9 Important Issues Hospitalists Should Discuss with ED Counterparts

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. 

Batching Admissions

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.  

Treatment Updates

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.

Teamwork Culture in Emergency Departments Improves Care Quality and Team Morale

Leaders building a brand-new rural community hospital in Texas asked me (along with some of my colleagues who now make up CareCulture’s leadership) to help them optimize their emergency department. The new facility was a fresh start, despite the fact that most of the doctors and nurses were familiar with each other and had been working in the same community for a long time. Most of their existing team members were entrenched in traditional, hierarchal methods of delivering emergency care. The hospital administration tasked us with establishing a culture based on teamwork, mutual respect, and a focus on patient needs. Because the team was deeply immersed in their long-established practices, shifting their approach was a formidable challenge.

I have served as medical director at a wide spectrum of emergency departments over the years—rural critical access hospitals and trauma centers alike—and every time the root cause behind the performance issues they face is their culture and the leadership style that perpetuates that culture. This department had a culture issue that was woven tightly into the traditional culture of healthcare delivery. It is one I felt strongly about unraveling: hierarchal, top-down leadership. As an alternative, I always encourage emergency departments to replace top-down management with team-based leadership that cultivates a safe environment for all team members to be empowered to speak up in the interest of better care for our patients.

When we arrived at this rural facility, we were seen as the “city folk”, outsiders from Dallas. The nursing staff and techs were anxious about our presence, assuming that we would follow the stratified approach to emergency department leadership to which they were accustomed. The leadership style depicted in the famous book, The House of God, in which attending physicians dictate orders while all other team members are expected to bow and nod their heads in agreement, carrying out their orders without question.

Inevitably, top-down leadership and the attitude that the entire ED staff exists to serve the medical director and attending physicians leads to conflict, unspoken frustration, and poorer care quality for our patients. When we started managing the new, small community hospital in Texas we took a different approach. Instead of dictating, we invited the nurses, techs, and administrative staff to the table and asked them how we could make their lives easier. We encouraged them to share their opinions and to question us (the physicians) if they saw a better way or had a question or suggestion.

It is a new way of viewing emergency department hierarchy. The team-based approach eliminates the feeling that nurses and techs exist to serve physicians and replaces it with the attitude that the entire team exists to serve each other to best serve the patient. This is not to say that the doctor will not have the final say on a course of action, but it does mean that the nurse or tech’s ideas are thoughtfully considered before making the final decision.

To shift the mindset of the team, we first speak with everyone on the team to discuss what is working well and what is not working. Any power dynamic between nurses and physicians needs to be broken down. We do this by creating regular opportunities for discussion and feedback, such as regularly scheduled all-hands meetings and an open dialogue during daily interactions. In the meetings, we make it clear that a nurse or tech questioning a physician is not just allowed, but expected. We expect to be held accountable. We impart the philosophy that we are servant leaders who do not just expect to be served, but are beholden to serving and respecting our colleagues as equally significant and influential members of the team—regardless of title.  

Nurses and techs are not the only ones who need to shift their mindset in order for this culture to take hold. Physicians must also feel comfortable and secure giving and receiving feedback and being questioned regularly and openly. Traditionally, some physicians may view being questioned by a nurse or tech as demeaning or a mark of failure. They may feel that because of their extensive training they know what is best. In turn, nurses may feel that it is disrespectful to question doctors. This new team-based, service-oriented culture enables physicians to set any pretense or power dynamic aside and prioritize what is best for the patient—no matter whose idea it is.

This culture change goes beyond the nurse-physician power dynamic, extending to EMS personnel, social workers and other professionals the emergency department regularly interfaces with. As part of our team-based approach, we encourage emergency department care providers to reach out—beyond the walls for the ED—to seek feedback and improve communication across the continuum of care. For example, at this particular hospital, EMS personnel who frequently brought patients to the ED were accustomed to being immediately interrupted by the doctor. This recurring behavior led them to immediately stop talking when a physician entered the room. As part of our management change, we encouraged EMS personnel to give a full report and encouraged our physician team to listen for the full report without questioning or interrupting. This approach worked, and more vital information was passed from the EMS personnel to the ED, allowing us to take better care of the patient.  

When this open, team-based approach takes hold, the entire team is more empowered and invested in the collective success of the department and hospital. Physician-nurse interactions are more open and positive. Communication between providers and patients improves. Team members are more excited about coming to work each day.

When we implemented this change at this newly rebuilt facility in rural Texas, we saw a notable improvement in the interactions between all emergency department providers and staff. Shortly after the opening of the hospital, several experienced nurses volunteered to take on more significant roles in the emergency department because their input was taken seriously, which empowered and inspired them to be more involved. The newer nurses were also more comfortable asking the doctors questions, which helped their understanding and improved the quality of care for the patients.

Taking a more open, lateral rather than hierarchal approach fosters a more nurturing, safe environment for physicians, nurses, techs, administrative staff, EMS providers, and other people who interface with the emergency department to openly share their ideas, which improves department efficiency, care quality, and patient experience as a whole.