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Hospitalist Consults on Psychiatric Patients Concern Nurses


 

I am a psychiatric nurse and am concerned about the new group of hospitalists who are taking over all the new ED patients:

  1. Are signing off to the nursing staff or in the electronic health record (EHR); they do not speak with the attending psychiatrist;
  2. Are not monitoring their own medications, including Coumadin or insulin (from what some other nurses have reported);
  3. Require that, if we need to speak with one, we are to call the triage hospitalist, who typically says that they can’t do anything because they didn’t start the medication and they don’t know the patient.

Many of our patients are very ill, not only psychiatrically but also medically. We feel the hospital has placed us and the patients in jeopardy. Is this typical? Do other hospitalist groups manage their patients like the ones I have described?

–Sincerely,

Psych Nurse Caught in the Middle

Dr. Hospitalist responds:

Dr. Hospitalist

amane kaneko

Since you mention that the “new group” of hospitalists is caring for “all the new ED patients,” I’m assuming the patients are being assigned to the hospitalist group because they are unassigned and either don’t have a primary care physician (who would direct them to a specific hospitalist) or the group is the only one in the hospital and receives all patients admitted through the ED who require admission to a hospitalist service. After all, if either you or the PCP is dissatisfied with the group and there were other groups to choose from, you would simply call another group.

I’ll address your concerns individually:

Although signing off from a consult in the EHR is fairly common, especially in busy practices, the process is usually mutually agreed upon by the clinicians involved. If the attending psychiatrist would like a call from the hospitalists before they sign off, then he or she should make that known to the group.

On most occasions, the sign-off does not occur until the hospitalist/consultant feels the patient is stable and the clinicians involved can handle “basic medical issues.” There are many patients in the hospital on insulin, Coumadin, and anti-hypertensive medications; if the hospitalist followed all of them throughout their entire hospitalization, there would be no time for the new consults. It is customary to follow patients until they are stable (e.g. the blood sugars are not markedly fluctuating and there is good sliding scale coverage, or the PT/INR [prothrombin time/international normalized ratio] has been relatively unchanged for several days). To do otherwise might also alert the CMS auditors to check the “medical necessity” for the ongoing visits.

While most large hospitalist programs have a designated triage person who receives all the calls from the ED, the other providers, and the transfer service, that person can usually answer basic patient care questions. If the person is very busy, or if the problem is more complex and the original consultant is not available, there is always someone covering for that person or the consult service to answer questions, since this is a very common occurrence.

Consults are meant to answer a specific question or assist with complex medical management issues. In order for the arrangement to work, both parties have to agree to well-defined parameters, and, at some point, there should be mutually agreed upon closure.

If no such arrangement exists, I would discuss the issue with the hospitalist director.

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