Posted by: notdeaddinosaur | March 15, 2013

Direct Admission; What’s That?

I’m so glad I was able to generate so much traffic for The Health Care Blog (with this post), where I am currently being eviscerated for hating on PAs. Clearly, all of the hullabaloo is from folks who have never read any of my other posts. In the six and a half years I’ve been blogging, I’ve also ragged on nurse practitioners, radiologists, podiatrists, cardiologists, orthopedists…I could go on and on (I really have been doing this for a long time.)

At any rate:

The post in question was about a patient with a rapidly progressing infected cat bite on the hand who needed to be admitted for IV antibiotics who was “sent to the ER.” A valid criticism of my (administrative) handling of the case was that because the diagnosis and plan were already known, the patient should have been admitted directly to the hospital instead of going through the ER.

Good point. And in the good old days of outpatient family docs routinely admitting and caring for hospital patients (before we got elbowed out by hospitalists and decreasing payments) that’s exactly what I would have done. Things have changed, though.

Ceding inpatient care to a generally competent cadre of physicians took some getting used to. And like most other hospital based groups, they pride themselves on “communication” and “customer service” to the referral base (that would be me and my outpatient colleagues). I have laminated cards from each local hospital listing phone numbers for getting in touch with them with any questions or concerns about my patients in the hospital. But what about admitting them directly?

Turns out that on paper, there is a mechanism for doing so. Granted it involves two phone calls to different places followed by callbacks from each before being able to tell the patient (sick and/or in pain) where to go. Because it’s been so long since I’ve had occasion to do this, I ran this by the chief hospitalist when I happened to run into him the other day. His response:

Better just to send them to the ER.

Further rationales quoted included ease of getting labs, starting IVs, and (of course) the billing.

No problem. I send the patient to the ER to be admitted. Does that mean they can bypass triage?

Oh no. Everyone who walks into the ER needs to go through Triage, where they will be asked if they feel safe at home (thank you, requirements for universal domestic violence screening) after waiting in line behind everyone else who didn’t come in on an ambulance.

If I call ahead and arrange everything with the hospitalist, does my patient still need to be seen by the ER doc?

Welll…They like to eyeball them just to make sure they’re stable.

Great.

So apparently the ER has now become the de facto Admissions Department for anything other than pre-registered elective surgery (more and more of which is being done at free-standing surgicenters; I wonder why?) Talk about mission creep.

Here’s a thought: They’ve already added Fast Track many places to punch through some of the bottlenecks. How about reserving a bed or two for “direct admits” coming through the ER. Give them (the admitting physician, that is) all the conveniences of the ER (nursing assistance, stat labs, etc.) without technically calling it an ER visit.

Because for better or worse, it looks like there is no longer any such thing as a Direct Admission.

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Responses

  1. Direct admission, bypassing the ER, means there can be no charge added for the ER.

  2. They like to eyeball them to be sure they can bill for a level 4 , more likely. At our hospital we wind up waiting half a day for somebody just to give us a bed. Usually if the patient is not unstable and they live close we have them wait at home.

  3. No direct admissions?
    I directly admitted a patient from my outreach clinic two hours away just two days ago. Friday. Of course, I bothered to call the accepting doctor and talk it over with her (something you didn’t do) . Also, I have bothered to get to know inpatient doctors and visa versa. They trust me when I call with an issue by and large. Do you?
    Lets get to the crux of the matter having read the healthcare blog. The big issue was not the PA, but rather lack of coordination of care which falls squarely on YOUR shoulders. YOU knew the story. I call ER’s all the time when my patients are being directed in to the ER. This includes ERs, on patients on vacation or snow birding? Why, because I know the story and the ER doesn’t. You made a comment about “only getting triage RN’s”. yeah i get triage people who are clueless and dont give a shit. NEWSFLASH…. Insist on actually speaking to the providers. The jaded and imappropriately arrogant nurse k’s of the world will not be the one making the final decision, the provider will be. YOU didn’t tell the ER the story of your care for your patient, don’t go blaming it on a PA for your dereliction of duty.
    As a former hospitalist, I wouldn’t have thought twice admitting a patient in the setting you have described ( can anybody say pasteurella multocida), with one caveat, if I don’t know you as a doc, I may have the patient go through the ER. Why, because I have been burned too many times by docs who have stretched the truth or outright lied for patient convenience to get a floor bed. This aint McDonalds. A septic/critically ill patient showing up on the floor as a direct admit is not a good thing. Are you that far removed from inpatient medicine to understand this? My own worst anecdote, is a PNA patient whom the referring doc stated was on nasal cannula, she neglected to add on the NRB (patient had both). I immediately intubated with BLS watching ( the patient left the rural hospital with a cannula/NRB combo, totally fucked up). My mantra from my hospitalist days became if I don’t know you, I don’t trust you, because of multiple direct admissions like this.
    My suggestion to you is as follows:
    1) you have a patient you are referring to the ER and worried about. CALL THE DAMN ER. Insist to speak to the provider, not the dont give a damn nurse k’s of the world.
    2) bother to get to know the inpatient docs. I regularly took direct admissions if patient was clinically stable and I knew/ trusted the doc/NP/PA on the other end of the line. (Yes I know the patient went to a hospital you were less familiar with, but the point is you didn’t even try).
    3) start treating other healthcare providers with a little respect. As repeatedly pointed out by the heathcare blog comment line, your own role was far, far from impressive. Healthcare is a team. You might fancy yourself as captain of the ship, but the ship isn’t going anywhere without the engine room or for that matter the person untying the lines. Over the years I have had docs/RN’s/NP’s/PA’s pull my patient’s bacon out of the fire, more times than I can count. I guess that’s the difference between you and me, I don’t get my rocks off breaking out the retroscope and shitting on others trying to help my patients, certainly not when my captain skills left a lot to be desired.

  4. Please allow me to explain why as a triage nurse, I really don’t care about 90% of doctor’s calls. Usually they go something like this: MD “I’m sending over a patient for rule out MI and I want them to be seen right away” Me: how are they getting here? MD: the patient’s wife is driving him over right now.” Me: “really?” MD “yes – I think he’s safe to go by car and he’ll need a CBC, Chem panel, troponin and CXR. and he has a hx of blah blah blah” FYI – I pretty much tuned out as soon as you said he’s coming by car. If you’re that worried about an MI, you’d call an ambulance. And don’t bother telling me all the labs you think need ordering. You’re not ordering them by calling me. The ER MD still has to see the patient and s/he will order what s/he wants which is very likely exactly what you want – so don’t even bother with that. And don’t tell the patient you called so that we would see them right away. We still have to balance your patient’s acuity against everyone else’s. Ideal call: “I’m sending you a patient X who I’m concerned has Y – what is your fax #? I’ll fax all the pertinent info.” If your patient has something weird, that is not immediately obvious that your patient cannot tell me himself then throw that in too otherwise keep it very brief – we’re busy out there! For your cat-bite cellulitis guy – stressing that it was spreading very rapidly would have helped but talking to the doc is best.

  5. Nurse k:
    Thanks for making my point. Your example of a “r/o mi” is among the most protocol driven diagnosis in medicine and you know it. Obviously the ER is better suited to acutely manage that particular acute diagnosis. The patient is either getting whisked off to the cath lab in the hour or being medically managed. It’s frankly a very poor example compared with dino’s example and you said I yourself “it would of helped but talking to the doc is best”
    To give you examples of my specialty, do you really want to hear the fine points of TTP or acute toxicities of the newer targeted chemotherapies and immunotherapies? I didn’t think so, and frankly believe it or not I to am busy (yes Virginia, despite what you think people see docs outside the ER) and have no interest in repeating myself to the person actually taking care of the person in the ER. Hence, I always insist on bypassing you. It is a waste of my and your time. My statements stands. Dino should have called the provider and quit offering lame excuses including throwing the PA under the bus.


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