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Viewpoint: Raiders of the Lost Admit

Cudnik, Michael T. MD; DeBard, Mark L. MD

doi: 10.1097/01.EEM.0000403716.02413.32
Dr. Cudnik

Dr. Cudnik

We've all been there. You are in the middle of a busy shift in the ED at 4 p.m. on a Friday with all the beds full. A trauma is rolling in with an ETA of five minutes, there are 20 patients in the waiting room, and the intern just dropped the lung on the little old lady who needed a central line. Then the phone rings (again), and Dr. (insert name) from (insert specialty) tells you that he has a patient from another ED he has accepted to your ED who he wants you to see. The doctor says the patient is an 80-year-old woman with a subdural hematoma (or a 30-year-old man with appendicitis, or a 50-year-old man with an infected kidney stone).

Hmm, you think. Sounds like the patient has a diagnosis and a disposition (ICU admit, OR, and floor admit, respectively). Naively (or wearily) you ask, “Why does this patient need to come to the ED (again)?” He responds, “Well, I would like the patient evaluated in our ED first.”

And so begins the redundant process of an ED-to-ED transfer for a patient who clearly does not need to be evaluated by another doctor, to be evaluated in another ED, to have his admission further prolonged and negatively affected by his perception of the care he is receiving, or to have an additional charge for a likely unnecessary second ED evaluation. So why does this occur in EDs throughout the country? It is absolutely not due to our colleagues on other services being incompetent. It occurs because of health system problems.

The first issue is patient stability, which is about trust between various specialties and the need for being cooperative rather than confrontational. Often we hear that the patient needs to be seen in another ED because the accepting doctor (who is not actually in the ED) does not know what they are getting and wants to ensure that the patient is stable. While we all have been burned by the patient who is under-triaged (think 80-year-old weak and dizzy who is really septic and hypotensive), that in itself should not prevent physicians from doing their job. There are still doctors and nurses on hospital wards, not just in the ED.

Once a patient decompensated and needed a higher level of care soon after arrival on our inpatient service. This is the same in the ED. Patients often change right in front of our eyes: the telemetry patient who now needs an ICU, the patient who was about to go home but faints and needs admission. This is the normal practice of medicine.

The second problem? The many needless rules and regulations put forth by various regulating bodies, many of whose members have never taken care of a patient in their life (or at least in this millennium).

And third: the ever-present medical-legal risk that we all face daily. This is typified by the fear of missing something or taking care of a patient who has a bad outcome, a fear often in the back of many physicians' minds. Rather than absorb any additional risk, it is much easier to simply have the patient seen in another ED that would allow the patient additional time to remain stable or declare himself. It also allows an additional set of eyes to be laid on a patient to determine if the patient is suitable for a floor bed.

Then there is the desire to have labs and radiographs done again so they are in your hospital's computer system, even though the patient already had them completed in the first ED, and will likely bring the results with him in some format.

Emergency departments in the United States are too crowded to let this continue. They are busier than ever: ED visits are up 23 percent in the past 10 years though the number of EDs has decreased by five percent in the same timeframe. (JAMA 2010;304[6]:664.) EDs are also the front door to most hospitals, responsible for more than 50 percent of all hospital admissions, a number that was 35 percent just 15 years ago. (Natl Health Stat Report 2008;7:1.)

It is up to us lowly emergency physicians to solve this problem despite often being at the bottom of the hospital's totem pole. First and foremost, we must be heard and involved in the process. Ensure that someone from your group or department is on the committee in charge of developing transfer protocols in your hospital. Then talk to your colleagues in other departments, and identify what has worked in their system to see if it will work in yours.

Most importantly, speak with your colleagues in other specialties to identify the barriers for accepting a patient directly to a hospital bed instead of requiring a repeat ED visit.

ED crowding will only worsen as our nation's population ages. Some of this can be reduced by avoiding ED-to-ED transfers. Such transfers result in redundant care that is wasteful, time-consuming, does nothing to reduce medical-legal risk, does not prevent patients from becoming unstable, and reduces patient satisfaction.

We emergency physicians will continue to care for all patients who come through our doors, no matter from where they arrive. It should not be the norm, however, for ED-to-ED transfers to become the standard of care. Our patients deserve better.

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