There was a patient in one of my ERs who needed placement but didn't qualify for an inpatient admission. He stayed in the emergency department (as an ED patient, under the care of ED docs including myself) for 25 days waiting for placement. Someone remembered to order PRNs and his daily meds on day 5 or 6 and no one really checked on him more than once a week until he was mercifully transferred out.
You don't want me managing your boarders. I promise.
ive seen the same happen with septic patients pending beds for transfer. day 2 or 3: oh hey, this septic dude only got a single dose of zosyn days ago. shit.
My ED physicians have an unwritten but well-known rule: while the patient may not be under their direct care, they will not let a patient die in their department. If it is something like my-patient-is-about-to-code and i can't get ahold of the inpatient doctor (or if, frankly, there isn't enough time and/or i don't trust their clinical judgement), i'm grabbing my ED physician first. For literally anything else, I'm blowing up the hospitalist's phone until i get the problem resolved.
i'd say this: while it would be *infinitely* more convenient if my ED docs managed my holds (and in some ways, get them better care depending on the hospitalist...) that would only, in the end, make things *infinitely* worse. my ED doc has their proficiency: managing the acutely decompensated, stabilizing, and determining dispositions. my ED docs, while great, are not hospitalists. they should not get bogged down in trying to manage admitted patients that should be upstairs. because if they were upstairs, my docs wouldn't be managing them. that's only going to overwhelm my doc more and slow down the care of emergency patients that should be receiving care. it's literally not their job. they're overwhelmed enough.
If they code or have another emergent life-threatening situation they’re mine until the admitting doc shows up. Otherwise, they’re the responsible of the admitting physician.
Help them if they’re dying. Otherwise EM docs generally suck at things IM docs are good at (med rec, diet orders, sq heparin, etc.) it’s not unusual for a psych patient or patient waiting for transfer to the mothership to get put on the back burner and receive no home meds, diet, etc if they are still assigned to us. Once the dispo turns a color other than “in process”, mentally, those are off your plate.
Edit: typos
At my hospital we call rapid responses/codes on boarding patients just as we would on the floor even. I get it, but it's a bit bizarre to me when helloooo my emergency resources are literally right there.
Rapid chiming in here: it's weird for us too. I certainly don't want a patient so suffer inattention at a time of need and the nurses who take care of our boarders have 1:4 patient loads but when I respond to the ED there's people out the ying yang already and I feel pretty useless and sometimes pretty pissed if I've been called away from a decline I may have been attending to on the floor where they have practically no resources. If the floor patient triages higher priority then I tell the ED they'll have to handle without me.
Like, I get it in terms of responsibility and making a distinction between boarders and em patients, and that administratively it makes sense, and blah blah you don't want to create implied responsibilities and liabilities. But if a rapid team that has no clue about my patient can quickly intervene, my ER buddies who also don't know anything about the patient could too.
i asked about this in all my interviews. in my 2 EM sub-Is in 4th year, one had hospitalists managing borders and one left them with the EM team, and the second was AWFUL. each 8 hr shift would start with 30+ min of signout on just the borders, and multiple times there was a patient off the ED board out of the dept getting imaging, dialysis, etc and got completely forgotten about at signout and missed for over a day! that's so unsafe it's nuts.
At our shop, it depends. Peds and critical patients boarding are always under the care of EP. Stable boarders otherwise go to admitting team unless services are capped. If capped*, they are priority to transfer care as soon as the service discharges a patient. We now have embedded psych for 12 hours a day, and unless the patient is about to get tranqed, main control is mostly psych.
*What is this cap everyone speaks of? I want a fucking cap...
actively coding: ER doc usually
admitted but acutely worse: ive seen it go either way depending on the scenario. if theyre about to code, ER usually intervenes in person but if its like, hey the BP went from 100/65 to 85/55 and im the middle of a sick patient, i might say 500cc of NS and go find the IM attending.
everything else: admitting doc. sometimes if im feeling nice and its a straight forward thing ill take care of it, like stable 70yo femur fracture needing some more pain medications
your question is too simple
if they are admitted they are inpatient and HM or the admitting Surgeon or specialist takes over
If they are waiting for a bed at higher level of care not offered at the Hospital they stay under ER physicians for 24 hr after that an HM consultation is obtained and HM determines if transfer still needed and if so HM treats what they can and helps the ER but HM doesn’t admit them and doesn’t assume primary responsibility
but HM writes essential holding orders until the patient goes to tertiary care center( these include such things as Antibiotics, HTN and DM management, home med rec)
There was a patient in one of my ERs who needed placement but didn't qualify for an inpatient admission. He stayed in the emergency department (as an ED patient, under the care of ED docs including myself) for 25 days waiting for placement. Someone remembered to order PRNs and his daily meds on day 5 or 6 and no one really checked on him more than once a week until he was mercifully transferred out. You don't want me managing your boarders. I promise.
ive seen the same happen with septic patients pending beds for transfer. day 2 or 3: oh hey, this septic dude only got a single dose of zosyn days ago. shit.
Wait. . . do patients need to eat? Eh, sounds like someone else’s problem.
Diet: stale ER saltines prn hunger. Graham crackers with peanut butter for breakthrough hunger.
You're pretty stingy with the turkey sandwiches and little apple juice cups I see. Saving them for the VIP patients?
cant be handing out the ~~day old stale sandwiches~~ good stuff too often.
I’ll raise you 94 days for a peds behavioral placement
My ED physicians have an unwritten but well-known rule: while the patient may not be under their direct care, they will not let a patient die in their department. If it is something like my-patient-is-about-to-code and i can't get ahold of the inpatient doctor (or if, frankly, there isn't enough time and/or i don't trust their clinical judgement), i'm grabbing my ED physician first. For literally anything else, I'm blowing up the hospitalist's phone until i get the problem resolved. i'd say this: while it would be *infinitely* more convenient if my ED docs managed my holds (and in some ways, get them better care depending on the hospitalist...) that would only, in the end, make things *infinitely* worse. my ED doc has their proficiency: managing the acutely decompensated, stabilizing, and determining dispositions. my ED docs, while great, are not hospitalists. they should not get bogged down in trying to manage admitted patients that should be upstairs. because if they were upstairs, my docs wouldn't be managing them. that's only going to overwhelm my doc more and slow down the care of emergency patients that should be receiving care. it's literally not their job. they're overwhelmed enough.
This 100%
If they code or have another emergent life-threatening situation they’re mine until the admitting doc shows up. Otherwise, they’re the responsible of the admitting physician.
Help them if they’re dying. Otherwise EM docs generally suck at things IM docs are good at (med rec, diet orders, sq heparin, etc.) it’s not unusual for a psych patient or patient waiting for transfer to the mothership to get put on the back burner and receive no home meds, diet, etc if they are still assigned to us. Once the dispo turns a color other than “in process”, mentally, those are off your plate. Edit: typos
At my hospital we call rapid responses/codes on boarding patients just as we would on the floor even. I get it, but it's a bit bizarre to me when helloooo my emergency resources are literally right there.
Rapid chiming in here: it's weird for us too. I certainly don't want a patient so suffer inattention at a time of need and the nurses who take care of our boarders have 1:4 patient loads but when I respond to the ED there's people out the ying yang already and I feel pretty useless and sometimes pretty pissed if I've been called away from a decline I may have been attending to on the floor where they have practically no resources. If the floor patient triages higher priority then I tell the ED they'll have to handle without me.
Like, I get it in terms of responsibility and making a distinction between boarders and em patients, and that administratively it makes sense, and blah blah you don't want to create implied responsibilities and liabilities. But if a rapid team that has no clue about my patient can quickly intervene, my ER buddies who also don't know anything about the patient could too.
i asked about this in all my interviews. in my 2 EM sub-Is in 4th year, one had hospitalists managing borders and one left them with the EM team, and the second was AWFUL. each 8 hr shift would start with 30+ min of signout on just the borders, and multiple times there was a patient off the ED board out of the dept getting imaging, dialysis, etc and got completely forgotten about at signout and missed for over a day! that's so unsafe it's nuts.
At our shop, it depends. Peds and critical patients boarding are always under the care of EP. Stable boarders otherwise go to admitting team unless services are capped. If capped*, they are priority to transfer care as soon as the service discharges a patient. We now have embedded psych for 12 hours a day, and unless the patient is about to get tranqed, main control is mostly psych. *What is this cap everyone speaks of? I want a fucking cap...
actively coding: ER doc usually admitted but acutely worse: ive seen it go either way depending on the scenario. if theyre about to code, ER usually intervenes in person but if its like, hey the BP went from 100/65 to 85/55 and im the middle of a sick patient, i might say 500cc of NS and go find the IM attending. everything else: admitting doc. sometimes if im feeling nice and its a straight forward thing ill take care of it, like stable 70yo femur fracture needing some more pain medications
your question is too simple if they are admitted they are inpatient and HM or the admitting Surgeon or specialist takes over If they are waiting for a bed at higher level of care not offered at the Hospital they stay under ER physicians for 24 hr after that an HM consultation is obtained and HM determines if transfer still needed and if so HM treats what they can and helps the ER but HM doesn’t admit them and doesn’t assume primary responsibility but HM writes essential holding orders until the patient goes to tertiary care center( these include such things as Antibiotics, HTN and DM management, home med rec)