That said, most, or nearly all, hospitalists could shorten the time from when the ED pages on a new admission to when we appear in the ED to see the patient.
Here is one scenario that gives rise to the type of delay I’m talking about. The ED doctor pages a triage hospitalist, and the two finally speak directly 10 minutes later. After a five-minute conversation, the triage doctor pages the hospitalist who will actually admit the patient, waits 10 minutes for the return call, relays the information (possibly leaving out or misrepresenting some of what the ED doc said), and the admitting hospitalist heads to the ED 15 minutes later. Each person in this scenario acted reasonably promptly, but the clock starts with the first ED page. The hospitalist is already at 45 minutes when they arrive to see the patient!
You need to minimize “daisy chain” communication between the ED doctor and the hospitalist who will actually see the patient. In the scenario above, I think it would be best to eliminate the triage doctor entirely (see my December 2008 column for ideas about how to do this) so that the hospitalist who will actually admit the patient learns of the new referral quickly and speaks directly with the ED doctor.
Another reason for a poor “page from ED to hospitalist at patient’s bedside” time is that the admitting hospitalist just doesn’t make it a priority to get to the ED quickly. They might decide to round on two or three more patients before working on the new admission. Of course, we must triage and sometimes delay getting to the ED while attending to an unstable floor patient, but not too often, in my experience.
I’m not suggesting that others adopt my habit: I typically don’t call the ED back at all. Instead, I just head to the ED immediately after being paged, and usually arrive in less time than I would have spent on hold waiting for the ED doc to come to the phone.
When presented with several ED patients to admit at the same time or tied up with a critical patient on the floor, getting to the ED quickly isn’t possible.
Write Admission or “Holding” Orders and Move the Patient to His/Her Room
This is frustrating for the admitting hospitalist, because among other problems, families often leave when the patient moves to the inpatient ward, and additional tests likely will take longer to complete from the floor rather than ED. And while it is hard to quantify, I think this practice increases the risk of errors—though some studies have shown that long ED stays are associated with worse outcomes for the patient, too.
One of the marquee principles of ED medicine has historically been “ED doctors should never write admission orders.” Even so, I sense that this view is shifting, and many now see this as clinically reasonable, and in some cases necessary, to ensure good performance. Our ED docs have agreed to do this if there is concern that the hospitalist can’t finish writing orders within an hour of first being paged about the patient. Ask me in a year and I’ll let you know just how this is going.
And, of course, another option is for the admitting hospitalist to provide admission orders or “holding” orders by phone. I think this is safe for many patients, as long as it is followed by a bedside admission visit by the hospitalist before too long.
Next month: What about throughput at the discharge end of the hospital stay? And yes, improving throughput risks quality of care, yet we have to do it while maintaining or improving quality.