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.
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.