Anybody else's Hospitalists not admitting patients anymore?

[JacobMcCandles]

---

Members don't see this ad.

Transferring an admitted patient is more challenging because EMTALA usually doesn't apply and the patient has to go to an available bed (as opposed to ED to ED; the admitted patient cannot go from floor to ED due to regulatory issues). We make exceptions for patients needing surgical intervention and just deal with it. We try to do what's best for the patient. Have an admitted patient on a blood thinner who falls, hits his head, and has a head bleed needing surgery? Yeah, we'll take that to the ER as a bouncing pad to go straight to OR. The last thing I want is for some patient to be dying because they can't get treatment. Now if we're holding 75 admissions and do not have capacity to care for the patients we have in our own department, then no, we don't have ability to accommodate that patient.

Right but none of this has anything to do with transfers being based on insurance. HCA is the only hospital system in my area that will do an ED to ED transfer.

 

[Angry Birds]

At my hospital, the hospitalist will often say that one and the same patient is either too sick to be admitted at our hospital or that they are well enough to go home. Plus, can't I obs them in the ED?

 

[Apollyon]

At my hospital, the hospitalist will often say that one and the same patient is either too sick to be admitted at our hospital or that they are well enough to go home. Plus, can't I obs them in the ED?

That reminds me of an IM resident when I was in residency. She would say "this pt is not appropriate for general internal medicine". You know who is not appropriate for general internal medicine? Peds and someone on-call to the OR. That's it.

Too sick, or doesn't need to be admitted? Tell me who is a shirking coward, and/or lazy, at that.

 

[Siggy]

I agree that they should be investigating if what you’re saying is happening. This seems to be an issue at that one hospital and you confirm other hospital systems readily accept the patients. I suspect the ED would run into the same issues with Jackson.

Regardless, that still doesn’t broadly explain why hospitalists say it’s harder to transfer an admitted patient. My suspicion is that it takes basically the same amount of work that they just don’t want do, which I understand, because I’d prefer not to do something if I could get someone else to do it.

EMTALA does not apply to inpatients. It's not an EMTALA violation for a hospital to refuse inpatient to inpatient transfers due to insurance requirements. There's no mechanism, to my knowledge, to force a hospital with additional resources to take an inpatient from a hospital that lacks ability to care for a worsening patient. I imagine that all of those hospitals "with no capacity" are still doing elective surgeries that require hospital beds.

"EMTALA does not apply to hospital inpatients. The existing hospital CoPs protect individuals who are already patients of a hospital and who experience an EMC.
Hospitals that fail to provide treatment to these patients may be subject to further enforcement actions"

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_v_emerg.pdf

...and don't get me wrong, I too have zero respect for the hospitalists who can't manage a patient past a consult order. However that doesn't change the fact that there's no tool to force a higher level of care hospital from accepting patients that need services not available at community hospitals.

 

[JacobMcCandles]

EMTALA does not apply to inpatients. It's not an EMTALA violation for a hospital to refuse inpatient to inpatient transfers due to insurance requirements. There's no mechanism, to my knowledge, to force a hospital with additional resources to take an inpatient from a hospital that lacks ability to care for a worsening patient. I imagine that all of those hospitals "with no capacity" are still doing elective surgeries that require hospital beds.

"EMTALA does not apply to hospital inpatients. The existing hospital CoPs protect individuals who are already patients of a hospital and who experience an EMC.
Hospitals that fail to provide treatment to these patients may be subject to further enforcement actions"

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_v_emerg.pdf

...and don't get me wrong, I too have zero respect for the hospitalists who can't manage a patient past a consult order. However that doesn't change the fact that there's no tool to force a higher level of care hospital from accepting patients that need services not available at community hospitals.

I’ve never said EMTALA applies to inpatients. Our conversation has evolved from my initial question on why hospitalists refuse to admit patients because at some point they could need a consultant that’s not available. They’ll come back and say that the reasoning for not admitting them is because it’ll be harder to transfer them as an admitted patient later, if needed, than in the ED, even if they may not ultimately need the aforementioned consultant so would never need to be transferred in the first place.

Our conversation has veered into you making it sound like it’s common practice for hospitals to refuse transfers based solely on the patient’s insurance, which I still don’t believe is common practice.

My bottom line is I believe hospitalists say it’s harder if they could potentially need to be transferred because it means less work for them. And ultimately, I think this is one of the many reasons many of the larger hospitals are always full (at least staffed beds) because so many more patients are being transferred automatically instead of an attempt being made to actually provide care to them first.

 

[AlmostAnMD]

Our conversation has veered into you making it sound like it’s common practice for hospitals to refuse transfers based solely on the patient’s insurance

Random info:

Ohio state told me MANY TIMES, on a recorded line, they would not take patients because they were under insured/not insured. Including a post op complication from a Spanish speaking male that was originally a trauma at Ohio state and got an eye infection from his eye surgery with puss coming out everywhere.

Our optho was furious at the reason i said we had to keep it. They dgaf about emtala

 

[Siggy]

I’ve never said EMTALA applies to inpatients. Our conversation has evolved from my initial question on why hospitalists refuse to admit patients because at some point they could need a consultant that’s not available. They’ll come back and say that the reasoning for not admitting them is because it’ll be harder to transfer them as an admitted patient later, if needed, than in the ED, even if they may not ultimately need the aforementioned consultant so would never need to be transferred in the first place.

Our conversation has veered into you making it sound like it’s common practice for hospitals to refuse transfers based solely on the patient’s insurance, which I still don’t believe is common practice.

My bottom line is I believe hospitalists say it’s harder if they could potentially need to be transferred because it means less work for them. And ultimately, I think this is one of the many reasons many of the larger hospitals are always full (at least staffed beds) because so many more patients are being transferred automatically instead of an attempt being made to actually provide care to them first.

ED wants to transfer and a hospital refuses? EMTALA violation.

Inpatient transfer and a hospital refuses? Shrug. There's no stick forcing outside hospitals to accept the patient.

That's why the inpatient teams refuse patients who have a good chance of needing a specialist that's not available at the hospital.

So you think that your inpatient teams are lying to you about how hard it is for them to transfer a patient?

 

[Siggy]

Random info:

Ohio state told me MANY TIMES, on a recorded line, they would not take patients because they were under insured/not insured. Including a post op complication from a Spanish speaking male that was originally a trauma at Ohio state and got an eye infection from his eye surgery with puss coming out everywhere.

Our optho was furious at the reason i said we had to keep it. They dgaf about emtala

On one hand, if you have optho on call then it's not an EMTALA violation for them to refuse. I guess there's an argument that on call and available are two different things when it comes to EMTALA.

On the other hand, everyone here has pinky swore that insurance is never considered for a transfer, regardless of whether EMTALA applies or not.

 

[JacobMcCandles]

So you think that your inpatient teams are lying to you about how hard it is for them to transfer a patient?

Partly because I haven’t heard of these hospital to hospital issues in my region. I think refusing to admit somebody that could almost certainly be taken care of at the initial hospital and then having to transfer that patient because at some point there’s a chance they could need a specialist is overall bad patient care (and many rural patients absolutely hate to get transferred for a variety of reasons) and a poor utilizer of resources. In my personal experience this has gotten much worse over the last 5 years.

As you said, HCA is basically an auto-accept system and in my region they have basically every specialist available so actually getting an accepting hospital is a foregone conclusion.

 

[AlmostAnMD]

On one hand, if you have optho on call then it's not an EMTALA violation for them to refuse. I guess there's an argument that on call and available are two different things when it comes to EMTALA.

On the other hand, everyone here has pinky swore that insurance is never considered for a transfer, regardless of whether EMTALA applies or not.

one more example to vent since you mentioned what's available at local shop

Ohio State is (or was) the ONLY regional hospital that could treat blood cancers. I had a sick as **** patient that came in that our pathologist looked at CBC and said was AML, undiagnosed. She was really ****ing sick. Was actually seen twice and mis dx as flank pain but actually it was just a super aggressive cancer.

I called to ask them for transfer and they were like, beds are tight

and I'm like, okay, but this person is incredibly sick and you're the only place this person can be treated. Just accept ED to ED.

One of our hospitalists (was on good terms with most of them) was near me as I was doing this conversation and gagged when transfer center nurse suggested we keep it at our place for a few days until a bed opens. He's saying what I'm thinking, no one can treat his here and she could just die waiting for a bed.

Still, transfer RN was saying the transfer was refused but they'd put her on the bed board. At that point I was ****ing furious. I told her that's fine, but I need her full name and RN license number to report her as an emtala violation so she can have her license suspended. Didn't respond, just hung up (note: this was a completely hollow threat, I had and still have zero idea how to "file an emtala").

5 minutes later the oncology fellow on call for OSU called back and said he accepted it to the ED and she was gone shortly thereafter.

Didn't mean to jack this topic and turn it into OSU hate but my god between football and owning the PR market due to local media kissing their ass hardly anyone knows it's a horrific medical center.

 

[CajunMedic]

Heck, I"ll name and shame on the wallet biopsies: UPMC. More than once, I've been transferring a patient from my community shop on the PA line. I've bounced through their transfer center, talked to the inpatient doc and gotten acceptance pending a bed. Then the transfer nurse will call back and hour or 2 later and decline the patient due to insurance. I brought it up with our admin more than once, but nothing ever came of it. I gave up and call AGH for everything unless they need something there.

 

[southerndoc]

Heck, I"ll name and shame on the wallet biopsies: UPMC. More than once, I've been transferring a patient from my community shop on the PA line. I've bounced through their transfer center, talked to the inpatient doc and gotten acceptance pending a bed. Then the transfer nurse will call back and hour or 2 later and decline the patient due to insurance. I brought it up with our admin more than once, but nothing ever came of it. I gave up and call AGH for everything unless they need something there.

They tell you they denied based on insurance? Wow

 

[Apollyon]

Heck, I"ll name and shame on the wallet biopsies: UPMC. More than once, I've been transferring a patient from my community shop on the PA line. I've bounced through their transfer center, talked to the inpatient doc and gotten acceptance pending a bed. Then the transfer nurse will call back and hour or 2 later and decline the patient due to insurance. I brought it up with our admin more than once, but nothing ever came of it. I gave up and call AGH for everything unless they need something there.

Since I worked for a UPMC shell corporation, they always took what I had. I don't think they could read our computers (they wouldn't spring for anything - at all - in the hinterlands), so they couldn't do the wallet biopsy.

UPMC still suxx.

 

[Splenda88]

I feel like our hospitalists admit less and less at the smaller hospitals where consultants are not available, and that creates big problems when bigger facilities don't have beds available.

- CHF on 2L O2 -> Might get worse so needs transferred for Cardiology. Whe we call Cardiology, they are confused about why our Hospitalists won't admit for diuresis here.
- Grandma has the stomach bug going around and is dehydrated, so her creatinine increased from 1.5 to 2.3. She would benefit from observation, fluids, and rechecking until po intake improves -> Hospitalist says the patient needs transferred for Nephrology consultation.
- Grandpa has a lumbar compression fracture, is having a hard time ambulating despite your best pain control efforts in the ED, and needs better pain control before he can go home. He might also benefit from PT/OT, and SNF placement. Spine surgery has already been consulted by phone, recommends supportive care +/- a TLSO for comfort, and follow up in the clinic -> Hospitalist won't admit because we don't have spine surgery here "in case he gets worse."

Whenever we try to transfer these patient's the doctors at the receiving hospitalist act like we are crazy for trying to transfer patients that can clearly be managed at any hospital with a general medicine service.

At our tertiary hospital, the Hospitalists seem to consult Cardiology for every slight CHF patient needing diuresis for a day or 2, ID for run of the mill infections and ABX management, Nephrology for mild or moderate pre-renal AKI, etc.

At this point... I'm not really sure how our Hospitalists can even justify being there. I guess they exist simply because the specialists won't admit their own patients.

On a related note... Has anybody had luck convincing hospitalists to admit uncomplicated SBOs at smaller hospitalist without General Surgery? The vast majority of SBOs do not require surgery, so I feel like it's reasonable to admit for bowel rest, fluids, NG tube if needed, and then transfer later if no improvement or if the patient decompensates. Obviously this would not apply to patients with an obvious anatomic cause of the obstruction such as an incarcerated hernia or other surgical problem.

Thoughts?

I am a hospitalist. Our shop is different. They like us here because we admit everything. We even admit brain bleed as long as the ED doc already talked to the neurosurgeon.

ObGyn even consult us to manage blood pressure on preeclampsia and uncontrolled BP in postpartum patients.

Surgeons call us all the time to fix abnormal heart rhythm on patients who are in the recovery room despite there is an anesthesiologist/CRNA/AA there.

We do complain, but we never give any push back.

 

[Janders]

Im not sure where some of yall work. In my ED I’ve called >23 hospitals before regarding a patient needing higher level of care, and had them pan rejected. Zero would take Ed to Ed. All cited capacity.

Not sure how it can be harder than that on the floor.

 

[Janders]

Im not sure where some of yall work. In my ED I’ve called >23 hospitals before regarding a patient needing higher level of care, and had them pan rejected. Zero would take Ed to Ed. All cited capacity.

Not sure how it can be harder than that on the floor.

Lung xplant on double Pressors for septic shock, hypoxic, pneumonia? Kept in our ED>30hr while literally everyone in the region rejected the patient.

Needless to say, none of our consultants wanted to even hear about the patient.

We need to reform THIS system

 

[Apollyon]

Lung xplant on double Pressors for septic shock, hypoxic, pneumonia? Kept in our ED>30hr while literally everyone in the region rejected the patient.

Needless to say, none of our consultants wanted to even hear about the patient.

We need to reform THIS system

How do you de-wimpify and de-lazyfy those people?

 

[JacobMcCandles]

How do you de-wimpify and de-lazyfy those people?

You don’t. I imagine it’s a micro-aggression if you give honest feedback to residents. I’ll admit that part of me is now the grumpy old man but doctors aren’t getting any better at doctoring.

 

[RustedFox]

one more example to vent since you mentioned what's available at local shop

Ohio State is (or was) the ONLY regional hospital that could treat blood cancers. I had a sick as **** patient that came in that our pathologist looked at CBC and said was AML, undiagnosed. She was really ****ing sick. Was actually seen twice and mis dx as flank pain but actually it was just a super aggressive cancer.

I called to ask them for transfer and they were like, beds are tight

and I'm like, okay, but this person is incredibly sick and you're the only place this person can be treated. Just accept ED to ED.

One of our hospitalists (was on good terms with most of them) was near me as I was doing this conversation and gagged when transfer center nurse suggested we keep it at our place for a few days until a bed opens. He's saying what I'm thinking, no one can treat his here and she could just die waiting for a bed.

Still, transfer RN was saying the transfer was refused but they'd put her on the bed board. At that point I was ****ing furious. I told her that's fine, but I need her full name and RN license number to report her as an emtala violation so she can have her license suspended. Didn't respond, just hung up (note: this was a completely hollow threat, I had and still have zero idea how to "file an emtala").

5 minutes later the oncology fellow on call for OSU called back and said he accepted it to the ED and she was gone shortly thereafter.

Didn't mean to jack this topic and turn it into OSU hate but my god between football and owning the PR market due to local media kissing their ass hardly anyone knows it's a horrific medical center.

What's OSU?
Ohio? Oregon?

 

[southerndoc]

Lung xplant on double Pressors for septic shock, hypoxic, pneumonia? Kept in our ED>30hr while literally everyone in the region rejected the patient.

Needless to say, none of our consultants wanted to even hear about the patient.

We need to reform THIS system

Am I missing something here? Why does this need a transplant center? This patient isn't going to get a new lung. Is there some sort of magic at the transplant center that my ignorance is causing me to miss?

 

[southerndoc]

I think I've mentioned this before, but will mention again. I'm all in favor of a 1:1 transfer. We take a patient from your hospital needing specialized care and you take one of our stable patients needing rehab/SNF placement just pending a bed. Would free up a lot of room for accepting transfers.

Unfortunately, the transfers we accept usually aren't discharged home. They have critical needs that when stabilized means they need a SNF or STR/LTR facility. They end up staying with us for a while pending placement. Taking those patients to allow us to accept more transfers would be very helpful.

We've started an internal boomerang system which I'm all in favor of. We take the patient, stabilize them, then ship them back. Works very well for patients needing a specialized procedure that can be managed at the referring hospital post-procedure (i.e., ERCP, IR, etc.).

 

[Apollyon]

What's OSU?
Ohio? Oregon?

Dude, Ohio State. It's right in the beginning of the post.

 

[Siggy]

Am I missing something here? Why does this need a transplant center? This patient isn't going to get a new lung. Is there some sort of magic at the transplant center that my ignorance is causing me to miss?

Normally transplant centers want their patient back. If anyone is going to screw up their organ they want it to be them. I’ve seen kidney transplants lost because outside hospital over diuresed a patient because the infiltrates on CXR couldn’t have been PNA… you know with a normal white count and no fever… in the immunosuppressed patient.


How good are you at monitoring for rejection? Managing rejection? Managing anti rejection meds? I don’t have any experience with that.

 

[Janders]

a heart or lung xplant who is critically is different in my book that a kidney.

Plus hospitalist won’t keep! Tertiary won’t accept! Board in ED limbo for daaaays

 

[RustedFox]

Dude, Ohio State. It's right in the beginning of the post.

You're right.
ADHD is real.
I absolutely whiffed on that'n.

 

[gutonc]

I think I've mentioned this before, but will mention again. I'm all in favor of a 1:1 transfer. We take a patient from your hospital needing specialized care and you take one of our stable patients needing rehab/SNF placement just pending a bed. Would free up a lot of room for accepting transfers.

Unfortunately, the transfers we accept usually aren't discharged home. They have critical needs that when stabilized means they need a SNF or STR/LTR facility. They end up staying with us for a while pending placement. Taking those patients to allow us to accept more transfers would be very helpful.

We've started an internal boomerang system which I'm all in favor of. We take the patient, stabilize them, then ship them back. Works very well for patients needing a specialized procedure that can be managed at the referring hospital post-procedure (i.e., ERCP, IR, etc.).

My rural CAH that is part of a large health system does this and it tends to work pretty well. The thing that does crack me up about it is that, when there is a complication or other reason that whoever did the procedure thinks they need to be observed for a day, the bed that was going to take a week to get them into in transfer, magically becomes available.

 

[Siggy]

a heart or lung xplant who is critically is different in my book that a kidney.

Plus hospitalist won’t keep! Tertiary won’t accept! Board in ED limbo for daaaays

The last kidney transplant patient I had was the first time I've had a facility refuse (supposedly it was long enough ago that they no longer followed the patient). Even the EM doc was surprised. But hey, an attempt to transfer was made so we accepted the patient after all.

 

[dozitgetchahi]

we need a medical version of DOGE

A true medical version of DOGE would involve stripping out the layers of overpaid rent seeking hospital executives, drug company execs, middleman grifter companies like Change Healthcare, PBCs, etc.

This will never happen, of course, because these groups are politically entrenched and have massive lobbying influence to keep things the way they are. But still.

 

[RustedFox]

A true medical version of DOGE would involve stripping out the layers of overpaid rent seeking hospital executives, drug company execs, middleman grifter companies like Change Healthcare, PBCs, etc.

This will never happen, of course, because these groups are politically entrenched and have massive lobbying influence to keep things the way they are. But still.

Call it the Healthcare Efficiency Coordination Committee.

The HECCin' DOGE .

 

[southerndoc]

How good are you at monitoring for rejection? Managing rejection? Managing anti rejection meds? I don’t have any experience with that.

Way less experienced than the average hospitalist. So it's doing the patient a disservice not to admit the patient until a transplant center can get a bed available.

 

[emergentmd]

Reading this makes me sorry for EM docs who are still working in the Pit and thankful I am out.

When I left the Pit 8 years ago, my community hospitalists were so easy to admit. I would say I get some minor pushback once a year. Went to locums, and admission was difficult but not to the extent described here.

What a liability zoo you guys are dealing with.

 

[doctorsun]

I feel like our hospitalists admit less and less at the smaller hospitals where consultants are not available, and that creates big problems when bigger facilities don't have beds available.

- CHF on 2L O2 -> Might get worse so needs transferred for Cardiology. Whe we call Cardiology, they are confused about why our Hospitalists won't admit for diuresis here.
- Grandma has the stomach bug going around and is dehydrated, so her creatinine increased from 1.5 to 2.3. She would benefit from observation, fluids, and rechecking until po intake improves -> Hospitalist says the patient needs transferred for Nephrology consultation.
- Grandpa has a lumbar compression fracture, is having a hard time ambulating despite your best pain control efforts in the ED, and needs better pain control before he can go home. He might also benefit from PT/OT, and SNF placement. Spine surgery has already been consulted by phone, recommends supportive care +/- a TLSO for comfort, and follow up in the clinic -> Hospitalist won't admit because we don't have spine surgery here "in case he gets worse."

Whenever we try to transfer these patient's the doctors at the receiving hospitalist act like we are crazy for trying to transfer patients that can clearly be managed at any hospital with a general medicine service.

At our tertiary hospital, the Hospitalists seem to consult Cardiology for every slight CHF patient needing diuresis for a day or 2, ID for run of the mill infections and ABX management, Nephrology for mild or moderate pre-renal AKI, etc.

At this point... I'm not really sure how our Hospitalists can even justify being there. I guess they exist simply because the specialists won't admit their own patients.

On a related note... Has anybody had luck convincing hospitalists to admit uncomplicated SBOs at smaller hospitalist without General Surgery? The vast majority of SBOs do not require surgery, so I feel like it's reasonable to admit for bowel rest, fluids, NG tube if needed, and then transfer later if no improvement or if the patient decompensates. Obviously this would not apply to patients with an obvious anatomic cause of the obstruction such as an incarcerated hernia or other surgical problem.

Thoughts?

Some of the patients you mention here are borderline admission, others are admitable, others risky admissions . all have incomplete workup but that may be because you are attempting to succinctly give examples. Hospitalists justify being there by taking care of patients that undergo proper workup in the ED, usage of standardized disposition scores, etc. I could make a similar argument about most ED physicians I've worked with who basically function as revolving doors. You think Grandma has a bump in Cr from 1.5 to 2.3 because she's dehydrated? So why not do proper AKI workup and if suspecting prerenal, address reduced PO intake, give IV, recheck labs, and DC? And if you're wrong and AKI worsens? Is it the hospitalist's fault that you try to dump patients without convincing evidence for admission or discharge? If the CHF patient only needs slight diuresis, why admit? CHF exacerbation, you don't explain reason for exacerbation, and some reasons do require cardiology intevention. If not and you're so sure, double the oral dose and DC with close follow up. You don't want to take the risk but you expect hospitalists to take risks because you think they should. Transfer the SBO patient -- do you know how many times I've been refused a transfer after a patient has been admitted because ED didn't do proper workup? At times, refusal and delay of care resulted in significant morbidity and even mortality.

Just like a hospitalist can't force a patient down your throat or tell you how to treat your patients, you can't force them to treat patients they can't treat based on their knowledge, experience, and judgement, which are dissimilar to yours. You can do proper workups and apply standardized scores to make a strong case, which you haven't in any of your examples, but that's about it. Tertiary facilities have way more problems than lack of subspecialties -- aggressive admins, incapable supporting staff, and so on. Hospitalists aren't there as sacrificial lambs of other physicians or administers.

 

[Jabbed]

Some of the patients you mention here are borderline admission, others are admitable, others risky admissions . all have incomplete workup but that may be because you are attempting to succinctly give examples. Hospitalists justify being there by taking care of patients that undergo proper workup in the ED, usage of standardized disposition scores, etc. I could make a similar argument about most ED physicians I've worked with who basically function as revolving doors. You think Grandma has a bump in Cr from 1.5 to 2.3 because she's dehydrated? So why not do proper AKI workup and if suspecting prerenal, address reduced PO intake, give IV, recheck labs, and DC? And if you're wrong and AKI worsens? Is it the hospitalist's fault that you try to dump patients without convincing evidence for admission or discharge? If the CHF patient only needs slight diuresis, why admit? CHF exacerbation, you don't explain reason for exacerbation, and some reasons do require cardiology intevention. If not and you're so sure, double the oral dose and DC with close follow up. You don't want to take the risk but you expect hospitalists to take risks because you think they should. Transfer the SBO patient -- do you know how many times I've been refused a transfer after a patient has been admitted because ED didn't do proper workup? At times, refusal and delay of care resulted in significant morbidity and even mortality.

Just like a hospitalist can't force a patient down your throat or tell you how to treat your patients, you can't force them to treat patients they can't treat based on their knowledge, experience, and judgement, which are dissimilar to yours. You can do proper workups and apply standardized scores to make a strong case, which you haven't in any of your examples, but that's about it. Tertiary facilities have way more problems than lack of subspecialties -- aggressive admins, incapable supporting staff, and so on. Hospitalists aren't there as sacrificial lambs of other physicians or administers.

All of your suggestions on how we could do our jobs better involve 12-24 hours of intervention, reassessment, and coordination of care.

a.k.a observation admission.

 

[throway134]

Am I missing something here? Why does this need a transplant center? This patient isn't going to get a new lung. Is there some sort of magic at the transplant center that my ignorance is causing me to miss?

Workup by a transplant team for uncommon infections and conditions which are standard to them but obscure to others
Access to a transplant surgeon to biopsy the transplant and assess for rejection
Access to pathologists used to working with transplants
Continuity of care for their 700th admission since transplant
Salvage procedures for the transplant that a transplant team is familiar with that other physicians may not be

I think the care complexity of these patients tends to be underestimated often. It’s like arguing that bariatric surgery doesn’t need a bariatric center. Might be technically true but the outcomes just aren’t going to be the same.

There probably isn’t a legal/emtala burden to accept outside the acute phase, but I would argue that especially in the first year or so after transplant there actually is one. Even after though, I think there’s the moral burden of what’s really right for the patient and I absolutely think that’s transfer to a mothership that deals with this crap.

Some of the patients you mention here are borderline admission, others are admitable, others risky admissions . all have incomplete workup but that may be because you are attempting to succinctly give examples. Hospitalists justify being there by taking care of patients that undergo proper workup in the ED, usage of standardized disposition scores, etc. I could make a similar argument about most ED physicians I've worked with who basically function as revolving doors. You think Grandma has a bump in Cr from 1.5 to 2.3 because she's dehydrated? So why not do proper AKI workup and if suspecting prerenal, address reduced PO intake, give IV, recheck labs, and DC? And if you're wrong and AKI worsens? Is it the hospitalist's fault that you try to dump patients without convincing evidence for admission or discharge? If the CHF patient only needs slight diuresis, why admit? CHF exacerbation, you don't explain reason for exacerbation, and some reasons do require cardiology intevention. If not and you're so sure, double the oral dose and DC with close follow up. You don't want to take the risk but you expect hospitalists to take risks because you think they should. Transfer the SBO patient -- do you know how many times I've been refused a transfer after a patient has been admitted because ED didn't do proper workup? At times, refusal and delay of care resulted in significant morbidity and even mortality.

Just like a hospitalist can't force a patient down your throat or tell you how to treat your patients, you can't force them to treat patients they can't treat based on their knowledge, experience, and judgement, which are dissimilar to yours. You can do proper workups and apply standardized scores to make a strong case, which you haven't in any of your examples, but that's about it. Tertiary facilities have way more problems than lack of subspecialties -- aggressive admins, incapable supporting staff, and so on. Hospitalists aren't there as sacrificial lambs of other physicians or administers.

If the workup takes longer than 4 hours it’s inappropriate for the Ed, and increases mortality for the patient as well as everyone in the waiting room not getting proper care.

 

[KGflyboy]

Some of the patients you mention here are borderline admission, others are admitable, others risky admissions . all have incomplete workup but that may be because you are attempting to succinctly give examples. Hospitalists justify being there by taking care of patients that undergo proper workup in the ED, usage of standardized disposition scores, etc. I could make a similar argument about most ED physicians I've worked with who basically function as revolving doors. You think Grandma has a bump in Cr from 1.5 to 2.3 because she's dehydrated? So why not do proper AKI workup and if suspecting prerenal, address reduced PO intake, give IV, recheck labs, and DC? And if you're wrong and AKI worsens? Is it the hospitalist's fault that you try to dump patients without convincing evidence for admission or discharge? If the CHF patient only needs slight diuresis, why admit? CHF exacerbation, you don't explain reason for exacerbation, and some reasons do require cardiology intevention. If not and you're so sure, double the oral dose and DC with close follow up. You don't want to take the risk but you expect hospitalists to take risks because you think they should. Transfer the SBO patient -- do you know how many times I've been refused a transfer after a patient has been admitted because ED didn't do proper workup? At times, refusal and delay of care resulted in significant morbidity and even mortality.

Just like a hospitalist can't force a patient down your throat or tell you how to treat your patients, you can't force them to treat patients they can't treat based on their knowledge, experience, and judgement, which are dissimilar to yours. You can do proper workups and apply standardized scores to make a strong case, which you haven't in any of your examples, but that's about it. Tertiary facilities have way more problems than lack of subspecialties -- aggressive admins, incapable supporting staff, and so on. Hospitalists aren't there as sacrificial lambs of other physicians or administers.

You can't be serious. If so, you really have no clue what should and should not be done in the ED vs an observation or inpatient unit.

 

[Janders]

You can't be serious. If so, you really have no clue what should and should not be done in the ED vs an observation or inpatient unit.

bingo. I’ve worked with the type. Expect the ED to do a 1-2 day hospital workup treatment and specialty reassessment prior to admission. Everyone is either too sick and needs ICU or too well and should be discharged. Like Goldilocks, constantly looking for the perfect floor admission and never finding it.

 

[doctorsun]

All of your suggestions on how we could do our jobs better involve 12-24 hours of intervention, reassessment, and coordination of care.

a.k.a observation admission.

Proper workup and discharge involve talking with patient, ordering appropriate labs, and discharging. At worst, keep patient warm in ED bed for a few hours. Observation isn't an admission. You should review your medicine and administrative medicine rather than dump patients on others.

 

[doctorsun]

You can't be serious. If so, you really have no clue what should and should not be done in the ED vs an observation or inpatient unit.

Sure... very convincing argument -- you have no clue, so you should do what we say. Typical ED.... You are actually, most of the time, the ones without a clue. Don't apply any standard of medicine, any scores, some of which based on studies located on the ED. Instead, the hospitalist does it most of the time and even when he comes to you with the scores you should've come to him with, you still bitch and moan and stick to your superiority complex.

 

[doctorsun]

bingo. I’ve worked with the type. Expect the ED to do a 1-2 day hospital workup treatment and specialty reassessment prior to admission. Everyone is either too sick and needs ICU or too well and should be discharged. Like Goldilocks, constantly looking for the perfect floor admission and never finding it.

1-2 day hospital workup!? If ED does a workup that takes more than an hours, 90% it is because they're doing shopping trying to find something in a grossly non-admittable patient. There are relatively few workups that require that much time even as inpatients, not to mention ED workups. How about you stick to doing proper ED workups and not trying to tell hospitalists what to do based on your knowledge or lack thereof / laziness / not giving a damn about patient / hospitalist and then we can talk about you doing 1-2 day workups?

 

[doctorsun]

Workup by a transplant team for uncommon infections and conditions which are standard to them but obscure to others
Access to a transplant surgeon to biopsy the transplant and assess for rejection
Access to pathologists used to working with transplants
Continuity of care for their 700th admission since transplant
Salvage procedures for the transplant that a transplant team is familiar with that other physicians may not be

I think the care complexity of these patients tends to be underestimated often. It’s like arguing that bariatric surgery doesn’t need a bariatric center. Might be technically true but the outcomes just aren’t going to be the same.

There probably isn’t a legal/emtala burden to accept outside the acute phase, but I would argue that especially in the first year or so after transplant there actually is one. Even after though, I think there’s the moral burden of what’s really right for the patient and I absolutely think that’s transfer to a mothership that deals with this crap.



If the workup takes longer than 4 hours it’s inappropriate for the Ed, and increases mortality for the patient as well as everyone in the waiting room not getting proper care.

If the workup takes longer than 4 hours it’s inappropriate for the Ed, and increases mortality for the patient as well as everyone in the waiting room not getting proper care.

Is that so? Based on? And why do you need 4 hours for a workup? Does a study differentiating AKI types require 4 hours? HF exacerbation etiology? And some of the other incomplete examples provided by author? I rarely got an ED patient after 4 hours of workup. Most of time, 10 minutes if anything....

And how does it compare to ED dumping all sorts of patients that don't qualify for admissions / wrong disposition / etc in terms of quality care and inappropriateness? All these "studies," "rules," etc mostly brought by ED Drs and administrators, who obviously have similar motives to push in patients, are ridiculous but more importantly, do not give you the right to shove a patient down another Drs' throat. Amusing that ED Drs who want more nap time and admins who want more money come to hospitalists under the veil of appropriateness and patient safety.... As if they no only have the intelectual but also the moral superiority over them. Regardless of how superior you and other sub-specialty physicians think you are in relation to hospitalists (and vice versa), you have no legal right to force a physician-patient relationship. In most cases, with exception of procedures, hospitalists are way better versed in medicine than ED physicians, especially when it comes to potential inpatients. ED deals with stabilization and outpatient, thus you bill as such, yet you, for some reason, think you have the capability to tell other physicians who specialize in inpatient what to do and who to treat. In practice, obviously you have the edge thanks to rubbing cheeks with admins. It is unfortunate that today's political medicine allow you to do that and harms patients way more than 4 hours etc. Recently had an ED physician (FM in training) stating next to administrator that Interqual is "the god of decisions whether to admit or not" so I replied to him, next to administrator, that interqual is written by nurses and admins (and "monitored" by physicians) for administrative purposes, not to overwrite a physician. Must be very convenient to be in position to scratch admin backs though....

 

[Janders]

1-2 day hospital workup!? There are relatively few workups that require that much time even as inpatients, not to mention ED workups. How about you stick to doing proper ED workups and not trying to tell hospitalists what to do based on your knowledge or lack thereof / laziness / not giving a damn about patient / hospitalist and then we can talk about you doing 1-2 day workups?

Listen dingus. You and I can disagree on the appropriate amount of time a patient should stay in the ED getting repeated interventions, labs, and workup. But stating I’m lazy or don’t give a damn about my patients is a personal affront, and I don’t know you well enough to accept that lying down.

Just because I think an old person with severe AKI of a likely pre-renal etiology needs admission to the floor upon recognition, and not another 6-8hr hanging in the ED while I get urine electrolytes, a formal renal US, a nephrology consult and serial labs after fluid resus to confirm the diagnosis, while 20 patients flounder in the waiting room…

Just because I think CHF exacerbations of unclear etiology needs more that “double the dose of your oral diuretic and good luck! Follow-up with that cardiologist!” That’s some lazy medicine. Have pride in your skills. Being a good internist is important. Chf exacerbations have significant recurrent mortality risks. Obviously if they ran out of lasix for a week, I can refill their lasix and we’re all happy.

Observation AND admission medicine is your job and expertise. Do your job?

 

[JacobMcCandles]

This person is a great example that not even physicians that are hospital based know how an ED works or should function. I’m glad they’re not a hospitalist at a place I work.

 

[doctorsun]

Listen dingus. You and I can disagree on the appropriate amount of time a patient should stay in the ED getting repeated interventions, labs, and workup. But stating I’m lazy or don’t give a damn about my patients is a personal affront, and I don’t know you well enough to accept that lying down.

Just because I think an old person with severe AKI of a likely pre-renal etiology needs admission to the floor upon recognition, and not another 6-8hr hanging in the ED while I get urine electrolytes, a formal renal US, a nephrology consult and serial labs after fluid resus to confirm the diagnosis, while 20 patients flounder in the waiting room…

Just because I think CHF exacerbations of unclear etiology needs more that “double the dose of your oral diuretic and good luck! Follow-up with that cardiologist!” That’s some lazy medicine. Have pride in your skills. Being a good internist is important. Chf exacerbations have significant recurrent mortality risks. Obviously if they ran out of lasix for a week, I can refill their lasix and we’re all happy.

Observation AND admission medicine is your job and expertise. Do your job?

Dingus? lol. Severe AKI? Likely prerenal etiology? urine electrolytes and US? LOL are you even a doctor!? You don't even know how to work up AKI appropriately. Even if a doctor, obviously not a very good one. You see, even though a hospitalist can tell you how to do proper ED workup of AKI, you think you can tell a hospitalist how to do his work. That is the problem. But hey, no worries, it's the hospitalists' fault even though you have no idea what you're talking about.

Besides, it doesn't matter what you think. That's what books and guidelines are for, and your lack of knowledge does not = hospitalists don't know what they're doing and should do as I say because I have admin back. Hospitalist do their job by telling you disposition of patient, don't they!? Is it their job to care for patients they shouldn't be caring for because you think otherwise!? Do ED physicians define Hospitalist jobs!? Unfortunately, bud, the same rules and laws that define your physician autonomy also define them lower intellect (at least from your point of view) hospitalists who need your help with their job. If hospitalists can save "grandma with severe AKI" a hefty bill because you and admin have selfish reasons or at best, are unprofessional, they will lawfully do so. Obviously, if hospitalist and ED both mature, professional, at least some ethical, they will have a conversation and make their points, but you don't get to one-sidedly force a physician patient relationship on another physician, kapish? LOL. look how hard it is for you to accept hospitalists as physician who have right to refuse such a relationship. Bet you don't have same issue with other specialties, now do you? Let's just call it what it is -- you think you're stronger, better, and in general superior to hospitalists so you expect them to do what you say, regardless of patient safety, appropriateness, blah blah blah. Don't beat around the bush, bud.

In conclusion, Do YOUR job buddy, perform basic ED screens and workups, do the HEART scores, stop taking d-dimers on every patient that comes in with shortness of breath and tachycardia, don't call for admission of radiologic pneumonia of a patient who just finished pneumonia treatment, etc. You know, do medicine... and meanwhile, stay out hospitalists' hair regardless of how superior you think you are. In reality, you're not. Hospitalists (inpatient doctors) don't come to ED and tell ED physician how to manage their patients in ED. Show same professional courtesy and maturity even if it costs you a couple of phone calls and a little less nap time.

 

[Janders]

SDN inserted dingus in the place of my preferred noun.

I’ll just go with troll for now, and excuse myself from feeding this one any further.

 

[doctorsun]

SDN inserted dingus in the place of my preferred noun.

I’ll just go with troll for now, and excuse myself from feeding this one any further.

Of course, my friend. Dingus and troll both reflect your capabilities as an adult, a communicator, etc and are therefore suitable for you to use. Just remember - hospitalists, or any other specialty physicians, don't work FOR you. You don't define for them who their patients are. Maybe once you come to peace with that, you will be better at YOUR job. Be well.

 

[JacobMcCandles]

Hospitalists (inpatient doctors) don't come to ED and tell ED physician how to manage their patients in ED.

Didn’t you just spend several posts doing exactly that?

 

[HemorrhagicShock]

You don't define for them who their patients are.

Do you understand the intended role of the ED or an ER doc?

I am genuinely asking you this question. I assume you're a board-certified internal medicine physician who is trained in the US.

I simply don't understand how you could write the line I quoted if you've spent any meaningful time practicing as a physician in the US

 

[RustedFox]

Of course, my friend. Dingus and troll both reflect your capabilities as an adult, a communicator, etc and are therefore suitable for you to use. Just remember - hospitalists, or any other specialty physicians, don't work FOR you. You don't define for them who their patients are. Maybe once you come to peace with that, you will be better at YOUR job. Be well.

Duuude.
You're gonna have a bad time.

 

[throway134]

Of course, my friend. Dingus and troll both reflect your capabilities as an adult, a communicator, etc and are therefore suitable for you to use. Just remember - hospitalists, or any other specialty physicians, don't work FOR you. You don't define for them who their patients are. Maybe once you come to peace with that, you will be better at YOUR job. Be well.

I can't quote your actual post since you embedded it in mine.

The association between length of emergency department boarding and mortality - PubMed

Hospital mortality and hospital LOS are associated with length of ED boarding.

pubmed.ncbi.nlm.nih.gov

there's about a million of these, feel free to critique them, none are particularly well done but they do match lived experience.

Arguing with you seems like a waste of time, as you lack the insight to understand that you don't actually know what the ED does (no longer what I do for the record). You seem to have a bizarre notion that the ED has more pull with administration than you do: spoiler, they do not.

There are a limited number of beds in any ED, and they are almost always filled to capacity. I have never worked in any ED where I was not seeing 3-4x more patients than the hospitalist, and also expected to do so while seeing undifferentiated critically ill patients. The notion that the ED gets "nap time" is by far the most bizarre thing you have said. I assume you work in a rural hospital and have some sort of complex about it given that you are working with FM folks in the ED, and think that ED docs typically nap on shift.

The ED deals with a lot of things you know nothing about: pediatrics, obstetrics, trauma, ortho, etc. If your big flex is that you know more internal medicine than they do...... You should. Good job. It would be completely pathetic if you didn't.

It's pretty shameful that you have so little understanding of how the hospital you spend all day at functions.

 

[VA Hopeful Dr]

You can respectfully disagree without turning personal or degrading an entire branch of medicine. Behave yourselves.