Published in the April 2016 issue of Today’s Hospitalist
YES, WE ALL SPENT TIME in the emergency department when we were in training. But now that some of us work in different specialties, our job and that of ED doctors are pretty different. Hospitalists like to know everything possible about a patient who is sick enough to be admitted. But in the ED, once a decision has been made and the most pressing needs met, the ED doc needs to move on to the next case.
We each do a lot of sniping at each other, but that’s not the answer. You already know what you wish “the guys down there” would do differently, but let’s look at their side of things and maybe we can work together a little better.
“Just send him home with an NSAID
”
No matter how many times you’ve admitted that patient (or other 20-somethings with sore ribs), today is a new day, and you haven’t evaluated this patient in person. If you want this patient discharged, you will almost always have to see him in the ED and write the discharge order yourself, along with any prescriptions or instructions. The legal and ethical responsibility belongs to the doctor who signs the discharge order.
There are no clear rules about when the patient becomes the admitting doctor’s responsibility.
One exception is when you have information that wasn’t available to the ED doctor, such as the result of a recent normal stress test or heart cath in a chest pain patient or (as happened at one Houston hospital) the pathology report of normal ovaries removed last year from somebody who claims to have ovarian cancer. Even then: Be sure to provide a copy of the report to the ED (and that fax number should be on everyone’s contact list), both to protect the ED doctor and to avoid future unnecessary hospital days.
“I’ll see her when she gets to the floor”
Some admitting physicians see no reason to see their patients in the ED. Maybe it’s too far from their group’s assigned floor, or they don’t like talking to new nurses. This is OK as long as patients move quickly from the ED to med-surg or the ICU. But if the beds are full or shift changes are causing delays, it’s time to rethink that policy.
I’m writing this during flu season, when most hospitals are telling freestanding emergency centers to wait an hour and we might have a place for your admission.” The several large hospitals within Houston’s Texas Medical Center should have plenty of beds— but shortages happen and lead to “ED boarding,” which can last from a couple of hours to a day or two.
A busy hospitalist may heave a sigh of relief, thinking that the ED will just take care of things until the patient moves upstairs. But not so fast, doc. There are several good reasons why you need to see that patient as soon as you have taken care of more urgent problems.
First, the ED doctor did only as much of an exam and testing as she needed to decide whether to admit or discharge the patient. The physical exam may have covered only the area of the present illness, with no attention to older problems. “Continue home meds” may not be appropriate any more, and chronic problems may have changed enough to require new testing.
Second, there are no clear rules about when the patient becomes the admitting doctor’s responsibility. If the case ends up in court, you and the ED doctor may get equal billing in the lawsuit, and many states have passed laws making it harder to get a judgment against emergency providers. If you have accepted the patient, at least make an appearance and tell the nurse how to reach you. Check the holding orders—if the ED doctor had time to write any—and let the patient and family know who you are.
Delays in the ED can range from brief waits for the nurse to call report (often until after shift change) to a couple of days while the hospital is on ICU drive-by. Some busy urban EDs may have a line of stretchers in the hallway, which is a violation of a half dozen regulations, but turning patients away is illegal too. You may have to resign yourself to occasionally treating the ED as an extra med-surg floor or ICU.
Nurses with attitude
Perhaps the strongest reason to see your patient early is ED nurses. In a busy ED, they will see as many critical patients as you do, maybe more, and if the nurse asks why a patient isn’t going to the ICU, you had better re-consider the admission.
It’s nurses who take down the patient’s medication list and medical and surgical history, and often will notice things like skin lesions that somebody focusing on the heart and lungs may overlook.
They are also more attuned to social issues and will describe them, usually bluntly: “Patient’s husband is a control freak and a nut job. You might want to have the social worker talk to her about domestic abuse.”
And if the patient is a frequent visitor, you may hear things that the patient and/or family won’t tell you, such as which narcotics work best and why the prescriptions weren’t filled last month.
“Call pulmonary and write some
holding orders, OK?”
Let’s suppose that things are quiet enough to allow the ED doctor to complete such tasks. But is that really a good idea?
Odds are that the nurse or unit secretary will make that phone call, although neither of them knows what services you expect from Dr. Pulmonary. The consultant may look at the message transmitted through his secretary, assume it’s something nonurgent and delay seeing the patient even longer than you. And holding orders are likely to be limited to: “Admit to floor, continue home meds, further orders per hospitalist.”
Hospital service chiefs have been trying for decades to get doctors to call consultants themselves and make it clear why they’re needed. A patient sick enough to require emergency admission is a good reason to do so because bad things can happen while a secretary looks up Dr. Consultant’s office number and persuades the answering service to page her.
As for orders, that new computer system will let you get the patient’s evaluation and treatment started even before you arrive. If the ED’s electronic system isn’t connected to the rest of the hospital, it should be soon. If not, that’s a topic you should discuss with whoever is in charge of EHR upgrades.
One thing the ED can help with is phone numbers. The smart doctors, nurses and secretaries keep a private file of cell phone and answering service numbers, which can make all the difference between the nephrologist helping you with that hyponatremia tonight or ambling by tomorrow after he finishes making rounds in the ICU. If you’re new to the hospital, the ED can also tell you which neurosurgeon will come right away to see an intracranial bleed and which one will send his physician assistant.
Where the ED shines
Other specialties tend to look down on ED doctors as generalists whose medical knowledge isn’t very deep. They don’t know much about the latest heart medications, they don’t suture as well as the surgeons and they have to look up stuff that is second nature to a hospital pediatrician.
But that ED doc can also save you from having to call a surgeon to drain a superficial abscess because she’ll have drained it before you arrive. If meningitis is a possibility, the spinal fluid results will be on the chart or EHR by the time she calls you.
As for the ED nurses (again): Talking to them on the phone may buy you time to see that sick ICU patient before hurrying down. The nurses are used to handling all kinds of crises, and they will have a very good idea of whether the patient needs urgent evaluation or can wait a while. The better they know you, the more likely they will be to offer comments and information.
You can’t always count on the floor nurses to page you the minute the patient arrives. A new patient means at least a half hour of evaluation and paperwork (or the EHR equivalent), and nowadays, patient satisfaction scores get a higher priority than notifying you, particularly when there’s already a set of orders that needs to be dealt with. Your chat with the ED nurse allows you to make sure that those orders include items that need to be handled first.
The bottom line
We often accept transfer patients from other doctors with little more than a brief description of their problems. But those patients come with written records of previous events and evaluations.
Our patients coming through the ED usually arrive with less than complete records and evaluations. We owe it to them and to our colleagues to make the most of the help that ED doctors and nurses can give—and to start doing our own job as soon as possible.
Stella J. Fitzgibbons, MD, has been a hospitalist since 2002, but before that she completed a fellowship in emergency medicine. She still takes shifts in local EDs.
