hi
i am a relatively new hospitalist and still in residency mode of not knowing how to say no to things
i think but am not sure that i now have a reputation among the ER docs that I pretty much accept anything and everything.. i should add that some of the other hospitlists have a reputation for being cantankerous and difficult to admit to
this has resulted in them dumping AMS / fall patient with pending CT head which later returned with brain bleed , and acute renal failure patients needing emergent HD with no formal Nephro recs yet or HD access
thankfully the outcomes were OK in these cases , and I learned my lesson about those specific cases , on why I would refuse them in the future
is there any other "Gotchas" to look out for during sign out? do you just refuse anything that has pending labs/imaging? im trying to get a sense of where the line is and whether they have been crossing it with me
Likely will be hospital-specific depending on local policies and culture and resources available at your specific facility, as others have said. But in general, outright refusing some ED admissions as a hospitalist may get you in trouble with admin.
Try to anticipate ahead of time what the patient may end up needing, especially it's is something not easily available at your hospital. In some cases, you should ask the ED to do more work-up and hold admission until key test results are back, or after they have discussed the case with another specialty that will likely get involved in the patient. Especially if the patient may end up needing a service that your hospital doesn't have, and require transfer to another hospital. This will minimize the chance that you get dumped on, and will have to do all the transfer work yourself after admitting the patient when the patient should have appropriately been transferred directly as an ER patient.
In terms of getting dumped on by your own colleagues, or whether it's acceptable to pass on late admissions to the next person, this is largely something to be worked out within your group with guidance from your director/administrator. Ideally your group should come up with a somewhat official rule that everyone is supposed to follow (eg okay to pass on admits within1 hour before your shift ends to the next person), so no one gets too upset. If that still doesn't solve the issue, then the volumes at your place may be too high and more staffing is probably the only real solution.
As for admitting "soft" admits that the ED provider doesn't want to send home (often due to fear of medicolegal implications), besides you admitting and discharging them yourself (which is often a lot of extra work-up, especially if it's already a busy time of the day with other admissions), you may be able to write a short consult note basically saying you're okay with the patient discharging from our standpoint. Some ED docs may be okay with discharging them afterwards themselves, though this will obviously shift a lot of the medicolegal liability to you. If you tell them over the phone that you're okay with them being discharged but without writing anything in the chart, the ED doc will probably still document in their note that you said that before discharging them (which again still puts some of the liability on you either way).
Would also get to know what other specialties at your hospital admit besides hospitalist. Unless your hospital has an official policy that "hospitalist admits everything," some specialties and maybe a few PCPs will at least admit their own established patients. This will require doing a quick chart review if you get called by the ED about one of the patients; they're often too busy or just don't care enough to look at the chart enough to figure this out, and may just default every admission to hospitalist, but you may be able to redirect a few admits to other services by reminding to the ED to check with another potential service first if they will admit.
