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New policy clarifies decision making on admission of Emergency Department patients

TStanford Hospital has established a new policy that describes the procedure to follow when there is disagreement over which service should admit a patient from the Emergency Department. The policy, which states that such questions should be resolved at the attending physician level, is meant to ensure that patients are treated by the most appropriate service, said Robert Norris, chief of Emergency Medicine. It is also intended to reduce delays in getting patients in and out of the Emergency Department.

Norris explained that disagreements sometimes arise over patients with multiple health problems who come to the ED following an injury-for example, an elderly woman with diabetes and emphysema who falls and breaks her hip. In the past, such patients may have been admitted to the medical service because of concerns about their various medical conditions.

In recent months, however, that service has found itself overloaded with patients, and its staff are sometimes unable to attend to all of their patients as promptly as they'd like, Norris said. Given this situation, careful consideration is needed to ensure that patients from the ED are admitted to the clinical service that can best respond to their presenting problem. The elderly woman cited above, for example, should be admitted to orthopedics in most cases, Norris explained. Similarly, a diabetic patient who presents to the ED with a foot ulcer would be admitted to vascular surgery.

"The key point is that we want the admitting decisions to be based on the patient's presenting problem," Norris said. "We need to ask ourselves, 'Whose scope of practice does this problem come under?'"

Norris pointed out that all of the hospital's clinical services are equipped to provide pain management for fractures and other injuries. He noted that if concerns arise over the management of medical conditions unrelated to the patient's presenting problem, consultations from the Department of Medicine are available on the patient units around the clock.

When there is disagreement over which service should admit a given patient, the new ED dispute-resolution policy emphasizes that "we need to get the issue taken care of at an attending-to-attending level as quickly as possible so residents' time is not taken up with this administrative function,"

Norris said. Norris said efforts are under way to inform the ED staff - and physicians in other key services such as medicine, general surgery and orthopedic surgery - about what clinical services are most appropriate for the problems most commonly seen in the ED. Emergency Medicine is working with the Department of Medicine to develop a reference list along these lines.

Under a new policy approved last month, the following procedure will be used to determine which service will admit patients from the Emergency Department:

The ED attending physician decides which service he/she feels is most appropriate for the patient requiring admission.
The designated service resident or fellow evaluates the patient in the ED. -- If the consulting resident or fellow feels the patient is not appropriate for the designated service, the resident will discuss the case with his/her attending physician.
If the specialty attending physician agrees that the patient should not be admitted to their service, he/she will discuss the situation directly with the ED attending.
If, after discussing the case with the ED attending, the consulting attending physician still declines to accept the patient, the specialty attending physician will come to the ED within 30 minutes to personally evaluate the patient.
If resolution remains elusive, the ED attending will contact the ED administrator on call, who will discuss the situation with the chief of staff.
In situations where two apparently appropriate services disagree over who should accept the case, the two consulting attending physicians will try to arrive at a solution. If the issue remains unresolved, both specialty attendings will come to the ED to evaluate the patient within 30 minutes.
The one exception to this policy is that if the ED is on "prevent" mode and is approaching the need to go on diversion, patients will be admitted to the most appropriate service as determined by the ED attending physician. Time will not be spent waiting for the receiving service to evaluate the patient in the ED.

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Questions or comments about this policy can be directed to Robert Norris at Bob.Norris@stanford.edu or (650) 725-9445.