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Admission Service Assignments for ED Patients (pdf)

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Whose patient is this?

by: LAWRENCE M. SHUER

Most physicians are familiar with the Great Emergency Department Standoff - even if their experience with this phenomenon is based solely on a frustrated patient's retelling or the experience of a family member.

Here's how it works:

A patient comes to the ED with one of myriad conditions, is stabilized, and then is sent to an inpatient unit. But which unit? And which service? While sometimes this is a no brainer, there are often nuances (some not so subtle) that mitigate for or against sending a patient to a particular service and inpatient unit. Often the decision is impacted by bed availability. And typically the admission is complicated and often delayed because the admitting physician or resident in the receiving unit must drop his or her patients, and come to the ED to complete paperwork.

Meanwhile, the patient waits for a hospital bed in perhaps the world's most costly patient waiting room - the hospital's Emergency Department.

I'm now glad to report that since Dec. 21, we have implemented a protocol, passed by the Medical Board, that should end or at least reduce delays and send stable patients to the appropriate hospital bed quickly - with minimal paperwork hassles to be faced by ED staff and admitting physicians.

Patient comfort and physician convenience are both good reasons for implementing this new protocol. Also, as most of you know, the closing of San Jose Medical Center's Trauma Center is expected to tax our ED capabilities, and this protocol will help ensure that patients receive the services they need - when and where they need it.

Here's how our expedited admissions of stable Emergency Department Patients protocol works:

1. The ED attending or senior Emergency Medicine (EM) resident determines that a patient requires admission and is stable for transfer to an inpatient unit.

2. The ED physician will discuss the case with the admitting attending (or the admitting resident for university service patients).

3. The ED and receiving physicians will agree upon "admission holding orders" (i.e. vital sign frequency, IV's, diet, activity, etc.).

4. The ED physicians will fill out the holding orders.

5. The admitting attending will advise the ED team whether or not an admitting house officer will be involved in the care of the patient. If so, the ED team will page the admitting house officer to review the "admission holding orders."

6. The ED unit secretary will enter the orders into POE, our electronic medical records base, as a written order.

7. From the time the orders are input by the ED Unit Secretary until the time the bed is ready, the admitting team is welcome to evaluate the patient in the ED. This process usually takes 30 to 60 minutes.

8. Once the bed is ready the patient will be transferred immediately to the designated unit for further evaluation and therapy and the admitting house officer or attending will be notified by pager once the patient arrives.

This protocol eliminates the need for the admitting physician to come to the ED to write admission orders. This will not only allow the admitting doctor to use his or her time more efficiently, but it will enable stable patients to be admitted sooner. Therefore, we will be able to utilize beds more efficiently and help deal with the anticipated increased volume of trauma patients.

Making this protocol work has required a lot of thoughtful effort on the part of the ED staff and service chiefs to overcome a traditional stumbling block: Which service will admit the patient? I'm happy to report that the various service chiefs have matched diagnostic conditions with appropriate specialties to produce guidelines that will direct patients to the appropriate bed. (Obviously, this policy cannot and should not replace attending-to-attending level discussions for difficult or complicated cases.)

Included with this column is a chart identifying the admitting service by the primary diagnosis that will serve as the basis for admission:

[ SEE TABLE/CHART ]

I'm mindful that the creation of this protocol required a lot of hard work, and I especially wish to thank the physicians who have worked so diligently on this project. These include Christopher Sharp of the medical service; Bob Norris, director of emergency services; and emergency medicine faculty member S. V. Mahadevan. I appreciate the legwork, wisdom and time consuming effort required of these three physicians to consult with various service chiefs to determine where patients with predetermined diagnostic conditions should be admitted.

I'm also grateful to a wide team of physicians, nurses and others for being able to identify that technology and modernized systems have made possible a change in protocol that even a few years ago would have been unthinkable. Crucial to this process is our ability to access orders and key patient data at several locations using our hospital data systems. Since critical patient information is available in the ED and on the receiving unit seamlessly, physicians and nurses are no longer tethered to a single paper chart.

Since last month patients have been admitted to medicine, cardiology, neurology, trauma and orthopedics under the protocol. Reports from the ED and the nursing service indicate that the process is working well.

I recognize that implementing this protocol like most changes requires a change in habit and practice for many of us. But it's healthy for us to keep in mind that 21st century communications tools and more effective methods to stabilize our patients have allowed us to take a fresh look at what we do every day.

To ensure safety, comfort and success, I have asked the administration to help us monitor this process to ensure that patient workups will be processed appropriately as patients move from one location to another on an altered but more expeditious timetable.

This process, I'm gratified to report, is one step further away from the old model which asked, "Who is in charge of this patient?" This latest reengineering is an excellent example of patient-centric medical care, since we are looking at "What does the patient need and who needs to do it?" And we are empowered by our understanding and ability to embrace the communication and data tools that now make reengineering of this sort not only possible, but better medicine as well.

We'll be doing more thinking like this - and taking action - in the future. I'm looking forward to telling you about innovative improvements.

(lshuer@stanford.edu)