Strategies for dealing with admission stalling/blocks

[Tesla MD]

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Hey, all. I'm a shiny new attending at a teaching hospital. Where I trained, the admission process was very simple: (with a couple of exceptions) admit to a service without talking to that service, care for pt until you get a bed assignment, call the senior on that team with report, send pt upstairs. At my new hospital, all services come down to assess pt prior to admitting and there is often impressive blocking that takes place--it takes 1-2 hours for admitting resident to see the pt, they want to check another lab or get another study prior to deciding whether the pt can be admitted to their service or not (sometimes valid, often not), or they say they have to talk with their attending and this can take five hours.

It is not unusual to have something simple, like a long bone fracture in a medically uncomplicated patient, and wait for hours to get admission approval from the ortho resident when we ALL know that the pt is coming to ortho no matter what. All the residents--admitting service and EM residents--are wasting a substantial amount of time dancing around trying to figure out a disposition.

I'm trying to think of a better solution, probably a time limit on resident admission decisions before an attending-to-attending conversation takes place. Has anyone implemented a similar change or feel compelled to share the admissions system at their hospital? Before I bang my head against the wall much more, I wanted to poll you all and see if there's a kinder, gentler way to admit a patient.

 

[Apollyon]

First, I LOVE the user name.

Now, my first thought is to say to the resident, "who is your attending? I am going to call." At Duke, IM was archly noted to be trying to block admissions all the time (such as a patient "not right for internal medicine" <-- huh?), and that talk turned to nothing after a few attendings were contacted in the middle of the night, saying that their residents were quibbling.

If a resident says that one lab value is the decision on which their service is to admit or not, that resident is lying to you. This is people trying to avoid work.

You're new - if they learn to walk all over you, your road will be rough (and that puts it gently).

Sorry if this sounds heavy handed. I have to go through the same thing right now as an attending at a free-standing ED.

 

[NinerNiner999]

I agree with Apollyon. But you are in a tough place for now. Being new, don't go setting fires that may come back to burn you - unless you need to. I would set some reasonable point in time for the residents to evaluate the patients (say 30-45 min.) Beyond that, a call to the attending for admission orders should be made - politely. After a few polite phone calls, the admitting attending will start to see a pattern with the residents.

 

[Tesla MD]

Apollyon, thanks for the reply. My current strategy has been to get a bad reputation with the admitting residents by calling attendings, and I've been testing out telling the admitting resident that they have X amount of time before I page their staff. This has worked for me. I would, being young and idealistic, like to get some kind of protocol to make the system more friendly to all our residents regardless of whether their EM attending wants to/has time to call the admitting attendings when their residents block. I'm working with the medical director to get a system in place such that we can admit with a single phone call within an hour or so of having enough data to know where the patient needs to go. I'm trying to figure out the most realistic way to do this.

 

[kajunman]

we were having a similar problem at the hospital that i am a resident at.....the was a policy change from very high up (CEO of hospital) that following any and all consults that they has to be a note on the chart and a disposition within one hour of consult call being placed.

took a few weeks but it has greatly helped pt flow...they are tracking the numbers and there is something like a 20% reduction in time for pt's to be admitted and moved up to the floor.

kajunman

Hey, all. I'm a shiny new attending at a teaching hospital. Where I trained, the admission process was very simple: (with a couple of exceptions) admit to a service without talking to that service, care for pt until you get a bed assignment, call the senior on that team with report, send pt upstairs. At my new hospital, all services come down to assess pt prior to admitting and there is often impressive blocking that takes place--it takes 1-2 hours for admitting resident to see the pt, they want to check another lab or get another study prior to deciding whether the pt can be admitted to their service or not (sometimes valid, often not), or they say they have to talk with their attending and this can take five hours.

It is not unusual to have something simple, like a long bone fracture in a medically uncomplicated patient, and wait for hours to get admission approval from the ortho resident when we ALL know that the pt is coming to ortho no matter what. All the residents--admitting service and EM residents--are wasting a substantial amount of time dancing around trying to figure out a disposition.

I'm trying to think of a better solution, probably a time limit on resident admission decisions before an attending-to-attending conversation takes place. Has anyone implemented a similar change or feel compelled to share the admissions system at their hospital? Before I bang my head against the wall much more, I wanted to poll you all and see if there's a kinder, gentler way to admit a patient.

 

[Tesla MD]

Kajunman,

That sounds like a spectacular solution to the problem. Do you know anything about how the CEO ended up making this decision? Was there a sentinel event of badness, did enough people just complain, or was it something else?

 

[BADMD]

Before I bang my head against the wall much more, I wanted to poll you all and see if there's a kinder, gentler way to admit a patient.

There is. I don't have it yet. But mine is easier than yours.

Think about what you are trying to do...derail a process with huge momentum. It has probably evolved over years. There were probably a few critical incidents that created a policy where IM has to see all patient before they are admitted. You may be trying to push around a fast moving Mach truck.

It isn't impossible, but you have to go in with a pretty big hammer and you have to hit the right place. It may take several months to gather the appropriate data to beat over Medicine's head.

First, track time from decision to admit until the admit order is entered. Then track time to going to the floor. Track how many beds are occupied with people waiting for their "Admission consultation" while simultaneously tracking your wait time and your LWBS/LWCT rate. Next gather all the literature you can about how bad things happening when patient's wait in the ED. Reference the IOM report a few times.

The next key is to come up with a plan. Make sure that plan is feasible for medicine (might need to look into the issues medicine has). Build an error recovery contingency into the system (some patient will go to the floor with a K of 6 some day). Their biggest objection may be that this method prevents ED screw ups.

Try to find a sympathetic ear on the medicine side that is willing to help you craft the process and is also willing to help champion it to their chair. Also make sure that you fully understand how Medicine gets paid and how patients are distributed to the attendings. Money flow has an amazing way to create convoluted process.

You need your chair to take this to the chair of medicine (CC: Chief of Staff and maybe the CEO). Show how the admissions process may harm patients and slows ED throughput. It would great if you can actually show that you could see more patients if only the darn bed was free. Putting dollars to the bottom line will melt the heart of the toughest CEO. See if you can show how a new process would off load the resident and benefit medicine and the residency director.

Then have a plan for how to pilot the process. Your buddy from medicine will be invaluable here. Every fourth patient gets the new process or something like that. You do need to have a complete plan going in and answers to objections. The plan on the way out may not be the same, but set the starting point and expectations.

Those are my two cents. Maybe it will work for you. But it is easier to fight when you are armed and you blind side your opponent.

 

[kajunman]

not a sentinel event per say but ED times were extremely long....something like average of 6-8 hrs of pt who eventlally being admitted being in the ED. Our department had been yelling about it for a while.

it came to a head when a huge money donor was in the dept, seen by ED and was waiting for consultant to show up....after 2 hours with consulant not showing up he left AMA and called the CEO, a golfing buddy, and said he was leaving and going to the private hosptial down the street.

this caused administration to take a hard look at time to bedside and time to admission orders for the consultants, the ED had been keeping this data for awhile but could not get anyone to look at it before... suddenly admin was very interested and changes happened very quickly when they noticed that wait times were not ED dependant but were consultant dependent.

Kajunman

Kajunman,

That sounds like a spectacular solution to the problem. Do you know anything about how the CEO ended up making this decision? Was there a sentinel event of badness, did enough people just complain, or was it something else?

 

[GeneralVeers]

I know that ER docs writing admission orders is not popular in here, however we do this at our hospitals. I was weary at first, but it has some benefits:

1. The patient is admitted as soon as I speak with the admitting doc. If that doc waits too long to call back, I admit the patient to their service anyway and hopefully they'll call back at some point during my shift. I can always change the admitting doctor later if need be. This has pretty much eliminated the wait for consultants.

2. The patient gets their inpatient workup started sooner, as I will put essential tests, studies, or treatment on the orders. The orders expire after 4-6 hours, so the admitting doc has to phone in new orders after that period.

3. Less attempts at turfing patients. If consultants don't have to come into the hospital at 2 AM to see a patient, they rarely give me any argument about an admission.

 

[Tiger26]

I know that ER docs writing admission orders is not popular in here, however we do this at our hospitals. I was weary at first, but it has some benefits:

1. The patient is admitted as soon as I speak with the admitting doc. If that doc waits too long to call back, I admit the patient to their service anyway and hopefully they'll call back at some point during my shift. I can always change the admitting doctor later if need be. This has pretty much eliminated the wait for consultants.

2. The patient gets their inpatient workup started sooner, as I will put essential tests, studies, or treatment on the orders. The orders expire after 4-6 hours, so the admitting doc has to phone in new orders after that period.

3. Less attempts at turfing patients. If consultants don't have to come into the hospital at 2 AM to see a patient, they rarely give me any argument about an admission.

That's awesome

 

[Hercules]

I know that ER docs writing admission orders is not popular in here, however we do this at our hospitals. I was weary at first, but it has some benefits:

1. The patient is admitted as soon as I speak with the admitting doc. If that doc waits too long to call back, I admit the patient to their service anyway and hopefully they'll call back at some point during my shift. I can always change the admitting doctor later if need be. This has pretty much eliminated the wait for consultants.

2. The patient gets their inpatient workup started sooner, as I will put essential tests, studies, or treatment on the orders. The orders expire after 4-6 hours, so the admitting doc has to phone in new orders after that period.

3. Less attempts at turfing patients. If consultants don't have to come into the hospital at 2 AM to see a patient, they rarely give me any argument about an admission.

Same experience here. I was not a fan at first, but I love how quickly patients can be admitted. Plus we're physician order entry for everything so I just have a skeleton admission order template that I can quickly click on in the computer and have a bed assigned in minutes. I'm a big fan of number 3 as well.

 

[Katydid]

Just remember, with all the suggestions posted here?

It is never a good idea to go Conan the Barbarian on someone, inhume them by removing their head from their body, and placing said head on a pike to parade around the hospital as an example to anyone else who might decide to go up against you.

Just sayin'.

 

[GeneralVeers]

Just remember, with all the suggestions posted here?

It is never a good idea to go Conan the Barbarian on someone, inhume them by removing their head from their body, and placing said head on a pike to parade around the hospital as an example to anyone else who might decide to go up against you.

Just sayin'.

Although it is extremely fun, and gets you winks from the pretty nurses.....

 

[Katydid]

Although it is extremely fun, and gets you winks from the pretty nurses.....

And wild applause and cheering from other people who are tired of dealing with the same fecal matter.....yeah, but then the police get involved, and there's broomsticks, and yelling, and everything ends in tasers and handcuffs.

Not my idea of a way to spend the afternoon.

 

[Tesla MD]

Update: so I have a new strategy that works for me. If there are appears to be potential blocking on a patient that I know is going to one service, I page the admitting resident and tell them that if we don't have a yes or no within 90 minutes, I'm going to call their staff so we can make a decision. This has been INCREDIBLY effective. Thus far, I've never had to actually call the staff if a definite deadline was given to their resident. I had been just going over the residents' heads to make the call without warning if they were being silly, but if I give a specific time, they have always had an answer for me by then.

 

[Jeff698]

I had been just going over the residents' heads to make the call without warning if they were being silly, but if I give a specific time, they have always had an answer for me by then.

As in most things in life, the key is finding the right motivation. It looks like you've found it. Congratulations!

Take care,
Jeff