If I decide that a patient does not meet the criteria for admission, who is then responsible for the discharge of that patient from the ED? The hospitalist usually dictates a consult and recommendation, and even sets up appropriate follow-up. However, since the patient was already given to me to admit, should ED docs discharge the patient or should I?

—Bharathi Upendran Thuraisamy, MD

Dr. Hospitalist responds:

This question is one that we confront frequently in our line of work. To me, there are three basic categories of admission:

1. The case that clearly needs admission. No need for extensive discussion there.
2. The case that can go home, but the ED is calling you just to “make sure” or ask for a quick piece of information. Now, this can get a bit tricky, but you should be able to judge it by the length of the phone call. Less than a minute? OK, sounds like you’re in agreement, and the ED doctor can take it from there.
3. The third category, which is described in your question, is when the ED says: “I have an admission for you,” and your reaction after hearing the presentation is, “Boy, that sure doesn’t sound like an admission to me.”

As a rule of thumb, if the ED physician describes it as an admission, then the onus will be on you to work up the patient and decide on the management plan. Generally, when the ED doctor thinks that a patient warrants admission, then, in their mind, the case then belongs to you, not them. This is consistent with the recent American College of Emergency Physicians’ position that ED doctors will no longer write admission orders.

At this point, if the ED doc thinks the patient needs to come in, then, as you describe, you’ll need to do an evaluation, dictate a consult, and decide on the disposition. Since the ED is technically an outpatient setting, you’ll need to bill your professional services accordingly, using CPT codes 99281-99288.

When it comes to the physical act of discharging a patient, I would use the discharge forms already present in your ED. In addition, I would make it a point to communicate directly with the nurse caring for the patient. My standard explanation would go something like this: “Dr. ED asked me to evaluate this patient. I saw them and told them that they could go home with appropriate follow-up. I’ve written/dictated a note and filled out the paperwork. Is there anything else that I need to do?”

More or less, I try to make it as easy for the nurse and the patient as possible. Please note that I did not include the ED doctor in that statement. It’s not that I don’t want you to be nice to them, but, depending on the physician, you can end up enabling their behavior, and pretty soon they’ll call you with every patient that might need admission. My favorite example was an older ED physician at a small community hospital who once called me to admit a patient. All he said was, “I’ve got a 67-year-old lady with abdominal pain.”

That’s it. He had not examined the patient, nor done any labs or studies. My mistake was just being available. Now, I know that’s what we do as hospitalists, but there’s a line between being helpful and getting worked over. So help when you can, and do it with a smile. But be firm.