitalist or university team to follow the patient while in house. Their signout is still the voicemail system.

Admissions to surgical specialties or neurology are not dictated since these require a consultation prior to admitting the patient. Cardiology admissions are dictated, but they also require discussing with the cardiology fellow or attending prior to admitting.

Overall, I like the system. At first I was highly skeptical and preferred the human interaction of signing out a patient over the phone where questions and suggestions can be made in real time. Now I see the benefit. I don't wait 20 minutes for an admitting team to call me back to get signout, nor do I need to tell the story again if for some reason a patient's floor is changed to another floor (which means it goes to a different admitting team since we use a geographical team service). It has really saved a lot of time, and our studies show it has decreased signout errors and has decreased ED length of stay for admitted patients. (Prior to this signout system, a resident was required to speak to the admitting team before the ED secretary was allowed to request transport to the patient's room.)
 
That system actually sounds pretty cool! I like the idea of talking to the Patient Acess Center and having them page the admitting team... You're right; that would definitely save tons of time... I could see at least 4 more patients per shift with a system like that (if not more).

Do you think that adds to patients time in the ED waiting for the primary service? Or are they sent up to the floor without orders (assuming they are stable)?

When you say "dictation," does that mean you have to dictate the whole H+P, labs, etc? Or is it a cursory, "Mr. SoandSo is a 65 y/o male with CP. He has multiple risk factors, blah blah blah..."?
 
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i'm not sure if youre referring to the philly area programs thread where i said we just put a call through our clerks?

if so, i meant the clerks make the call so we arent stuck calling offices and navigating answering services. once they contact the admitting office, the clerk puts us on the line with the admitting physician and we then present the admission. :)

if not referring to that thread, nevermind :laugh:
 
EMCC, it has significantly decreased the length of stay in the ED because patients can be transferred as soon as a bed is clean. Prior to that, we often found that a bed became available, but the resident hadn't discussed the patient with the admitting team. Therefore, the secretary (IA, information associate) couldn't request transport to the admitting floor until the resident spoke with the admitting team.

Now, the dictation is made as soon as the admit request is entered into the computer (the resident enters their own requests directly, which are sent electronically to the admission office and also gives the IA a printed page to note that a patient has been admitted). The admission office starts looking for a bed, and the IA knows to check the bed management software to find out which floor and team the patient has been assigned. Once a team is assigned, the IA then pages with the information so the admitting team can retrieve the information. He/she may also request transport for the patient as soon as the bed is clean. If for whatever reason we need to hold a patient for a diagnostic study, procedure, etc., then we write "HOLD" on our whiteboard and the IA doesn't request transport until the notation is removed.

Regarding patients being evaluated in the ED, I would say that 95% of our admissions go to the floor without being seen by the admitting resident. The only time admitting teams see patients in the ED is when there is a shortage of beds and patients have an extended length of stay in the ED.

Medical and cardiac ICU patients are NOT dictated because of their acuity. We discuss over the telephone with the admitting resident. Patients are sent to the medical ICU with automatic admission criteria and are not evaluated by the admitting resident until they get to the ICU. If they do not meet automatic admission criteria (and the list is lengthy), then we discuss it with the MICU fellow prior to admitting the patient. Cardiac ICU admissions always require discussion with a cardiology fellow or attending.
 
EMCC, it has significantly decreased the length of stay in the ED because patients can be transferred as soon as a bed is clean. Prior to that, we often found that a bed became available, but the resident hadn't discussed the patient with the admitting team. Therefore, the secretary (IA, information associate) couldn't request transport to the admitting floor until the resident spoke with the admitting team.

Now, the dictation is made as soon as the admit request is entered into the computer (the resident enters their own requests directly, which are sent electronically to the admission office and also gives the IA a printed page to note that a patient has been admitted). The admission office starts looking for a bed, and the IA knows to check the bed management software to find out which floor and team the patient has been assigned. Once a team is assigned, the IA then pages with the information so the admitting team can retrieve the information. He/she may also request transport for the patient as soon as the bed is clean. If for whatever reason we need to hold a patient for a diagnostic study, procedure, etc., then we write "HOLD" on our whiteboard and the IA doesn't request transport until the notation is removed.

Regarding patients being evaluated in the ED, I would say that 95% of our admissions go to the floor without being seen by the admitting resident. The only time admitting teams see patients in the ED is when there is a shortage of beds and patients have an extended length of stay in the ED.

Medical and cardiac ICU patients are NOT dictated because of their acuity. We discuss over the telephone with the admitting resident. Patients are sent to the medical ICU with automatic admission criteria and are not evaluated by the admitting resident until they get to the ICU. If they do not meet automatic admission criteria (and the list is lengthy), then we discuss it with the MICU fellow prior to admitting the patient. Cardiac ICU admissions always require discussion with a cardiology fellow or attending.


Maybe I missed it, but do you dictate the H and P/ labs for the floor pts you send up? Or is the a paper record of ED events?
streetdoc
 
i'm not sure if youre referring to the philly area programs thread where i said we just put a call through our clerks?

if so, i meant the clerks make the call so we arent stuck calling offices and navigating answering services. once they contact the admitting office, the clerk puts us on the line with the admitting physician and we then present the admission. :)

if not referring to that thread, nevermind :laugh:

Ah, yeah, that was what I was referring to... My apologies for misunderstanding what you wrote... All of our units clerks do the same--except for one who is still there "but for the grace of god." Her idea of workign is gossiping and talking on the phone with her kids... When you ask her do to something, she replies, "What, did someone cut your arms off?"... sigh. Other than her, the other clerks go through the hassle of getting docs on the phone for us...

Nevertheless, got a good response from Southerndoc... Since I am finishing up residency soon, I am starting to look for ways to streamline the process to get me to generate more RVUs for once I am out there in the real world...

:)
 
Maybe I missed it, but do you dictate the H and P/ labs for the floor pts you send up? Or is the a paper record of ED events?
streetdoc
It's a signout, not an H&P. There is a suggested template to follow. It's basically your name, location in the ED (north, south, central v. major med), patient's name, medical record unit number, admitting physician (if the patient has a private primary care physician), type of bed admitted to (floor v. telemetry), and a brief story. If labs are pertinent, then yes, you mention them. A lot of my signouts are "labs are normal, cardiac enzymes are negative." You mention pertinent physical exam findings, things done in the ED and any responses (e.g., 1 liter normal saline with an increase in blood pressure; patient is now normotensive). I usually end the dictation by repeating my name and my Spectralink phone number.

So it's a signout, just like you would give over the phone if you were talking to a live person, except there are no interruptions or questions asked by the person while you are talking. They have the option to call you for more information. If you dictate very little ("pancreatitis coming your way"), then expect to get a phone call. If you dictate too much info, then you're wasting your time.

The signouts are not transcribed, and they are only kept in the system for something like 48-72 hours.
 
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