There is a growing movement towards embedding hospitalists in the emergency room to improve efficiency in the transitions of care. I think great things come from collaboration, but after working very closely with our hospitalist team over the years and trying to balance what they want and need with what we want and need, I have concluded that emergency physicians (EPs) can actually enable hospitalists to spend their time more efficiently on the inpatient floor and not the ED.
In working with our hospitalist leaders on a variety of projects, from bridging orders to sepsis care, the key ingredient that seems to be missing again and again is trust. The EP lacks trust that the hospitalist will assume care of the patient in a timely manner, and the hospitalist lacks trust that the EP has done an appropriately thorough workup and arrived at an appropriate disposition decision.
The concept of the “right stuff” came to me as I was meeting with our hospitalist team to discuss these issues. Together we asked the questions: “If you were my most important customer, what would I be willing to do for you?” and, “If I were your most important customer, what would you be willing to do for me?” From here, we began to hone in on what each group wanted from the other. The result is a list of commitments that can be agreed upon by both groups beforehand in order to achieve a result we both desire, and, most importantly, provide safe and efficient care for our patients.
Our team came up with a set of principles that commits the ED to doing “the right stuff.” We recognized the perspectives that we in the ED have that are different from hospitalists. So we identified priorities to make sure the hospitalists’ and patients’ needs are met. These priorities are:
- Right work-up – Appropriate lab and imaging to arrive at appropriate disposition and destination decision.
- Right diagnosis – No surprises when they see the patient.
- Right disposition – We get on the same page about criteria for outpatient, observation, and inpatient.
- Right destination – We become knowledgeable about capabilities of floors and units.
- Right timing – We refrain from “bolusing” admissions at the end of our shifts; sign out pending work-ups to our partners in the ED, not the hospitalist.
- Right communication – We commit to communicating the key information needed so the hospitalist can agree with disposition, diagnostic and destination decisions.
- Right treatment – We commit to agreeing beforehand on who does line placement, fluid resuscitation, antibiotics, etc.
This commitment to doing “the right stuff,” has the goal of moving us toward an atmosphere of trust and mutual confidence. If the hospitalist and the EP are confident after a telephone discussion about a given patient that he or she will be seen promptly upon floor arrival and that he or she will be “as described” upon arrival, ED operational efficiency is greatly enhanced. Most importantly, the efficiency, quality and perception of care by the patient increase dramatically. By redefining our focus, we can ensure that collaboration between the two groups occurs at the administrative and strategic levels, and these priorities should be established based on such collaboration before the discussion of a specific patient takes place.
Our goal, beyond improving care for the patient, is to save time for the EP, the hospitalist, and the patient. With more time available, the EP can maximize throughput in the ED, the hospitalist can focus on his hospitalized patients and the patient can receive appropriate treatment without risky, anxious and painful wasted time.
Currently, at most facilities, a hospitalist order is needed for a bed request. The hospitalist who comes to evaluate a patient in the ED usually is expected to respond within 30 minutes. Add to that the additional 30-50 minutes the typical hospitalist spends evaluating, adding new orders and writing admission orders in the ED, and we are talking about at least one hour in the best of cases before the patient has orders and a bed. If an EP could start that request, in collaboration with the hospitalist over the phone, time would be saved for everyone.
An extremely useful tool in establishing “the right stuff” agreements between EPs and hospitalists is an Admission Status Worksheet (ASW), which presents criteria for hospital admission based on disease. Our partner, Sergio Hernandez, developed such a worksheet, along with accompanying educational modules, to help EPs and hospitalists get on the same page when it comes to “right work-up,” “right diagnosis,” “right disposition” and “right destination” for the bulk of our admitted patients. The EP’s decision is thereby more objective and less biased by the needs of the hospitalist to keep census at a manageable level or the needs of the EP to bump patients into the hospital to free up ED beds.
The ASW furthers the goal of “right workup” by spelling out the lab and ancillary studies needed to support disposition. It helps to establish the “right diagnosis.” And it facilitates “right communication” as part of a good case presentation and a clear picture of the patient for the hospitalist.
Another key element in operationalizing the “right stuff” is having regular meetings with the hospitalists, which focus on tracking performance of well-chosen metrics. This allows for real work to be done at these meetings on the issues that are leading to failures. Once identified, we can work to perfect our systems and approach. With good planning, good communication at the strategic level and the delivery of the right stuff, we EPs can do our part to allow us to practice emergency medicine while letting hospitalists function as hospitalists.