ED Observation as an alternative to admission...

[Old_Mil]

Admissions at Tertiary General are a problem. Our hospialists grudgingly admit until around 4 to 430 in the morning at which point they stop returning calls. Shift change is at 6am. The new on call hospitalist will then wait to return the call sometime between 6:30 and 7:00, and bitch endlessly if not try and block an admission on a patient they have yet to lay eyes on. So basically we run into a 3 (sometimes 3.5 if they stop calling at 3:30) hour gap in which we cannot admit anyone, and a period following that when admissions are blocked.

Anyone else work in a system like this, and what are some of the tools you use to get around the problem?

Alternatively, when the admitting service proposes a plan of care that is dumb as hell, what do you do about it?

Anyone ever simply transfer a patient to ED observation status for an extended period of time (say up to 12-24 hours) to simply avoid such problems?

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[deleted109597]

Watching people in my ED doesn't not fix any problems encountered by holding on to them until someone answers the phone.
What you need is for someone at your hospital to show that the hospitalists are doing the patients a disservice, and also that this logjam affects patient safety. This may be tougher if your ED has an empty waiting room at 3am, but many do not.
A way around it is to subvert the hospitalists and have a "standing orders" protocol. It saves them initial effort, and if they find that they are getting too many admissions then they need to answer their phone sooner.

 

[Old_Mil]

Watching people in my ED doesn't not fix any problems encountered by holding on to them until someone answers the phone.
What you need is for someone at your hospital to show that the hospitalists are doing the patients a disservice, and also that this logjam affects patient safety. This may be tougher if your ED has an empty waiting room at 3am, but many do not.
A way around it is to subvert the hospitalists and have a "standing orders" protocol. It saves them initial effort, and if they find that they are getting too many admissions then they need to answer their phone sooner.

That protocol exists, but it can't be implemented without first talking to them and getting an admitting physician name to place on the order set. The waiting room is never empty. I'm thinking of obs as an alternative where we can treat them and function as short term inpatient docs if there's an admission problem. Yes, in a perfect world this is not what an ED physician should have to do. No, this is not a perfect world.

We have an obs area, I'm wondering more from a performance measures and payment perspective (which is really the only thing the admin cares about as far as the ED is concerned).

 

[VALSALVA]

I would suggest you call the CMO at 4AM. The inability to get a patient dispositioned for 3-4 hours is a serious patient care, patient satisfaction, medical staff morale problem. CMOs are concerned with all three issues. In my experience, I start getting calls back from hospitalists/consultants SOON after I place a call to the CMO (happens twice a year).

 

[kungfufishing]

I would suggest you call the CMO at 4AM. The inability to get a patient dispositioned for 3-4 hours is a serious patient care, patient satisfaction, medical staff morale problem. CMOs are concerned with all three issues. In my experience, I start getting calls back from hospitalists/consultants SOON after I place a call to the CMO (happens twice a year).

This is one of the areas where the goals of administration and the ED are somewhat aligned. We both want to move patients. Useful leverage and good for patient care, both those we've seen and the invisible queue that extends out of the waiting room door.

 

[southerndoc]

Luckily our hospitalists are onboard with our 4 hour door to floor goal. It's pushed from the health system CEO, so our hospitalists call back fairly quickly (within 15 minutes) unless something is going on. We use transition orders and they see the patient on the floor and not the ED. Our intensivist group has PA's in house 24/7 and so does cardiology. Those patients are a breeze to dispo.

We meet with our hospitalists frequently to discuss issues, and I suggest you start with this step first. Have your CMO/hospital medical director be there as well. Start with this instead or arguing in real time. That will help more.

Get your CMO to support an escalation policy for callbacks. Any consultant, hospitalists, etc has 20 mins to call back. If they dont then they get a second page and only 10 mins to respond. If no call back then, then the secretary calls their home (or office if business hours) and then their cell. If that doesn't get someone immediately, then we randomly call a cell phone of one of their partners. You can magine how an orthopod will take it out on his partner for not returning calls.