In our August 2014 issue, a clinician comments on the “appalling” practice of “tuck-in” orders without seeing the patient. Dr. Barthel explains how her hospitalist group has asked for revision of bylaws to prevent such practices.
WE ARE NOW EXPERIENCING a major shift in how ED physicians communicate with the hospitalists.
When I was in training, the ED called the senior resident “who first asked questions and then called the intern. The intern then went to the ED to see the patient (and asked more questions, ordered more tests and eventually got around to getting the patient up to a medical floor). But the past decade has taught us that wait times and ED bottlenecks have a direct impact on hospital flow and length of stay.
To encourage faster flow through the ED, emergency physicians now get a bonus based on quality measures that include minimizing the amount of time patients spend in the ED. When ED doctors call to admit, they want us to help move the patient quickly.
If I were a patient sitting on an ED cart, I would rather be in a slightly more comfortable hospital bed and getting a bite to eat than sitting in the ED all night. Lately, though, the pressure to move patients upstairs has caused our communication “as well as tolerance and patience “to deteriorate. Our hospitalist group is beginning to feel like we don’t have “permission” to ask questions at all!
A rush to admit
Half of our group has been here since the program started in 2010, and we have gotten along well with our ED colleagues. We have had several new physicians and locum tenens helping out for the past year or so, and many of them prefer to get as much information as possible from the ED physician during the handoff.
Over the same 18 months, several new ED physicians have started right out of residency. Some basically want to give you the patient’s name and room number and let you figure out the rest.
Like in most hospitals, the ED doctors identify patients who may need to be admitted. But ultimately, it is up to a hospitalist to decide whether the patient needs inpatient treatment, observation care or discharge home with close outpatient follow-up. For some reason, despite the fact that we still see all these patients, the ED physicians seem to assume that if we ask a lot of questions, we are trying to get out of seeing the patient.
Unfortunately, some hospitalists oblige the ED by simply taking the patient’s name, having the ED send the patient to the floor with tuck-in orders and, usually, not seeing the patient until the next day. Because this works great for the ED, this has become the new standard. If the ED gets any sense that we are resisting an admission, they just call another hospitalist.
Unless we are so swamped that we cannot possibly get free, we have always tried to see patients in the ED before we transfer them upstairs. This allows us to start orders early and make sure we get the patient to the appropriate unit.
And of course, we perform our own chart review, history and physical exam and do not rely completely on what we get in the handoff. But it is still important for us to hear the ED physician’s impressions of the situation, what information family members might have shared before they left (which never makes its way into the chart), and what interventions already took place in the ED so we don’t duplicate medications and tests.
All of that takes on average less than five minutes. More importantly, this dialogue helps build confidence, rapport and trust between the ED doctors and the hospitalists.
A policy change
As the hospitalist program medical director, I meet regularly with the ED medical director, who is very collaborative, understanding and approachable. I’ve also discussed this issue with our CMO. While neither of them advocates for physicians not spending time on the handoff, I find that even their expectations are beginning to shift toward “less talk, more action.”
When hospitalists ask too many questions, they are seen as “grilling” the other physician. Perhaps it is difficult to appreciate how much good communication can help ensure a smooth transition of care unless you are the one accepting responsibility for the patient’s stay.
In response, I recently adjusted our program policy regarding ED admissions. Now, the expectation is that we go to the ED to see every patient.
It sends a message to the ED physicians: It’s not that we don’t want to see patients, but we do want to gather all the necessary data before making decisions about diagnosis, testing, treatment and disposition. In some cases, we have discharged patients from the ED after doing a “consultation,” setting them up with outpatient appointments. But we never refuse to see them.
The time we spend in the ED typically does not extend patients’ stay there because the hospital is simultaneously arranging a bed on the floor. Having our staff in the ED also allows for direct face-to-face communication between physicians. It takes time to do “and it interrupts the flow of our multidisciplinary rounds “but that is the trade-off for better communication.
A culture of safety
With all the talk about how we need to nurture a culture of safety, it’s hard to see how we can admit patients without physician-to-physician communication. We need to work in an environment where people can talk to each other, ask questions and offer suggestions without everyone feeling pressured to move his or her own agenda.
We need young physicians to know that this is precisely the communication that builds relationships among colleagues and makes the hospital a safer place. We need more established physicians to set the example and maintain the expectation that communication takes place before patient care is transferred.
And while we are at it, many of us could stand to improve the manner in which we communicate with nurses, care managers, secretaries, social workers, therapists and CNAs. Otherwise, they may be afraid to call any one of us when they are worried about a patient because the last time they called, someone yelled at them, or was obnoxious or rude. I don’t want to be a patient in that hospital.
We are all busy, and we all have a lot going on. But we need to reprioritize and make more time for the communication that ensures the safety of the hospital and its patients. This is just as important as the best clinical guideline or evidence-based protocol out there.
So to my ED colleagues: “Here’s my number. Call me maybe!”
Mary Frances Barthel, MD, is director of the Cogent Healthcare hospitalist program at Blessing Hospital in Quincy, Ill. Dr. Barthel has been a hospitalist since 2002.
