Hospitalists and emergency medicine physicians interface at a crucial point in the patient care continuum: where patients in need of further treatment are discharged for outpatient treatment or admitted to the hospital. Both groups share the same prerogative: provide high quality patient care and achieve positive outcomes. However, there are times when the two groups are at odds, especially when there is a gray area regarding the best care setting for a given patient.
Hospitalists and ED physicians have different, and sometimes conflicting, priorities. ED physicians are driven by throughput: moving patients through the ED quickly and efficiently. Hospitalists are driven by efficiently managing inpatient length of stay. The key to reducing tension between the two groups is to bring them together to discuss how they can better serve one another.
In my experience as a hospitalist, I have found that there are a few key issues that are crucial to discuss with my ED counterparts. The list below is a good reference for common issues to address at an interdisciplinary meeting.
Inpatient Patient Sources
The ED is not a hospitalist’s only source of patients. We also manage consults from other services, direct admissions from primary care physicians, ICU transfers, and admissions from free standing emergency departments. Simply discussing the patient load and being open about the fact that the ED is not the only source of patients can help reframe your conversation. A hospitalist and ED physician should always take time understand the volume of patients the other practice is handling to better understand one another’s perspective and make informed requests and decisions together.
Labs and Imaging before Admission Calls
When possible, it is extremely helpful for hospitalists when the ED completes labs and imaging before admission rather than admitting a patient with pending results. Sometimes, the results change whether the patient can be admitted to the floor vs. the ICU. A good starting point is to determine a protocol for labs and imaging and establish common exceptions so that everyone shares the same expectation of how labs and imaging will be handled.
Protocol for Borderline-for-Admission Patients
When it is not clear whether a patient needs to be admitted, it is helpful for an ED physician to ask their hospitalist counterpart their opinion before making a decision. Guidelines evolve and patients that we would have been admitted just five years ago can often be treated safely as an outpatient (e.g. in the case of a stable pulmonary embolism). It is helpful to discuss these types of cases and establish an interdisciplinary algorithm on how to handle each case.
Documentation of Conversations with Consultants
To avoid confusion over whether an ED physician spoke with a consultant, it is important that ED physicians always document whether they talked to a consultant directly or whether they are awaiting a call back from a consultant. If this is not mutually understood, confusion and delay of patient care is common, especially if the patient is admitted overnight and there is a handoff to a daytime hospitalist. A good remedy for this is to establish a protocol on how to handle overnight admissions handoffs and documentation of conversations with consultants. Thorough communication and documentation are critical.
Sometimes, calling in multiple admissions at once is impossible to avoid. However, it can be very difficult for a hospitalist practice to handle 3, 4, 5, or even more admissions at once. In my experience, there are certain ED physicians who have a reputation for calling with a bundle of admissions at the end of their shift. Often, this is simply because that physician does not fully grasp the effect it has on their hospitalist counterpart. The best solution is to openly communicate and establish mutually beneficial strategies to avoid bundling admissions.
There are often changes in things like recommended antibiotics for certain infections or new drugs like novel oral anticoagulants (NOACs). When these changes occur it often changes the recommendations related to treatment and which labs to order or not order. I recommend establishing regular interdisciplinary meetings where updates like these can be shared. And, when in doubt, I recommend that providers speak to one another about their choice to ensure there is no confusion and that the patient receives the best treatment possible.
Stating Patient Name and Room Number
As hospitalists, we understand that the ED is always working to make patients better in the fastest way possible. However, it is crucial to slow down to communicate details to avoid errors. I recommend establishing a simple checklist for the order of information shared on a phone call between a hospitalist and ED physician. In my experience, it is very helpful for the ED doctor to slowly and clearly spell the patient’s name and state their room number before sharing any diagnosis or medical information.
Being Upfront about Challenges
Hospitalists understand that we will not always know precisely what is going on with the patient at the time they present. As hospitalists, we have the luxury of figuring it out over days instead of hours. I recommend establishing a safe, trusting culture of communication between the two practices, where ED physicians feel comfortable stating that they are not sure what is wrong with the patient, that it is a social admission and there is no safe place for the patient to go outside of the hospital, or that they forgot to order something important. When a hospitalist is not informed, it puts us in a difficult position, especially if we cannot see the patient immediately.
Protocol for Primary Psychiatric Diagnosis.
Most hospitalists and acute care hospitals are not equipped to take care of primary psychiatric patients safely. If this is the case at your facility, it is important to make your ED colleagues aware that often once a primary psychiatric patient is admitted, transfer is much harder from the inpatient side vs. from the ED. Establishing a set protocol for handling psychiatric patients will alleviate difficult situations for both practices.
Overall, the best place to start is to ask your ED colleagues how you can make their life easier, and brainstorm collaborative, mutually beneficial solutions. Simply being aware of our counterpart’s perspective and establishing interdisciplinary protocols to reference goes a long way to improve transitions of care from the ED.