18 December 2008

I hate to admit it

Not to join the ranks of the colleague-bashers, but one thing that has bugged me since we got a internal medicine hospitalist program is that "direct admits" seem to have become a thing of the past. It used to be that if an internist had a patient in their office who clearly needed admission, they called admitting, gave orders, and the patient went directly to the floor. Nowadays, they have to call the hospitalists, and they usually ask that the patient go to the ER for assessment prior to admission. They argue that the workups are easier to do in the ER, and that some of the patients can go home after some intensive ER therapy, and we bristle at the added cost, the added burden to the busy ER, and the feeling of getting dumped on.

It's a little annoying, but what the hell, it's not like we can prevent it so I suck it up with good grace.

So today I got a call from a clinic doc who I have known and respected for a long time. He was very apologetic: he had a lady with obvious pyelo who was clearly sick enough to be admitted and he had to send her to the ER. The hospitalists had been called, and did not want to take her without an ER evaluation. He made it clear from his tone that he thought they were being weak and that this was another waste of time and effort. As I always do, I thanked him with good cheer and said we'd be happy to see her.

Well, when she showed up, there turned out to be more to the tale. She was septic as hell, with a blood pressure in the seventies. Her lactate was four and a half, and she turned out to have not pyelo but a right sided diverticular abscess. (I was proud of figuring that out, since it really did seem like pyelo.) She went not to the floor, but to interventional radiology and then to the ICU. A little while later I happened to speak with the hospitalist, who inquired if the patient had ever showed up. I related the tale, and he laughed and said, "Yeah, it sounded funny. That's why I had them go to the ER first." I hate to admit it, but he had a point.

Damn it.

Note: Yes, I realize that there are probably a lot of direct admits that I never know about because they do bypass the ER. I'm not going to let some tawdry facts get in the way of a good rant.


  1. Complain away - that is not bashing. Bashing is when you say "all internists are idiots" or something of that sort.

    I am frustrated with this from the other end as well. Our hospitalists say that we need to send people to the ED because of poor nursing staffing on the floors. If we send them to the floor directly, it will take hours before an antibiotic gets in them and before they are seen by a physician. In the ED, it will be almost immediate (depending on the time of day). I have had surgeons say the same.

    Hard to argue.

  2. I have to say we hospitalists are picky with direct admits. I have a policy not to direct admit chest pain, and am very careful to pin primary care docs down on vital signs on patients with pneumonia and UTIs. Frequently, we are told "oh yeah, they're stable," but come to find out they have a blood pressure of 80 and are now on 6 litres of oxygen. Hardly "stable" in my book. It's not that we don't like direct admits, sometimes we can't get to them in a timely fashion, as Rob points out.

  3. I direct admit everyone every time, unless. What a waste of money to send them to the ED.

    In your case, the patient would have done just fine by hanging fluids wide open in on the floor and arranging for an ICU bed.

    In the grand scheme, sending direct admits to the ED makes my premiums go up.

    If a patient shows up sicker than they should be, I do the doctor thing and doctor them.


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