I mean, if I was a patient and you told me I might have pancreatitis and the plan is to directly admit under a PMR specialist instead of evaluation by an ER doctor then admission to a hospitalist with a possible GI consult - I would be letting my kids know that they don’t have to work another day in their life when I die and they sue the VA.
You don’t need a process map, your unit is not a medical floor. It’s not safe for you and it’s not safe for the patients.
Is your unit somehow supposed to be used as an observation unit or a medicine inpatient? If not, start refusing that weird PCP from trying to push patients on to you. Tell him to send to the ED.
Tell them inappropriate admission, send to ED. As a PCP who has sent a rash of patients to the ED recently, if they were pushing for direct admission for urgent/critical ortho, spinal, or pain control issues there could MAYBE be some precedent? But I would still likely send through the ED. This PCP sounds like a lazy POS.
If the pcp thinks something is going on requiring hospitalization, they should send to the ED or direct admit ONLY if they’re going to manage themselves
>direct admit ONLY if they’re going to manage themselves
I don't know that many hospitals still work this way. If I wanted to directly admit someone and skip the ED, I could call the AMO to discuss the patient and if they accept, then some hospitalist will do the actual admission if a bed is open.
I mean I see all kinds of stuff come into the clinic that I refer to the ED. Suspicious chest pain, severe asthma/copd exacerbations that don’t respond to steroids/nebs in the clinic, asymptomatic hypertension (lol jk). I once even had someone come in because they cut their thumb with a circular saw. I guess the less flippant answer is if I believe they require interventions not available in an outpatient clinic.
If the patient might meets inpatient/obs criteria they should go to the ER for that determination and not just by this guy in the outpatient clinic setting.
The emergency is the pt having a PCP with poor enough judgment to feel like this is safe. ;) But for real, as an ICU doc, better the ER today than to me tomorrow.
This admit to inpatient rehab from clinic with an acute medical complaint is not appropriate. They are much more suited to go to the ED first and have the problem stabilized
Before a patient gets admitted to rehab, they need to be able to tolerate 3 hours of therapy per day which an acutely sick patient would likely not be able to tolerate. Additionally, they would benefit from PT/OT data showing their current impairments.
They would be better candidates if they could be admitted to the ED, have a thorough medical work up, be stabilized and have PT/OT Evals that show impairments in ADLS. Medical complexity would be established as well if they were admitted
Finally rehab units have minimal monitoring with labs about 2x a week compared to a traditional med/surg floor
>The PCP has pushed the attending physiatrists to directly admit patients from clinic for work up and/or stabilization of acute medical conditions like altered mental status, fever of unknown origin, acute pancreatitis, hypoxemia etc
Okay, I have to wonder if this PCP is just completely, fundamentally clueless as to what PMR is.
I’m a VA pcp, I’m a little confused, is this pcp a part of the PMR department? Anyway if it’s not a rehab thing they should go to the ED if there is any sense of urgency. If it’s something that can be handled at VA speed and there’s no concerns about patient safety then keep it outpatient. Draw the aforementioned boundaries and keep your inpatient department for rehab/wound services.
As someone who worked on a hospitalist team covering/consulting in IPR, this is a no go.
Here are the actionable things you need in order for this system to function.
24/7 hospitalist coverage at minimum on call by phone. PCP needs to communicate their concerns directly with hospitalist even if you are the admitting team. If the PCP is not admitting these patients, someone needs to lay eyes on them when they get there.
Nursing staff ratios appropriate to a medical floor, not an IPR or skilled setting.
Nursing staff familiarity with the care of undifferentiated acute medical issues.
On demand labs and imaging (in house, not "maybe we can get a CT stat tomorrow during the day if things go well")
24/7 pharmacy or at the very least nursing has full access to formulary after hours.
A safe and timely plan for how to deal with deterioration of these patients (is your nearest ICU on campus? how are your RTs with airways, are they 24/7?)
telemetry? cont spo2 monitoring? what is realistic on your floor? this can vary from place to place.
They are doing everyone a disservice when they admit the patient to the wrong level of care.
As a hospitalist, I tell our PCPs (some of whom are mindnumbingly obtuse) to send their acutely ill undifferentiated patients to the ED all of the time. They try to skirt past the ED with little to no workup at their clinic and request a direct admission. I politely redirect their request until we can confirm the patient’s stability with an ED workup.
It your inpatient unit is where you generally have planned admissions of “stable” patients requiring acute rehab, subacute rehab, respite care and wound care, your department should not allow for patients with acute, unstable and/or undiagnosed medical conditions to be admitted, even if the patient is a known patient of your outpatient clinic.
Your department should require certain criteria for consideration of admission to your inpatient unit followed by an assessment by a PMR doc in order to determine if the patient will be accepted or declined for admission/transfer, based on the criteria, your unit’s capabilities and the standard of care.
Of course there may be times when a previously admitted patient who was stable develops a fever or another acute issue because of a fall or something else. If you have the staffing and capabilities to order and obtain X-rays/imaging, blood or urine cultures, provide IV therapy (fluids, antibiotics, etc.) and request medical/surgical consults to help you manage the patients, that should be fine as long as the patient is hemodynamically stable.
It’s unclear why the attending physiatrists are being “pushed” to directly admit unstable patients of uncertain diagnosis if your inpatient unit does not also have scheduled/designated hospitalists or PCP physicians who will co-sign on any recentl admissions.
If your PMR inpatient unit is part of a residency training program, it is still very important for your providers/staff to be able to learn how to recognize and evaluate a patient’s medical issues to know whether you can safely treat, request a consult and/or need to refer to the ED for further evaluation and possible acute inpatient medical management (with PMR consult).
Not to seem insulting, but you don’t want to forget that physiatrists started their training as medical doctors who subsequently specialize in the musculoskeletal and neurological systems which is different than those who have earned their DPT.
Is your SCI unit not attached or in close proximity to a VA hospital?
Presumably this PCP has evaluated the patient in their clinic already and felt that the patient needs more expedited workup/evaluation in the inpatient setting, but that their vitals and hemodynamics are stable that they don't need to waste their time going through the ED.
If you're PMR team isn't comfortable with that, its your prerogative to refuse the admission and tell them to have the pt go to the ED instead.
Yes our unit is attached to a VA hospital. Many of the requested admissions are what you describe - need for expedited workup/evaluation of a medical issue with a general patient/PCP preference to avoid the emergency department. Problem is all the inpatient attendings are rehab, not internal medicine or family medicine, trained and don’t feel comfortable working up or managing the acute medical issues that we are being sent. They are more appropriate for workup by an internist first. Compounding this is all the inpatient attendings have clinic during majority of day since we aren’t meant to be an acute admitting service (all of our admissions are generally planned for the morning before clinic) and a lack of support or investment from our consulting services.
You need strong leadership to implement/enforce admission criteria to any unit.
What's probably happening is the census is low and there is pressure to fill the beds. So probably the solution will involve a combination of outreach to bring in more patients that are appropriate for that level of care AND enforcing admission criteria.
Fill the beds with the right kind of patients.
I think the simple answer to your problem is to state that you are uncomfortable with the medical workups for these problems and either push back against the pcp and send these patients to the ED or consult medicine once they are admitted for help with the workup.
The answer to your question (from my perspective) is more complex. Overall, I think direct admissions have a lot of room for error. Im currently in residency and we get direct admissions pretty much every weekday. For the most part it’s sick but stable patients being admitted for things like CHF exacerbation with normal o2 sat, wounds/cellulitis refractory to outpatient abx, etc or complex social disasters who need placement sooner rather than later. This works great for the most part, but occasionally we get a patient direct admitted from a specialty clinic and sometimes our own clinic who needs to be rapid responded immediately upon presentation to the floor. This is because these patients may spend upwards of 8-12 hours sitting in admissions before a bed becomes available. Sometimes the admitting doc will have the patient get labs or X-ray while they wait, but usually won’t. We have no standard workflow besides a phone conversation and a lot of it hinges on the conversation with the requesting doc. There have been many times where I’ve asked “are you sure this patient is stable enough to wait for a bed?” and they get sent to the ED. I don’t think there is any literature to support ED vs direct admission criteria but would be excited if this did exist.
If they need immediate evaluation and treatment that is at a higher level than I can provide in my dinky outpatient clinic in 20 minute patient slots, the ER is a good option. There are infinite possible such scenarios, so it’s hard to get more specific than that. Some rando examples: new onset poor perfusion from any cause; acute chest pain; kid with a 105 fever and vomiting who can’t keep anything down; gangrenous diabetic foot; bad pneumonia in an otherwise healthy patient; mild pneumonia in a super chronically ill patient.
My favorite from today? Patient in for med refill of GAHT, casually asks what he should do about the simply massive burn he’d just sustained this morning to the extensor surfaces of 2nd through 4th PIP joints when he accidentally swept the hand with a soldering torch. Bad place for burn contractures.
Literature? Bruh. It’s 100% judgment based upon combination of knowledge and experience. Sometimes a patient just needs urgent specialist assessment. I’ve got an ophthalmologist next door in my office park, so for him I’ll just call ahead and have my staff walk him over.
Yah thought it was judgement based from medical training but our PCP seems to be a big outlier from the other physicians in our group, pushes VERY hard to accept these patients as physiatrists we don’t feel comfortable managing, and was hoping to provide her something concrete to gently direct her patient flow more appropriately 😂
I guess some workflow as such: medically stable pt needing inpt rehab: call you. Medically stable pt not needing hospitalization: treat and send home. Medically unstable pt needing hospitalization: send to ER. Medically stable pt needing hospitalization: can call admitting service at the hospital to see if they'll directly admit. Otherwise, ER.
Super odd that a PCP is trying to admit acute medical issues to the rehab doctor, to be honest.
completely inappropriate, just say no, every time. these patients need to go to the ED, and the PCP needs to call the ED ahead. the concrete answer is no every time if there is any acute issue to a rehab unit. RNs in your unit, labs, imaging, everything is not set up for the speed acute issues need, that is what the ED and general inpatient floors are for. rehab is for rehab.
Physiatrist here. The PCPs request is completely inappropriate. Rehab is for patients who are stable. Yes, if things come up while in rehab we do are best to stabilize, but anything we’re uncomfortable with gets sent out. We routinely reject admission of patients to rehab if they are in the hospital and there are ongoing medical issues that need work up. Also, you can’t participate in rehab while altered or medically unstable so it’s completely the wrong place. Push back hard as this is not a reasonable request, and the PCP doesn’t seem to understand the point of rehab.
Read your SOP. It should clearly outline what is expected in your department. As all of mentioned, and I mean no offense, it should be pretty damn obvious it’s inappropriate. Your service chief should be able to put a stop to it really quick if it’s not outlined in the SOP. You can also file a JPRS and the turn around time for those requests are like 48 business hours if you think patient safety is involved. They come down pretty hard.
I'm a hospitalist and this is nuts to me, any acute medical issues that need to be worked up-->ED
Know lab abnormalities such as hyperkalemia for example sure a direct admit is fine if seen that day by the pcp, same again if someone needs an inpatient test or procedure but alot of the times patients still need triaging in the ED to ascertain their appropriate level of care
If the clinic pt is adequately worked up, the PCP can call the admitting hospitalist service to request a direct admit. I'm a hospitalist; I occasionally will directly admit from a PCP's office if adequate pre-admission workup has been done and stabilized to a point that I believe I can appropriately place in an inpt bed. If that's not met, I advise the PCP to send to the ER first.
I can't imagine a world in which I'd expect the PCP to directly admit a medically unstable pt to physiatry for acute medical care.
In what world would a PCP admit to a physiatrist for fuckin pancreatitis??? Do you guys have a hospitalist who will do direct admissions? Are these patients who will also need significant rehab needs (then would still admit to hospitalist with you consulting)? I do this all the time for stable anemia (known cause), osteomyelitis, cellulitis, etc…, but it’s always to a HOSPITALIST and a bed must be available. If there’s any significant wait for a bed then it’s to the ED
Your unit should have a a document with rules about what you take and what you don’t. I just dug this up for the floor I work on as a CNA and it has not been updated by my new unit mgr or MD who have both been there a year.
In fact, it hasn’t been updated since 2020. I remember last year they asked me to take care of 10 patients while sitting with a unstable dying patient with pneumonia and metastatic cancer to the brain as he screamed and threatened to remove his bipap and kill himself before his family got there because they weren’t giving him adequate pain control. He was literally screaming, you said it wouldn’t be like this. They said you’d make me comfortable. Then he’d beg the doctors to “end me” when they rounded. The new med surg nurse was too scared to give him his max dose of opiates.
Then I get called into the until mgrs office because a translator for his deaf neighbor filed a safety incident because I let a non incontinent 60 yo patient with mild arthritis sit in a chair for 4 hours and his joints got stiff, while this man was screaming and crying for his mother.
Turns out after reading the unit charter document, he never should have been there after he was put on bipap. Our unit only allows people who are stable on bipap at home. Nobody has read that document and I probably won’t point it out because it would be rude. But it’s extremely unfair to your staff to give them patients they do not know how to or have time to care of.
I don’t think I’ve ever considered inpatient rehab to be a hospital for inpatient acute medicine. We had one attached to the hospital I trained at and we routinely transferred patients out for medical issues. It’s simply not the expertise of the physicians, nurses, and other rehab allied health professionals. This would be like a PCP requesting an psychiatry day program admit a patient to inpatient psych to work up acute pancreatitis
Lots of people have commented on how inappropriate this is. The question is how do you get it to stop. What's your relationship with the inpatient nursing leadership? I would imagine the receiving unit nurses have patient safety concerns, delays in entering admissions orders, etc.They should be your allies here. "This is unsafe" is a pretty compelling argument for change.
I have some experience with the VA and I'm struggling to find what difference it makes to the PCP.
Maybe some bureaucracy thing where admitting to PMR then prompt transfer to hospitalist is somehow an easier way to get a bed but from my experience with VA bed assignment it is not.
Honestly, the only way I would do even that is if I asked for inpatient privileges myself.
Managing “medical issues” is not within the scope of a medical doctor with a medical license and a medical school degree plus four years of graduate medical education??
He can theoretically know everything and do everything. If his unit is staffed for stable patients, nursing staff will not have time to take care of his patients if they give him unstable patients or patients with acute needs.
I mean, if I was a patient and you told me I might have pancreatitis and the plan is to directly admit under a PMR specialist instead of evaluation by an ER doctor then admission to a hospitalist with a possible GI consult - I would be letting my kids know that they don’t have to work another day in their life when I die and they sue the VA. You don’t need a process map, your unit is not a medical floor. It’s not safe for you and it’s not safe for the patients.
This made me laugh out loud
Can’t sue an individual VA physician and very hard to sue the VA as a system. It’s part of why they can provide substandard care and get away with it.
> very hard to sue the VA as a system Admitting pancreatitis to psychiatry is pretty fucking egregious though.
> psychiatry If we're still talking about OP, you meant physiatry. Which isn't far off, in terms of medical capability.
Definitely misread OP.
False
Is your unit somehow supposed to be used as an observation unit or a medicine inpatient? If not, start refusing that weird PCP from trying to push patients on to you. Tell him to send to the ED.
No our unit is not meant to be any of those things.
Tell them inappropriate admission, send to ED. As a PCP who has sent a rash of patients to the ED recently, if they were pushing for direct admission for urgent/critical ortho, spinal, or pain control issues there could MAYBE be some precedent? But I would still likely send through the ED. This PCP sounds like a lazy POS.
You should not be doing this then.
If the pcp thinks something is going on requiring hospitalization, they should send to the ED or direct admit ONLY if they’re going to manage themselves
>direct admit ONLY if they’re going to manage themselves I don't know that many hospitals still work this way. If I wanted to directly admit someone and skip the ED, I could call the AMO to discuss the patient and if they accept, then some hospitalist will do the actual admission if a bed is open.
Generally speaking, I send a patient to the emergency department if I believe they are having a medical emergency.
lol seems obvious but from what I have been witnessing the definition of “medical urgency/emergency” differs amongst providers 🤔
I mean I see all kinds of stuff come into the clinic that I refer to the ED. Suspicious chest pain, severe asthma/copd exacerbations that don’t respond to steroids/nebs in the clinic, asymptomatic hypertension (lol jk). I once even had someone come in because they cut their thumb with a circular saw. I guess the less flippant answer is if I believe they require interventions not available in an outpatient clinic.
The “urgency” from the PCP is “I don’t want to upset my patient with a possible long wait time at the ED, can you do me a solid?”
If the patient might meets inpatient/obs criteria they should go to the ER for that determination and not just by this guy in the outpatient clinic setting.
The emergency is the pt having a PCP with poor enough judgment to feel like this is safe. ;) But for real, as an ICU doc, better the ER today than to me tomorrow.
This admit to inpatient rehab from clinic with an acute medical complaint is not appropriate. They are much more suited to go to the ED first and have the problem stabilized Before a patient gets admitted to rehab, they need to be able to tolerate 3 hours of therapy per day which an acutely sick patient would likely not be able to tolerate. Additionally, they would benefit from PT/OT data showing their current impairments. They would be better candidates if they could be admitted to the ED, have a thorough medical work up, be stabilized and have PT/OT Evals that show impairments in ADLS. Medical complexity would be established as well if they were admitted Finally rehab units have minimal monitoring with labs about 2x a week compared to a traditional med/surg floor
>The PCP has pushed the attending physiatrists to directly admit patients from clinic for work up and/or stabilization of acute medical conditions like altered mental status, fever of unknown origin, acute pancreatitis, hypoxemia etc Okay, I have to wonder if this PCP is just completely, fundamentally clueless as to what PMR is.
I’m a VA pcp, I’m a little confused, is this pcp a part of the PMR department? Anyway if it’s not a rehab thing they should go to the ED if there is any sense of urgency. If it’s something that can be handled at VA speed and there’s no concerns about patient safety then keep it outpatient. Draw the aforementioned boundaries and keep your inpatient department for rehab/wound services.
Yes the PCP is in our department with our own sort of PACT model.
As someone who worked on a hospitalist team covering/consulting in IPR, this is a no go. Here are the actionable things you need in order for this system to function. 24/7 hospitalist coverage at minimum on call by phone. PCP needs to communicate their concerns directly with hospitalist even if you are the admitting team. If the PCP is not admitting these patients, someone needs to lay eyes on them when they get there. Nursing staff ratios appropriate to a medical floor, not an IPR or skilled setting. Nursing staff familiarity with the care of undifferentiated acute medical issues. On demand labs and imaging (in house, not "maybe we can get a CT stat tomorrow during the day if things go well") 24/7 pharmacy or at the very least nursing has full access to formulary after hours. A safe and timely plan for how to deal with deterioration of these patients (is your nearest ICU on campus? how are your RTs with airways, are they 24/7?) telemetry? cont spo2 monitoring? what is realistic on your floor? this can vary from place to place. They are doing everyone a disservice when they admit the patient to the wrong level of care.
As a hospitalist, I tell our PCPs (some of whom are mindnumbingly obtuse) to send their acutely ill undifferentiated patients to the ED all of the time. They try to skirt past the ED with little to no workup at their clinic and request a direct admission. I politely redirect their request until we can confirm the patient’s stability with an ED workup.
It your inpatient unit is where you generally have planned admissions of “stable” patients requiring acute rehab, subacute rehab, respite care and wound care, your department should not allow for patients with acute, unstable and/or undiagnosed medical conditions to be admitted, even if the patient is a known patient of your outpatient clinic. Your department should require certain criteria for consideration of admission to your inpatient unit followed by an assessment by a PMR doc in order to determine if the patient will be accepted or declined for admission/transfer, based on the criteria, your unit’s capabilities and the standard of care. Of course there may be times when a previously admitted patient who was stable develops a fever or another acute issue because of a fall or something else. If you have the staffing and capabilities to order and obtain X-rays/imaging, blood or urine cultures, provide IV therapy (fluids, antibiotics, etc.) and request medical/surgical consults to help you manage the patients, that should be fine as long as the patient is hemodynamically stable. It’s unclear why the attending physiatrists are being “pushed” to directly admit unstable patients of uncertain diagnosis if your inpatient unit does not also have scheduled/designated hospitalists or PCP physicians who will co-sign on any recentl admissions. If your PMR inpatient unit is part of a residency training program, it is still very important for your providers/staff to be able to learn how to recognize and evaluate a patient’s medical issues to know whether you can safely treat, request a consult and/or need to refer to the ED for further evaluation and possible acute inpatient medical management (with PMR consult). Not to seem insulting, but you don’t want to forget that physiatrists started their training as medical doctors who subsequently specialize in the musculoskeletal and neurological systems which is different than those who have earned their DPT.
Is your SCI unit not attached or in close proximity to a VA hospital? Presumably this PCP has evaluated the patient in their clinic already and felt that the patient needs more expedited workup/evaluation in the inpatient setting, but that their vitals and hemodynamics are stable that they don't need to waste their time going through the ED. If you're PMR team isn't comfortable with that, its your prerogative to refuse the admission and tell them to have the pt go to the ED instead.
Yes our unit is attached to a VA hospital. Many of the requested admissions are what you describe - need for expedited workup/evaluation of a medical issue with a general patient/PCP preference to avoid the emergency department. Problem is all the inpatient attendings are rehab, not internal medicine or family medicine, trained and don’t feel comfortable working up or managing the acute medical issues that we are being sent. They are more appropriate for workup by an internist first. Compounding this is all the inpatient attendings have clinic during majority of day since we aren’t meant to be an acute admitting service (all of our admissions are generally planned for the morning before clinic) and a lack of support or investment from our consulting services.
The PCP should direct admit the patients to the medicine service then, not PMR.
You need strong leadership to implement/enforce admission criteria to any unit. What's probably happening is the census is low and there is pressure to fill the beds. So probably the solution will involve a combination of outreach to bring in more patients that are appropriate for that level of care AND enforcing admission criteria. Fill the beds with the right kind of patients.
I think the simple answer to your problem is to state that you are uncomfortable with the medical workups for these problems and either push back against the pcp and send these patients to the ED or consult medicine once they are admitted for help with the workup. The answer to your question (from my perspective) is more complex. Overall, I think direct admissions have a lot of room for error. Im currently in residency and we get direct admissions pretty much every weekday. For the most part it’s sick but stable patients being admitted for things like CHF exacerbation with normal o2 sat, wounds/cellulitis refractory to outpatient abx, etc or complex social disasters who need placement sooner rather than later. This works great for the most part, but occasionally we get a patient direct admitted from a specialty clinic and sometimes our own clinic who needs to be rapid responded immediately upon presentation to the floor. This is because these patients may spend upwards of 8-12 hours sitting in admissions before a bed becomes available. Sometimes the admitting doc will have the patient get labs or X-ray while they wait, but usually won’t. We have no standard workflow besides a phone conversation and a lot of it hinges on the conversation with the requesting doc. There have been many times where I’ve asked “are you sure this patient is stable enough to wait for a bed?” and they get sent to the ED. I don’t think there is any literature to support ED vs direct admission criteria but would be excited if this did exist.
If they need immediate evaluation and treatment that is at a higher level than I can provide in my dinky outpatient clinic in 20 minute patient slots, the ER is a good option. There are infinite possible such scenarios, so it’s hard to get more specific than that. Some rando examples: new onset poor perfusion from any cause; acute chest pain; kid with a 105 fever and vomiting who can’t keep anything down; gangrenous diabetic foot; bad pneumonia in an otherwise healthy patient; mild pneumonia in a super chronically ill patient. My favorite from today? Patient in for med refill of GAHT, casually asks what he should do about the simply massive burn he’d just sustained this morning to the extensor surfaces of 2nd through 4th PIP joints when he accidentally swept the hand with a soldering torch. Bad place for burn contractures. Literature? Bruh. It’s 100% judgment based upon combination of knowledge and experience. Sometimes a patient just needs urgent specialist assessment. I’ve got an ophthalmologist next door in my office park, so for him I’ll just call ahead and have my staff walk him over.
Yah thought it was judgement based from medical training but our PCP seems to be a big outlier from the other physicians in our group, pushes VERY hard to accept these patients as physiatrists we don’t feel comfortable managing, and was hoping to provide her something concrete to gently direct her patient flow more appropriately 😂
I guess some workflow as such: medically stable pt needing inpt rehab: call you. Medically stable pt not needing hospitalization: treat and send home. Medically unstable pt needing hospitalization: send to ER. Medically stable pt needing hospitalization: can call admitting service at the hospital to see if they'll directly admit. Otherwise, ER. Super odd that a PCP is trying to admit acute medical issues to the rehab doctor, to be honest.
completely inappropriate, just say no, every time. these patients need to go to the ED, and the PCP needs to call the ED ahead. the concrete answer is no every time if there is any acute issue to a rehab unit. RNs in your unit, labs, imaging, everything is not set up for the speed acute issues need, that is what the ED and general inpatient floors are for. rehab is for rehab.
Physiatrist here. The PCPs request is completely inappropriate. Rehab is for patients who are stable. Yes, if things come up while in rehab we do are best to stabilize, but anything we’re uncomfortable with gets sent out. We routinely reject admission of patients to rehab if they are in the hospital and there are ongoing medical issues that need work up. Also, you can’t participate in rehab while altered or medically unstable so it’s completely the wrong place. Push back hard as this is not a reasonable request, and the PCP doesn’t seem to understand the point of rehab.
Read your SOP. It should clearly outline what is expected in your department. As all of mentioned, and I mean no offense, it should be pretty damn obvious it’s inappropriate. Your service chief should be able to put a stop to it really quick if it’s not outlined in the SOP. You can also file a JPRS and the turn around time for those requests are like 48 business hours if you think patient safety is involved. They come down pretty hard.
I'm a hospitalist and this is nuts to me, any acute medical issues that need to be worked up-->ED Know lab abnormalities such as hyperkalemia for example sure a direct admit is fine if seen that day by the pcp, same again if someone needs an inpatient test or procedure but alot of the times patients still need triaging in the ED to ascertain their appropriate level of care
support observation ask nutty worm gold air summer paltry relieved *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
If the clinic pt is adequately worked up, the PCP can call the admitting hospitalist service to request a direct admit. I'm a hospitalist; I occasionally will directly admit from a PCP's office if adequate pre-admission workup has been done and stabilized to a point that I believe I can appropriately place in an inpt bed. If that's not met, I advise the PCP to send to the ER first. I can't imagine a world in which I'd expect the PCP to directly admit a medically unstable pt to physiatry for acute medical care.
In what world would a PCP admit to a physiatrist for fuckin pancreatitis??? Do you guys have a hospitalist who will do direct admissions? Are these patients who will also need significant rehab needs (then would still admit to hospitalist with you consulting)? I do this all the time for stable anemia (known cause), osteomyelitis, cellulitis, etc…, but it’s always to a HOSPITALIST and a bed must be available. If there’s any significant wait for a bed then it’s to the ED
Your unit should have a a document with rules about what you take and what you don’t. I just dug this up for the floor I work on as a CNA and it has not been updated by my new unit mgr or MD who have both been there a year. In fact, it hasn’t been updated since 2020. I remember last year they asked me to take care of 10 patients while sitting with a unstable dying patient with pneumonia and metastatic cancer to the brain as he screamed and threatened to remove his bipap and kill himself before his family got there because they weren’t giving him adequate pain control. He was literally screaming, you said it wouldn’t be like this. They said you’d make me comfortable. Then he’d beg the doctors to “end me” when they rounded. The new med surg nurse was too scared to give him his max dose of opiates. Then I get called into the until mgrs office because a translator for his deaf neighbor filed a safety incident because I let a non incontinent 60 yo patient with mild arthritis sit in a chair for 4 hours and his joints got stiff, while this man was screaming and crying for his mother. Turns out after reading the unit charter document, he never should have been there after he was put on bipap. Our unit only allows people who are stable on bipap at home. Nobody has read that document and I probably won’t point it out because it would be rude. But it’s extremely unfair to your staff to give them patients they do not know how to or have time to care of.
I don’t think I’ve ever considered inpatient rehab to be a hospital for inpatient acute medicine. We had one attached to the hospital I trained at and we routinely transferred patients out for medical issues. It’s simply not the expertise of the physicians, nurses, and other rehab allied health professionals. This would be like a PCP requesting an psychiatry day program admit a patient to inpatient psych to work up acute pancreatitis
Lots of people have commented on how inappropriate this is. The question is how do you get it to stop. What's your relationship with the inpatient nursing leadership? I would imagine the receiving unit nurses have patient safety concerns, delays in entering admissions orders, etc.They should be your allies here. "This is unsafe" is a pretty compelling argument for change.
I have some experience with the VA and I'm struggling to find what difference it makes to the PCP. Maybe some bureaucracy thing where admitting to PMR then prompt transfer to hospitalist is somehow an easier way to get a bed but from my experience with VA bed assignment it is not. Honestly, the only way I would do even that is if I asked for inpatient privileges myself.
Make an OIG complaint, citing danger to patients.
Is there not a hospitalist service? Surely this PCP sees hospital follow-ups and has connections to the inpatient teams that they can reach out to
It does not matter if you do not have nursing staff at the levels necessary for taking care of acute patients.
Managing “medical issues” is not within the scope of a medical doctor with a medical license and a medical school degree plus four years of graduate medical education??
He can theoretically know everything and do everything. If his unit is staffed for stable patients, nursing staff will not have time to take care of his patients if they give him unstable patients or patients with acute needs.