Strategies to Avoid Contested Admissions

How to stop getting your patients blocked

When medical students ask about the downsides of emergency medicine practice, experienced docs commonly identify issues such as burnout, difficult-to-use electronic medical records, stressful work conditions, and working night shifts, weekends, and holidays.  But near the top of any list are “contested admissions,” situations when ED docs and hospitalists and/or consultants disagree over a particular decision surrounding the hospital admission status for a patient.

Contested admissions are not patients with clear-cut diagnoses: e.g. acute myocardial infarction, stroke or sepsis where hospital admission service designation is clear. Contested admissions include a hodge-podge of gray-area admissions where for a variety of reasons either the service assignment is not straightforward, or the admission decision itself is not so clear-cut.

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There have been are no formal estimates of the prevalence of contested admissions.  But they are increasingly common in emergency medicine practice, especially with greater pressure to keep patients out of the hospital. But what is certainly true is that the prevalence of contested admissions varies by hospital.  Important factors are hospital admission privileges of emergency physicians, the personalities of the physicians who work there, and how policies and people combine to create a hospital’s culture.

Every emergency physician has memorable stories about contested admissions, and many of those stories draw feelings of ire, frustration and even personal resentment.

It’s not my problem

A common contested admission scenario is where one person (i.e. ED physician) thinks the patient should be admitted and one person (i.e. hospitalist and/or consultant) thinks the patient can be discharged or that some other pathway is more appropriate.  When the admitting service is called, there is a “Not my problem!” response.

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Examples: admission for pain control with no clear diagnosis; admissions for test X because test X is not readily available, but the patient really needs it anyway; admissions for concerning symptoms (i.e. syncope) that are undiagnosed, but potentially serious.

Alternatively, in contested admissions it may be clear that a patient needs admission, but the patient’s condition straddles two services where it is not entirely apparent who is responsible.  This sometimes results in the Pointed Finger(s).

The archetypal Pointed Finger: the elderly patient with a hip fracture and no comorbidities: “Admit to orthopedics or to medicine?”  Who gets this patient often depends upon the personalities of the physicians involved and whether a history of hypertension on one medication is considered a true comorbidity.

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A third example is an admission that involves an on-the-fly, superimposed contingency. This is called a Why don’t you… For example, “Why don’t you get a CT of the abdomen and then call me back?”  Or, “Why don’t you have surgery see the patient and see where there is anything they recommend?”

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One of the factors that lead to contested admissions is siloed nature of hospitals where each service unit tends to think of itself as an island, rather than part of a single team.  There is an Us v. Them mentality, where group members show loyalty to one another (i.e. among surgeons, among hospitalists or among ED physicians) yet sometimes treat outsiders with contempt.  In this framework, the siloed hospital is a series of tribes, where That ED! is a seen as a common scapegoat.

ED scapegoating occurs for several reasons. First, the ED doles out work to non-ED tribes. Second, work is sometimes doled out in variable ways. Third, histories are often incomplete in the ED which makes this variability in assigning work seem capricious.

Fourth, timing of the work is often more important to the ED than the consultants, because the ED is concerned with ED flow and consultants are less concerned because they don’t live in the ED. Fifth, people are overworked. And sixth, consultants sometimes have greater knowledge about the condition in question.  In this environment, it should be no surprise that calls from the ED — particularly in equivocal situations — can result in contested admissions.

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Issues with contested admissions

Contested admissions are an issue for several reasons.  The first is that they delay patient care and lengthen the time a patient spends in the ED.  Increasing ED dwell time can create problems, particularly as the traditional focus of ED care to diagnose and disposition does not mesh with the goals of inpatient services to coordinate complex recommendations from different consultants.[i]

Second, contested admissions can be a patient safety problem if, through the process of being contested, unsafe care is delivered. This can sometimes create medico-legal problems for the ED physician and sometimes for all parties involved.  For example, take an example where a recommendation to discharge a patient is made by a hospitalist who has not seen the patient or written a note and it ends in a poor outcome.  Although no one involved wants a poor outcome, the ED physician may be the only one on the veritable hook.

Third, it can confuse the patient and the family when they hear one plan by one team and a different one by a second.  Fourth, contested admissions create strife in a work environment where people are, and in general should be, in the business of helping other people.

Finally, they create additional work — sometimes tremendously so — for ED physicians to coordinate care among multiple services, or can create additional work for other services.  Contested admissions don’t always have a sad ending. Sometimes the process of talking through a patient in depth can identify new and important inferences about their condition or new pathways that hadn’t been considered.

Obstacles along the way

It is important to cast contested admissions correctly.  Contested admissions are not always about the ED being in the right and everything non-ED being in the wrong, or vice versa.  Contested admissions are about two or more human beings — each with their own personal style, sense of “ownership” when it comes to patient care and clinical knowledge — disagreeing over the course of action for an ill or injured patient who has entrusted their health to those individuals.

Personal style is important to the outcome of contested admissions because sometimes the stronger-willed or more stubborn party prevails.  Some physicians are known to resort to anger and threatening language to force the other party to concede.  This is common in academic hospitals where attendings by definition have more power than residents, or between residents this can become a battle of wills or just a staring contest. This is what is termed the Forcer tactic, or if particularly harsh, the Intimidator tactic. However, forcing and intimidating can damage relationships between providers and services and creates general disdain.

By contrast, some hospitalist physicians and consultants are Blockers, and repeating blocking can similarly damage relationships.  However, from the perspective of the “blocking” physician, sometimes there may be a clinical justification that deserves discussion; yet forcing (and intimidation) may be necessary when the motivation for blocking is clearly driven by laziness.  Alternatively, ED physicians may opt for a Ninja Move: having the two services fight out who will and won’t take the patient on their service.  The Ninja ED doc acts as referee rather than combatant; i.e. let orthopedics and medicine battle it out. According to Sun Tzu, “The supreme art of war is to subdue the enemy without fighting.”

How this all plays out varies greatly.  Often, how physicians perceive ownership is an important factor: certain physicians feel more ownership about patient care, while others are more apt to try to avoid an equivocal situation.  Ownership is state-dependent, where an overwhelmed physician may be more likely to avoid getting involved: classically, the “…But I just got 10 admissions” refrain.

Ownership can be even less in teaching hospitals where the combination of residents being overworked, not get paid any more for the “next” patient and sometimes juvenile attitudes can create difficult situations.  This can manifest as a resident playing the role of The Wall: a physician who refuses to get involved in the care of a patient, or the more passive aggressive Pocket Veto, where a resident may agree to see the patient, but create unusual delays.  Medical knowledge is vital and can become the decider when one party has greater knowledge about the patient, the condition or available processes of care than the other.

Truce: Beyond Blocking and Forcing

In Daniel Coyle’s recent bestseller, The Culture Code: The Secrets of Highly Successful Groups (2018), he describes how the best functioning teams have three elements: they build safety, they have shared vulnerability and an established purpose. These factors have important implications, as what creates contested admissions in the first place is poor team dynamics.

Creating a safe environment among the various hospital tribes and improving teamwork can be established by sending what Coyle calls “belonging cues.” These are little behaviors that send the message that the other person is cared about and respected. Belonging cues in a group are actually a strong predictor of group performance, even more so than intelligence and leadership.

Examples of belonging cues in the ED may be little gestures that demonstrate that you care about each other.  In addition, physicians can also show their vulnerability which can increase collaboration. For example, starting an admission call with “I have an admission in Room 5 that I need to see right away, when will you be here?” as compared with “How are you? I know you must be having a busy day, but I need your help on case in Room 5. Here is what I think is going on, but it’s a confusing case and I could use your expertise. When might you be available?”

Increasing belonging cues and shared vulnerability can improve collaboration. Belonging can also be promoted organizationally through shared activities that bring together members of different services around activities promotes team building.

This may include an ED physician-hospitalist happy hour where people get to know each other outside of work. Alternatively, a ropes course (i.e. corporate team building) can have value so people can socialize and share their own vulnerabilities.  Finally, it is important to frame a contested admission around the shared purpose of helping the patient, rather than solving a problem for the ED (i.e. freeing up a bed).

Another relevant work from the psychology literature is Influence: The Psychology of Persuasion (1984) by Robert Cialdini. Tactics of influence should be used as first line, rather than resorting early to Forcer or Intimidator tactics.  While not all the weapons from the book apply, two are most relevant. The first is reciprocation: the concept that if someone gives you something, you feel like you owe them something. What can you give a hospitalist? A lot, in fact, like a cold ginger ale and a warm smile when they come to the ED to see your patient.

The second is commitment & consistency: the tendency for people to have a strong desire to act consistently, and are more likely to get to yes if they become committed through small steps.  To get a hospitalist committed, you must not start by “you’ve got to take this patient now, or else.” Rather, “I need your help with this patient, who I think needs admission. Here’s the story… Can you come see him, and let me know what you think?” Once they get involved with the case, they may feel more committed — and have greater ownership — and may be more willing to help finding alternatives.

Being organized in describing the reason for admission is important. Ideally, the conversation should be optimized.  Models include the “5 C’s” model of consultation: Contact, Communicate, Core Question, Collaborate and Close the Loop have been shown to improve effectiveness in medical trainees, and may also reduce the likelihood that an admission would become contested in the first place, especially if an organized presentation is given.[2]

Institutional Policies

While the ideal might be a smooth relationship between the ED and other services, sometimes this cannot occur due to the personalities involved, or other barriers in institutional culture or policies. At the February 2018 meeting of the Emergency Department Benchmarking Alliance, Shari Welch, MD of Intermountain Healthcare, described some of contested admission policies she’d seen around the country.

The first is admission agreements. These originated at Stanford University and describe a matrix of potential admission scenarios. One limitation is that matrices take time to develop and can’t anticipate every situation. An easier way to implement admission agreements is to focus on evidence-based decision rules, such as using the HEART score for chest pain admission. The second is bridge orders — the short-term orders that allow admission before the patient can be seen by the admitting team, so that contested admissions are not held indefinitely in ED limbo. The third is shared metrics where not only is the ED held accountable for ED length of stay, but the whole hospital.

Making the hospitalists bonus contingent of ED length of stay for admitted patients would likely light a tremendous motivational fire. Dr. Welch also describes a “no refusal policy” where the ED is always empowered to determine the admitting service, where admitting services are not allowed to say no. This is in effect, institutionalized brute force, and assumes the ED is right in every decision, which just isn’t true.

Another concept used in some EDs is the concept of the medicine consult. Before you have a grand mal seizure, listen up.  A medicine consult for contested admissions with strict boundaries — done in a timely, helpful way — may help improve patient care by increasing the number of eyes on a patient case, which may help diagnose or even identify previously unrecognized pathways for outpatient care.

In the end, contested admissions will likely continue to be an issue within hospitals that are organized in tribes with differential information, power and priorities.  Ultimately, strategies are needed that prevent blocking by institutionalizing not only clear policies around admissions, but more importantly a culture of belonging, safety and collaboration.

I know you have a story of a contested admission. Please share it in the comments below.

References

[1] Singer AJ, Thode HC Jr, Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011 Dec;18(12):1324-9.

[2] Kessler CS, Tadisina KK, Saks M, Franzen D, Woods R, Banh KV, Bounds R, Smith M, Deiorio N, Schwartz A. The 5Cs of Consultation: Training Medical Students to Communicate Effectively in the Emergency Department. J Emerg Med. 2015 Nov;49(5):713-21