John Nelson writes…
I think the medical system should find a way for some patients who “self-present” to the hospital, to safely bypass the ED and get admitted directly to the hospital.
This isn’t an idea that is ready for implementation on a large scale, and some might even say it is bad idea and not worth spending time on. But I think it is worth thinking about for a minute.
One of the questions patients/families ask of me most often is whether they can bypass the ED if they get sick and require readmission. I try to be as understanding as I can, but typically tell them that no, they will need to start off in the ED again if they have to return. I tell them that I understand why they’d like to skip this step, but that it is necessary to ensure that a doctor sees them quickly and determines the best things to do initially. Bypassing the ED would mean things would probably happen more slowly potentially reducing the chance of the best outcome for the patient.
I wonder when that will change. Which will be the first hospital to institute a system in which the triage nurse in the ED can use a set of criteria to identify some patients who would go straight to a hospitalist and bypass the ED doctor? Would this be a good thing? Maybe such a system is worth thinking about if the criteria for deciding which patients can bypass the ED are narrow enough that both the really sick and not so sick patients (likely to be sent home without hospitalization) are kept in the ED and treated first by the ED doctor. But maybe a frail elderly patient who was “found down” and has an altered mental status and fever (but reasonable vital signs and O2 sat) could go straight to the hospitalist.
Of course there are a lot of reasons that system of patients going straight from ED triage to the hospitalist might not be a good idea. Even if we had robust research to define the set of patients who might be appropriately managed this way, we would still have to come up with a system that can produce a hospitalist as quickly as an ED doctor, and get ED turnaround time on labs and X-rays. And after just a few hours in the hospital it will become clear that some of these carefully selected patients shouldn’t have been admitted and can go home after all. And it will be tougher to get patients and families to accept this if they’re upstairs on the medical ward instead of still waiting in the ED. And some patients will need to transfer to the ICU only hours after arrival in a “floor” bed.
Concerns like these may mean it is just unrealistic to conceive of a protocol allowing some patients to bypass the ED, or at least the ED doctor. Sure there are costs and risks to such a system. But aren’t there also risks and costs to the current practice of having most or all hospitalist admission seen first by the ED doctor? It is easy to accept the current system as the only reasonable option and accept or ignore its costs. When it is pretty clear to everyone that admission is the next step isn’t there something we can do to address patient’s unhappiness with having to stop in the ED? And can’t we spare some patients the risk incurred by an ED doctor to hospitalist handoff, and reduce the sometimes unnecessarily broad workup and testing done in the ED? (I’m thinking of an emergent head CT in a demented patient who presents with fever and altered mental status. If there is an obvious source of infection such as a UTI, the head CT is really low yield. And did that patient really need the D-dimer and BNP ordered by the ED doctor?)
You may have seen Eric Howell’s article describing a system of involving hospitalists much earlier in the ED stay that got a lot of attention last year. I’m just raising the possibility of continuing to involve the admitting hospitalist ever earlier after the patient arrives in the ED.
I’ve tried to stir up a little controversy here and I’d love to hear your thoughts about this. I think most hospitalists and other doctors are likely to dismiss the idea as a non-starter, but maybe there are a few people who agree with me that it is worth thinking about.