In part 1 of this two-part series (July 2007, p. 16), hospitalists and emergency medicine physicians expressed their views on the relationship between their two specialties. In part 2, we look at how those relationships intersect—and what issues are at stake when they do.
One area where there is a bit of overlap between hospital medicine and emergency medicine is observational medicine,” says James W. Hoekstra, MD, professor and chairman, Department of Emergency Medicine, Wake Forest University Health Sciences Center, Winston-Salem, N.C.
Those patients who require a short stay for observation, he says, are neither in the ED or admitted to the hospital—they are in a zone of their own.
“That’s a gray zone in terms of who takes care of those patients,” he says, “and it depends on the hospital. It will be interesting to see how that works out, or whether that is ever worked out. It may just stay a shared area.”
The observation conundrum is complicated by the fact that many people use emergency departments for primary care. (See Figure 1, p. 33) “ True emergencies make up only some of the patient [cases] in the ED,” says Debra L. Burgy, MD, a hospitalist at Abbott Northwestern Hospital in Minneapolis. “We do have a 23-hour observation unit of 10 beds, and, frankly, could use 10 more to [handle unpredictable volumes of patients and insufficient support staff. That unit] has certainly helped to alleviate unnecessary admissions.”
Collaboration between hospitalists and emergency medicine physicians happens a number of ways at the University of Colorado at Denver and Health Sciences Center, where Jeff Glasheen, MD, is director of both the hospital medicine program and inpatient clinical services in the department of medicine.
“One way we work closely with the ED—because we think it is the right thing to do—is by building a much more comprehensive observation unit,” Dr. Glasheen says. “In some settings the observation unit lives in the ED and is run by the ED and in others, it is run by hospitalists. The hospitalists [here] will now run the unit, but we want to help solve some of the ED’s throughput issues.”
When Dr. Glasheen arrived at his institution, the observation unit was limited to patients with chest pain. “I didn’t understand why we would get chest pain patients through efficiently and not all patients,” he says.
A team that began operating in July will be available for all patients under the admission status of observation. The team will be hospitalist-led and aim to reduce length of stay and increase quality of care for those patients.
“Right now those patients are very scattered throughout the system and they may be [covered by] six to eight different teams,” Dr. Glasheen explains. One team of caregivers will be more efficient and reduce length of stay, he says.
By nurturing their working relationship with the emergency department, hospitalists will be able to more easily say: “We understand that that workup’s not complete, but we also understand that they’re going to come into the hospital and let us know what things need to be done. We’ll be happy to take that patient a little earlier than we did in the past to get them out of the ED.”