Background:
ER physicians tend to be risk averse. Out of fear for what cannot be determined in a short time and concerns over litigation, many ER doctors believe they are erring on the side of caution by admitting a patient. However, with growing concerns over in‐house medication errors, risk of iatrogenic events, and the danger of nosocomial infections, admitting a patient just to be on the safe side may not be all that safe. Further, with greater scrutiny by payers about the appropriateness of admissions and with limited bed availability an issue at many hospitals, hospitalist teams may be able to play a role in bridging appropriate outpatient care without admitting the patient.
Methods:
Our hospitalist program has dedicated case managers and a rotating, dedicated triage MD who sees patients in the ER when called for an admission. If after an evaluation, the hospitalist deems the patient to not require admission, the case is discussed with the referring ER physician and the patient, and the admission is declined. Our on‐call case manager is activated to arrange any follow‐up testing and appointments. The hospitalist dictates a medicine consultation and notifies the patient's PMD. A follow‐up call is placed to the patient within 48 hours to ensure clinical stability and compliance with the plan. The case is logged as an avoided unnecessary admission (AUA). All AUAs are tracked for a 7‐day period to identify ER revisits or eventual hospitalizations.
Results:
One hundred and seventy‐two AUAs (representing 7% of our patient volume) were logged in a 12‐month period, spanning a wide range of diagnoses and payer types. Nineteen patients (11%) returned to the ED for any reason within 7 days, including 9 (5%) who were subsequently admitted to the hospital. All 9 patients were appropriately treated by our hospitalist team and were safely discharged, with a raw ALOS of 5.7 days (ranging from 2 to 15 days).
Conclusions:
With increased time constraints and litigious pressure on ED physicians, hospitalist programs may be able to provide value‐added consultative services to help avoid unnecessary admissions. A team‐based approach with dedicated case managers is essential to coordinate with PMDs and provide necessary care and follow‐up. If this becomes a more widely adopted service by hospitalist programs, clear definitions and criteria need to be established. Careful attention must also be paid to the political sensitivity and liability exposure of questioning the necessity of a requested admission by an ER physician.
Author Disclosure:
B. Rosen, none; M. Sabnis, none.