The absence of research studies doesn’t stop a lot of people, including me, from expressing their opinions. Numerous articles and opinion pieces are available on the Internet. They generally summarize that despite having the same goal of safe and efficient patient care, PCPs and hospitalists often see direct admissions a little differently.
An Internet search of ”direct admission + hospitalist” turns up the practice website for a hospitalist group. I found several such sites that do accept direct admissions. Presumably, those hospitalist groups that refuse to accept direct admissions don’t advertise that on their website so don’t turn up in a search. This one is typical:
Hospitalists are also available to facilitate direct admissions to Beth Israel Deaconess Hospital-Needham, so that patients can avoid a trip through the emergency department. Please note that it is Beth Israel Deaconess Hospital-Needham policy that the patient needs to have been seen by the primary-care provider or specialist physician within the previous 24 hours to qualify for direct admission status.
Mass General Hospital for Children in Boston has posted a very detailed approach to direct admissions2 allowing them only from some PCP groups (presumably those in their system), and only when the patient has been seen in the office on the day of admission. And the hospitalist program at Johns Hopkins Hospital in Baltimore advertises its “VIP Direct-Admitting Service.”3
I’ve come to the following conclusions that I think most groups could follow, though I realize thoughtful people can see this differently.
- Most hospitalist groups should not have a policy of refusing all direct admissions. They should thoughtfully listen every time a doctor calls asking to refer a patient directly from an office setting. And, at least some of the time, they should say yes.
- You should more liberally accept direct admissions from PCPs you work with regularly. The better you know the PCP (i.e. have cared for many of that doctor’s patients), the more you can judge the risk the patient will arrive in a condition other than described.
- Requiring that the patient be in the office at the time of the decision to accept the direct admission, or within the preceding 12 or 24 hours, is a good idea.
- Work with your hospital to improve the speed of testing like blood work and X-rays done “on the floor” on new admissions so they’re resulted as quickly as in the ED. Consider notifying in advance the relevant department that you’ll likely be ordering a stat study as soon as the patient arrives. This is sort of like calling a restaurant to get in line for a table before you arrive.
- The hospitalist should have the final say regarding whether a patient is appropriate for direct admission, or whether it is best to stop in the ED first. That is the case for all the practices I mentioned above. But don’t let this insulate you from the very real frustration suffered by PCPs and patients, should you unfairly refuse to allow it.
I don’t have any idea what might be an appropriate portion of direct admissions for a typical hospitalist practice; it’s probably no more than 1% or 2%. But I don’t think it should be zero.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].
- Kulkarni N, Williams M. Is it safe to be direct? Agency for Healthcare Research and Quality website. Available at: http://www.webmm.ahrq.gov/case.aspx?caseID=178. Accessed Feb. 2, 2013.
- MassGeneral Hospital for Children. Direct admit policy. MassGeneral Hospital for Children website. Available at: http://www.massgeneral.org/children/professionals/direct_admit_policy.aspx. Accessed Feb. 2, 2013.
- Johns Hopkins Medicine. Hospitalists Introduce VIP Direct-Admitting Service. Johns Hopkins Medicine website. Available at: http://www.hopkinsmedicine.org/gim/news/2010_News_Items/6-17-10.html. Accessed Feb. 2, 2013.