When does transition of care occur at your shop?

[Backpack234]

In residency, we had what now seems like a great system. Call the hospitalist/ICU. They put initial orders in and a symbol pops up on the tracking board. Then when they see the patient and place the rest of their orders in, another symbol pops up. Mark that time. Transition of care.

Now that I'm in a community shop, that's not the case at all. I asked my boss a while back when to mark transition of care and he said "just be helpful". So we've gone years without acknowledging when to actually transition to the inpatient docs, who apparently have 12-24 hours to see a patient after they're admitted, and there's a ton of liability in between. This also leads to waiting for EVERYTHING to come back before admitting the patient leading to bad patient flow through the department. And if I don't wait for a test, I wake up worried the next day that the inpatient doc didn't follow it which adds to my own stress.

How does this work in your shops? When does transition of care occur? And do you count on inpatient docs to review any pending studies?

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[NYEMMED]

In residency, we had what now seems like a great system. Call the hospitalist/ICU. They put initial orders in and a symbol pops up on the tracking board. Then when they see the patient and place the rest of their orders in, another symbol pops up. Mark that time. Transition of care.

Now that I'm in a community shop, that's not the case at all. I asked my boss a while back when to mark transition of care and he said "just be helpful". So we've gone years without acknowledging when to actually transition to the inpatient docs, who apparently have 12-24 hours to see a patient after they're admitted, and there's a ton of liability in between. This also leads to waiting for EVERYTHING to come back before admitting the patient leading to bad patient flow through the department. And if I don't wait for a test, I wake up worried the next day that the inpatient doc didn't follow it which adds to my own stress.

How does this work in your shops? When does transition of care occur? And do you count on inpatient docs to review any pending studies?

As soon as the discussion occurs with the hospitalist it is required the admit order be in within 30 mins.
Transition of care is when the order is in

 

[GonnaBeADoc2222]

"just be helpful"

Sounds like a boss who doesn't have the ER's back

 

[clibby]

Your medical staff bylaws should specify this, though actual practice varies. Your medical director needs to push on the hospitalists/admitting docs to enter orders. They may have 24 hours to see the patient, but they need to place admission orders to move the patient out of the department. One shop I work at has this kind of problem, but the moment we place the transition orders (which requests a bed), the hospitalist is responsible from there on out. If they don't place orders for 12 hours, they are still responsible. We have been trying to get them to be more timely for years, but a few have been notoriously difficult and I often add additional PRNs for those patients in case they need it. My other shop has very responsible hospitalists and they have orders in 20 minutes or less; this is a much safer model. Now if the patient is in the department boarding and you are there, you are a fool to think that you don't have some responsibility if they are crashing, but routine follow up should still be on the admitting physician.

 

[Siggy]

In IM residency we had a few ER nurses who would refuse to call the admitting team for issues because, "I have a doctor right here to ask."

Yea... but he's transitioned care to us... so it's not up to the EMP to decide care for this patient any more.

 

[BoardingDoc]

How does this work in your shops? When does transition of care occur? And do you count on inpatient docs to review any pending studies?

I click admit and page the hospitalist. They take anywhere from 5 minutes to an hour to review my chart and if needed call me (rare). They then click "accepted" on our tracker. They are now the hospitalist's patient. They review anything still pending when I hit admit unless I've had a conversation with them otherwise.

 

[BoardingDoc]

In IM residency we had a few ER nurses who would refuse to call the admitting team for issues because, "I have a doctor right here to ask."

Yea... but he's transitioned care to us... so it's not up to the EMP to decide care for this patient any more.

Yeah, I have RNs that will sometimes try that as well. I just say that the patient is inpatient now and the hospitalist is driving the boat. If the patient is looking proper sick, I'll go do things and then page the hospitalist afterwards.

 

[3rdJob]

So a long, long time ago, I had an admitted patient (hospitalist had written orders and everything) that the nurse came to me wanting me to do something. So I did. A few hours later (patient boarded in the ED) the hospitalist rightfully ripped me a new one with the comment, "Dude! That's my patient now! If you do something different, I won't know about it, and then I could really mess things up for the patient. DON'T DO THAT AGAIN, PLEASE!" (Me: hung my head in appropriate shame....).

Bottom Line: The 'medical chain of command' for the patient has to be clear. Once they're admitted, they should NOT belong to you anymore. Obviously codes, and acute decompensation are a different story.

 

[Aonyx]

In residency, we had what now seems like a great system. Call the hospitalist/ICU. They put initial orders in and a symbol pops up on the tracking board. Then when they see the patient and place the rest of their orders in, another symbol pops up. Mark that time. Transition of care.

Now that I'm in a community shop, that's not the case at all. I asked my boss a while back when to mark transition of care and he said "just be helpful". So we've gone years without acknowledging when to actually transition to the inpatient docs, who apparently have 12-24 hours to see a patient after they're admitted, and there's a ton of liability in between. This also leads to waiting for EVERYTHING to come back before admitting the patient leading to bad patient flow through the department. And if I don't wait for a test, I wake up worried the next day that the inpatient doc didn't follow it which adds to my own stress.

How does this work in your shops? When does transition of care occur? And do you count on inpatient docs to review any pending studies?

Waiting 12-24hours? That seems outrageous. Its variable between the 3 places I work at which are all part of the same hospital system. Most typically the hospitalist assumes care after the phone discussion. We put in the order for the admission/bed and the hospitalist takes over from there. After that, if the patient needs something urgently and it shortly after admission, I will help out, like if patient needs a dose of pain meds and the hospitalist hasn't come down yet. Patients board for hours to days at one shop and I direct the nurses to contact the hospitalist if its more than an hour or two or after the hospitalist puts orders in. If its something that would alter their care plan, I tell the hospitalist right away, or if a critical lab comes back and the nurses tell me.

I also work at a free standing that boards patients for hours to days, where the hospitalist doesn't usually see them until they are at the main hospital. They are supposed to call us daily and discuss the patients that are boarding. Other than that we get to (unfortunately) be the hospitalist. We order the home meds, the insulin, the DVT prophylaxis and the AM labs and continued ABX/etc and its definitely a liability issue, but no one seems to want to do anything about it. They've discussed us even discharging people that complete their workup before actually getting to the main hospital (i.e. stroke patients), and most of us have drawn the line with that. I'm not a hospitalist, and I am not qualified to discharge someone after a stroke work up. If they want to AMA, that's fine or if the hospitalist comes out and writes and H&P and see the patient then that's fine, but I am not going to do it.

 

[PianoMedic]

I click admit and page the hospitalist. They take anywhere from 5 minutes to an hour to review my chart and if needed call me (rare). They then click "accepted" on our tracker. They are now the hospitalist's patient. They review anything still pending when I hit admit unless I've had a conversation with them otherwise.

Don’t want to derail thread so feel free to PM with response, but curious which EMR you use? This seems very helpful to be able to click the admit button to start the process rolling and notify all appropriate parties.

 

[Janders]

Don’t want to derail thread so feel free to PM with response, but curious which EMR you use? This seems very helpful to be able to click the admit button to start the process rolling and notify all appropriate parties.

Its meditech. We drop bed request, secure text hospitalist, and use the patient Status feature to switch the patient to “DECISION TO ADMIT”

When they are cool with the patient, they switch to “ACCEPTED MEDICINE”

It turns green, and thats the signal to nursing, transport, etc that the patient can roll upstairs as soon as a room number is assigned (which might be before or after acceptance, parallel processes to speed flow).

 

[southerndoc]

Yeah, I have RNs that will sometimes try that as well. I just say that the patient is inpatient now and the hospitalist is driving the boat. If the patient is looking proper sick, I'll go do things and then page the hospitalist afterwards.

You should tell those RN's to do something to a patient that they aren't taking care of, and then document in the chart "relayed to nurse so and so to administer diltiazem." They'll learn quick enough.

 

[DrSnips]

There are seriously places where a hospitalist takes over a day later? That's crazy to me. The patient's mine when I place admit orders, approx 30 mins after getting the call. I think the actual time limit is like 45 mins? It honestly never comes up. Codes that happen in the ED are typically run by you guys, even if the patient has been boarding for days. "Codes" that happen in the lobby are ours and generally consist of someone vomiting after eating the lobby sushi that has been sitting out in questionable refrigeration since last Thursday.

 

[emergentmd]

we had what now seems like a great system. Call the hospitalist/ICU. They put initial orders in and a symbol pops up on the tracking board.

This is how it has been in Every place I have worked. Never do I put in orders and "hope" that someone takes over care. If I ever put in orders, I will clearly state in my chart that, "Dr. X service consulted, agrees for admission and assumes care/care transferred to Dr X @2100. All further patient care orders per Dr. X"

I asked my boss a while back when to mark transition of care and he said "just be helpful".

That sounds like what I tell my kids when they have no use to me. Just be helpful=don't get in my way. Are you a kid? What kind of boss is that?

inpatient docs, who apparently have 12-24 hours to see a patient after they're admitted

No way this is true. They may come in and examine the pt but there is not up to 24 hrs gap of having no docs. I bet the hospitalist took over care and all calls coming to them, otherwise it would go to you.

And if I don't wait for a test, I wake up worried the next day that the inpatient doc didn't follow it which adds to my own stress.

You need to step back and not worry about the small stuff like this. You are an ER doc, and if this keeps you up at night, then you may be in the wrong specialty. I don't think I have ever went to sleep worried about a test/patient.

 

[The kitchen sink]

Speaking from the inpatient side, I come from a place where generally the ER is given complete liberty to admit patients with impunity. The result has been that boarding time in ER has dropped off significantly, but leads to a small but significant enough number of patients are dropped off on the inpatient side that either did not need to be admitted, or if going to the ICU, the ER generally only functions as a triage area before the patient is wheeled directly to the ICU for work-up and stabilization (so in a sense the ICU team takes over ER and inpatient functions for critically ill patients). It makes me wonder why the ER folks are paid so much better than us inpatient folks, when my particular ER is basically run by a triage nurse. My theory is that it is generally such a low volume hospital, so although bad outcomes occur, they are temporally far enough apart, that people forget and move on. I don’t really know what the solution would be but I do wish we could find ways to improve the system. It doesn’t help when you have difficulty hiring a chief for your ER, and the current one directs the patient to the ICU for intubations because he doesn’t feel comfortable intubating in the ER (the ER is tiny and not economical on space).

Now on the flipside if you go to the big city its totally different, the ER teams usually stabilize the living f out of the patient before moving them up.

So interesting how hospital cultures can differ vastly.

 

[Apollyon]

Just be helpful? WTH

Thats what I tell my kids when they have no use to me.

That sounds like what I tell my kids when they have no use to me. Just be helpful=don't get in my way. Are you a kid? What kind of boss is that?

Did you realize that you had already posted this a day or two ago?

 

[Fox800]

Speaking from the inpatient side, I come from a place where generally the ER is given complete liberty to admit patients with impunity. The result has been that boarding time in ER has dropped off significantly, but leads to a small but significant enough number of patients are dropped off on the inpatient side that either did not need to be admitted, or if going to the ICU, the ER generally only functions as a triage area before the patient is wheeled directly to the ICU for work-up and stabilization (so in a sense the ICU team takes over ER and inpatient functions for critically ill patients). It makes me wonder why the ER folks are paid so much better than us inpatient folks, when my particular ER is basically run by a triage nurse. My theory is that it is generally such a low volume hospital, so although bad outcomes occur, they are temporally far enough apart, that people forget and move on. I don’t really know what the solution would be but I do wish we could find ways to improve the system. It doesn’t help when you have difficulty hiring a chief for your ER, and the current one directs the patient to the ICU for intubations because he doesn’t feel comfortable intubating in the ER (the ER is tiny and not economical on space).

Now on the flipside if you go to the big city its totally different, the ER teams usually stabilize the living f out of the patient before moving them up.

So interesting how hospital cultures can differ vastly.

Sounds like you're at a dumpster fire of a place where the ED docs are not EM-trained, or so far out of residency that they are incompetent. Tends to happen at tiny places, especially if they aren't paying appropriately.

 

[The kitchen sink]

Sounds like you're at a dumpster fire of a place where the ED docs are not EM-trained, or so far out of residency that they are incompetent. Tends to happen at tiny places, especially if they aren't paying appropriately.

Tiny hospital syndrome lol

 

[Mushdoc]

Ive worked places where hospitalist had 24 hours to see patient. You had to put in admit orders and basic work up orders (insulin, AM labs, diet status, MRI for stroke, Echo for heart failure, etc), consult orders. Technically though if there was an issue they would page the hospitalist, so it was better to make the patient NPO and not given any PRNs so the nurse would page them to get them involved. Would not like to do that again

 

[Backpack234]

This is how it has been in Every place I have worked. Never do I put in orders and "hope" that someone takes over care. If I ever put in orders, I will clearly state in my chart that, "Dr. X service consulted, agrees for admission and assumes care/care transferred to Dr X @2100. All further patient care orders per Dr. X"


That sounds like what I tell my kids when they have no use to me. Just be helpful=don't get in my way. Are you a kid? What kind of boss is that?

No way this is true. They may come in and examine the pt but there is not up to 24 hrs gap of having no docs. I bet the hospitalist took over care and all calls coming to them, otherwise it would go to you.

You need to step back and not worry about the small stuff like this. You are an ER doc, and if this keeps you up at night, then you may be in the wrong specialty. I don't think I have ever went to sleep worried about a test/patient.

Yep. Everything I said is true. The hospitalists probably see patients sooner, but the bylaws say they have that long. It’s kinda screwy.

And

Ive worked places where hospitalist had 24 hours to see patient. You had to put in admit orders and basic work up orders (insulin, AM labs, diet status, MRI for stroke, Echo for heart failure, etc), consult orders. Technically though if there was an issue they would page the hospitalist, so it was better to make the patient NPO and not given any PRNs so the nurse would page them to get them involved. Would not like to do that again

This is my current gig. It’s very annoying and seems to take all the liability off the hospitalist and put it onto the ER doc

 

[southerndoc]

This is my current gig. It’s very annoying and seems to take all the liability off the hospitalist and put it onto the ER doc

I'm assuming they aren't in-house?