winterallsummer Posted February 26, 2016 Share Posted February 26, 2016 At your ER, what is your protocol for calling consultants during day time on patients admitted to medicine? Do you call them yourself always? Only for emergent procedure (eg surgery or emergent EGD)? Never and let hospitalist do it? Link to comment Share on other sites More sharing options...
dmdpac Posted February 26, 2016 Share Posted February 26, 2016 If I'm trying to get them admitted to medicine and want to let the consultant know in advance I'll call them directly during the day. (This is sometimes necessary as we have two hospitalist groups. One is reasonable and will take patients without much pushback. The other service, however, will fight tooth and nail with you to not have to admit a patient. If I know I will have to call this particular hospitalist group it can help to say that I've already spoken with the consultant in question and s/he is expecting that the patient will be admitted.) Once they're actually admitted to medicine it's up to the hospitalist to call. Link to comment Share on other sites More sharing options...
Evolute Posted February 27, 2016 Share Posted February 27, 2016 My situation is a bit different in that I work in rural med. So I am the ED provider as well as the hospitalist. Which works well if I admit a pt to "my" hospital. If I am wanting to transfer a pt that I feel needs a higher level of care, including specialists (cards, GI, pulm, ortho etc). I call the specialist first then call the admitting hospitalist at which ever hospital. I do this for a number of reasons; first I think its good pt care to involve the specialist early, second if the given specialist will not agree to consult, the hospitalist will be stuck, which may result in another pt transfer. Again not good medicine IMHO. Lastly, I can tell the hospitalist that I have spoken with the specialist and he/she agrees to consult. Once I have an accepting and the pt is admitted to said hospital its up to the hospitalist to contact the specialists. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 28, 2016 Moderator Share Posted February 28, 2016 Unless the specialist agrees to consult and the hospitalist refuses the pt....happened to me last weekend. pregnant lady with pyelo and kidney stone. called urology. they are fine with consulting if ob admits and manages. ob says pt too sick for their facility. next facility says pt not sick enough for transfer to tertiary care ctr...total clutser. worked out at 3rd facility 6 hrs later.... Link to comment Share on other sites More sharing options...
Boatswain2PA Posted February 28, 2016 Share Posted February 28, 2016 EMTALA violation for 2nd facility.... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 28, 2016 Moderator Share Posted February 28, 2016 EMTALA violation for 2nd facility.... they had some BS about having to keep beds for sicker pts and recommended facility #3 where pt eventually went.... Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted February 28, 2016 Administrator Share Posted February 28, 2016 EMTALA violation for 2nd facility.... Nope. Patient hadn't presented to 2nd facility. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 28, 2016 Moderator Share Posted February 28, 2016 Nope. Patient hadn't presented to 2nd facility. there is some criteria for refusing reasonable transfers if you have bed space and a needed specialty as well. Link to comment Share on other sites More sharing options...
Evolute Posted February 28, 2016 Share Posted February 28, 2016 Unless the specialist agrees to consult and the hospitalist refuses the pt....happened to me last weekend. pregnant lady with pyelo and kidney stone. called urology. they are fine with consulting if ob admits and manages. ob says pt too sick for their facility. next facility says pt not sick enough for transfer to tertiary care ctr...total clutser. worked out at 3rd facility 6 hrs later.... Never had this happen to me, but have had the specialist(s) refuse. Link to comment Share on other sites More sharing options...
Boatswain2PA Posted February 29, 2016 Share Posted February 29, 2016 Just had to do an hour and a half EMTALA training because someone at the level II center I part-time at screwed up. Receiving hospitals can't refuse a transfer that meets 2 criteria: #1: They have specialty coverage and availability, and #2: The receiving hospital is more capable to caring for that patient. If those two criteria are met, and the receiving hospital refuses, it's an EMTALA violation. I tucked that note away in my brain-box for future reference. Sometimes I get pushback from ICU guys at tertiary centers not wanting to accept people because "they shouldn't have been full code", or "they don't sound like their stable to me." No $hit they're not stable, they were dead 10 minutes ago, now they need an ICU, and I don't have one! Link to comment Share on other sites More sharing options...
Evolute Posted February 29, 2016 Share Posted February 29, 2016 Just had to do an hour and a half EMTALA training because someone at the level II center I part-time at screwed up. Receiving hospitals can't refuse a transfer that meets 2 criteria: #1: They have specialty coverage and availability, and #2: The receiving hospital is more capable to caring for that patient. If those two criteria are met, and the receiving hospital refuses, it's an EMTALA violation. I tucked that note away in my brain-box for future reference. Sometimes I get pushback from ICU guys at tertiary centers not wanting to accept people because "they shouldn't have been full code", or "they don't sound like their stable to me." No $hit they're not stable, they were dead 10 minutes ago, now they need an ICU, and I don't have one! That's what I thought, but wasn't certain. thanks for sharing. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted February 29, 2016 Administrator Share Posted February 29, 2016 Just had to do an hour and a half EMTALA training because someone at the level II center I part-time at screwed up. Receiving hospitals can't refuse a transfer that meets 2 criteria: #1: They have specialty coverage and availability, and #2: The receiving hospital is more capable to caring for that patient. If those two criteria are met, and the receiving hospital refuses, it's an EMTALA violation. I tucked that note away in my brain-box for future reference. Sometimes I get pushback from ICU guys at tertiary centers not wanting to accept people because "they shouldn't have been full code", or "they don't sound like their stable to me." No $hit they're not stable, they were dead 10 minutes ago, now they need an ICU, and I don't have one! Huh. I did not know that. Thanks! Link to comment Share on other sites More sharing options...
medic25 Posted February 29, 2016 Share Posted February 29, 2016 We typically only call the consultant if there is something that needs to get addressed urgently/emergently, or to give them right of first refusal prior to admitting to medicine (e.g. stable chest pain patient requiring admission; we might offer it to cardiology first, and if they decline we admit to hospitalist and have a cards consult). At our hospital, we have the advantage of never having to convince or sell the hospitalist on the admission; EM has the right to admit patients to any service in the hospital, and if we want to admit to medicine it's a simple as just putting in an order in the computer. In those cases we may just document in our note (read by the hospitalist) our recommendations for inpatient admission (example from tonight; diabetic foot infection admitted to medicine, with a note in our chart suggesting a consult from podiatry and vascular surgery). Ultimately it'll be the decision of the admitting team to figure out who they want to consult. Link to comment Share on other sites More sharing options...
winterallsummer Posted February 29, 2016 Author Share Posted February 29, 2016 Wow medic25 that is pretty surprising. I couldn't imagine that. From ER perspective is awesome but from hospitalist perspective seems you would get dumped on all the time. Yes a facility refusing a pt because they "need the beds for sicker pt" is an EMTALA violation. I'm not one to advocate writing people up but that would really piss me off and if they were written up I'm sure they'd learn their lesson. Link to comment Share on other sites More sharing options...
medic25 Posted February 29, 2016 Share Posted February 29, 2016 Wow medic25 that is pretty surprising. I couldn't imagine that. From ER perspective is awesome but from hospitalist perspective seems you would get dumped on all the time. As an EM provider, this is the ideal way to practice; we are the ones at the bedside, so I think we are the ones who should be making the call to admit or not. We try not to abuse it; having worked in ED's where I had to "sell" the admission this is vastly better for patient care and department flow. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 1, 2016 Moderator Share Posted March 1, 2016 the job I am trying to leave is a "sell the admission" kind of place... Link to comment Share on other sites More sharing options...
sk732 Posted March 1, 2016 Share Posted March 1, 2016 I hate having to sell admissions - which is the vast majority of the time. It gets even worse when we have no beds and have to send to the peripheral facilities where if the person has an infected hangnail, the accepting doc and or the nursing staff will try to balk...especially since that patient is often from one of those communities and is in my ER due to them not wanting to show up for work in their's. I'll stop now before the rant gets less polite. SK Link to comment Share on other sites More sharing options...
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