Directing Admitting Traffic
Published on Jul 08, 2015
A recent survey confirms that the emergency department (ED) remains the primary front door for most hospitalizations. And as more and more hospitalists are admitting these patients, the role of the admitting hospitalist continues to take on new shape to comply with medical necessity requirements and efficient patient flow. We haven't seen a single 'best practice' trend,' but most programs use a variation of an admitting hospitalist (AH) with some frequent features.
For example, the AH is generally a rotating position and typically carries a census half that of his or her peers. In large hospitals, the AH 'lives' in the ED or the Access Management area while in smaller hospitals, the AH is 'on call' for a possible admission. In many large hospitals with a dedicated admitting hospitalist, that individual may also provide EMTALA triage to confirm emergent cases and avoid having the patient cross the threshold into the ED treatment area.
Following discussions with the ED medical staff, the AH reviews the case and, together with the Access UR Specialist, determines whether the patient 's immediate needs require hospital level of care and whether that care is expected to exceed 2 midnights. Once an inpatient level of care is confirmed the UR specialist may coach documentation while the AH contacts the patient's PCP, assigns the patient to the hospitalist team and recommends the level of care needed: ICU, CCU, etal.
In many hospitals,we also see the AH working closely with Access Management team to manage direct admissions and transfers. A really good AH will guide the community attending to determine the need for a direct admission. The AH may be able to say "this chronic anemia patient sounds like he's doing fine so we can set him up for an outpatient transfusion or outpatient iron therapy. Here's how we can help arrange that for you." Admittedly, the Access Mgmt role is particularly challenging when the facility is a regional hospital accepting referrals from smaller hospitals in the area but the AH is best positioned to make sure that the transfer is appropriate for the patient and the organization.
The AH role can be very stressful because it includes a strong 'gatekeeping' component which is not generally well received - or understood - by many community based primary physicians. Hospitalists straight out of residency or whom have never spent time in an ambulatory setting are not always the best candidate for this role until they have more experience under their belt. But an experienced AH working collaboratively with the Access UR specialist gets to know the community attendings and is a valuable resource to the ED medical team and the Access team.