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.

3 Reasons to Combine your Low Volume Hospital’s Emergency and Inpatient Service

The idea that a hospitalist program is cost prohibitive for smaller community hospitals (less than 12,000 annual emergency department visits) is a dated myth. Reaping the benefits of a robust hospitalist program and emergency department without the cost of two full programs is possible. It simply requires innovation. Hybrid emergency department and inpatient care management is that innovative solution.

Emergency medicine and hospital medicine can be integrated by combining the two services into a single patient care service. In this model, inpatient care is provided as an extension of traditional emergency department services by providers who are skilled in both emergency and inpatient care. A single physician (or physician and advanced practice provider team) cares for the same patient throughout their hospital visit.

This model is a good fit for smaller hospitals because it allows for the most efficient use of provider coverage. The staffing model will vary based on your volume trends. When designing your staffing model for a hybrid program you must consider:

·      Arrival and average daily census patterns

·      Physician shift length (12 or 24)

·      How to cover volume surges

·      After midnight admission processes

In our experience, the program works best when there is a backup call schedule arranged for volume surges and physicians work 24 hour shifts, handling rounding in the morning before ED volumes peak for the day and writing H&Ps during rounding time for patients admitted after midnight. 

The hybrid model is a cost-effective and efficient alternative to running separate programs or managing rotating call with community physicians. Below are the top 3 reasons to adopt a hybrid model at your small community hospital, rural hospital, or critical access hospital.

1.     Cost effectiveness.

The price tag associated with running emergency and inpatient programs is typically cost prohibitive for smaller community hospitals. The patient volume in most smaller community hospitals doesn’t financially support two separate programs. The hybrid approach offers a lower cost solution than two programs while also improving admit/ transfer ratios.

2.     Improved care continuity.

In the hybrid ED and hospitalist management model, one physician cares for a single patient as they transition from emergency care to inpatient care. This eliminates the risks often associated with transitions of care, including: communication breakdowns, unnecessary readmissions, poor patient experience, and more. The hybrid model allows you to implement standardized clinical pathways and order sets that transition seamlessly from the ED to inpatient care so the patient has a positive, consistent experience.

3.     Added inpatient care delivery stability and consistency.  

Traditional ED and hospitalist programs can have difficultly aligning performance and patient experience. Additionally, the two common alternatives to two separate programs—rounding by community physicians and reliance on locum tenens providers—make it difficult to ensure consistent, reliable care. A community physician’s primary commitment is to his/her outpatient clinic patients, so rounding often happens outside of clinic office hours. This results in delays to inpatient codes, patient status changes, order clarification and/or changes, and consultations, which increases length of stay. By implementing a dedicated provider or provider team that is committed to both ED and inpatient care, unassigned admissions are reduced because all patients are admitted by the same service line.

A hybrid emergency and hospitalist program is a great alternative to two, high-cost separate programs, relying on community physicians to accommodate rounding in their already-busy schedules, or calling in locum tenens physicians who are not invested in the community to provide inpatient care. The hybrid program adds more continuity to your patient’s experience, shortens length of stay, increases efficiency of the admissions process, and improves admit/transfer ratios, ultimately improving hospital performance overall.