Hospitals charge emergency medicine physicians and hospitalists with the same goal: to provide the best care possible for their patients at all times.
These two groups can, however, at times, find themselves working in opposition to one another due to conflicting priorities: moving patients through the ED quickly, and efficiently managing inpatient length of stay, respectively.
A two-pronged solution stressing empathy and prevention is in order.
The fundamental answer to emergency medicine/hospitalist medicine conflict is seeing things from the other’s perspective. Because such empathy is more easily counseled than practiced, it must be systematized. Anticipate where and when conflicts are likely to occur and then create and communicate policies that avert contention before it has a chance to surface.
Using those maxims as guides, below are five steps that will enable emergency medicine physicians and hospitalists to work collaboratively to resolve conflict and improve patient care.
1. Jointly Develop Guidelines for Specific Areas of Concern
The most common point of contention of the EM/HM relationship is deciding when patients leave the ED and where they’ll go.
Hospitals tend to favor the EM physician’s priority of either discharging patients or admitting them in the shortest amount of time possible -- a task critical for ED-specific performance metrics and the hospital’s bottom line.
Hospitalists, on the other hand, have a quite different perspective: seeing patients early in the day to discharge them before noon, to have beds available for new patients coming from the ED.
The hospitalist’s goal of seeing new admissions is often at odds with efforts to see existing inpatients and discharge them as soon as medically appropriate -- a responsibility that directly impacts reimbursement. A certain amount of pushback is to be expected when physicians are told that they have new admissions when they haven’t had the chance to see the earlier ones, especially when those delays carry performance consequences.
Add to that the fact that specialists can also disrupt negotiations.
While specialists may have the option of refusing to admit a patient, hospitalists don't feel they have the option to say no. When a specialist pressures an ED physician to admit the patient to the hospitalist service rather than to the specialist service, emergency physicians can often feel like they are up against a wall.
The solution lies in establishing criteria for when to admit patients to the hospital versus when to send them to the surgeon.
Making the call about who to admit to the hospitalist or specialist services should not be done at 10 p.m. on a Saturday night, with 20 patients waiting.
Instead, leaders from the ED, the hospitalist program, and the specialist service must come together -- outside of the clinical space -- to determine the criteria they will follow in those high-stakes, high-stress times.
2. Make Systems Changes about X-ray and Lab Test Prioritizing
X-rays and lab tests can also be a source of frustration for emergency and hospitalists providers.
Because tests performed in the emergency department often get returned more quickly than hospitalist-ordered tests, hospitalists may request they be administered in the ED, before admission. Conversely, ED physicians, focused on the patient’s disposition, may question why those tests cannot take place post-admission.
Grasping these pressures -- the time crunch of multiple admissions on the hospitalist side and the intense pressure to move or discharge patients on the ED side -- is the first step to avoiding this impasse.
Hospitalists aren’t trying to be obstructionist; they are thinking primarily about how to get the test results quickly. Knowing that, the emergency physician is equipped to meet halfway: “Will you accept the patient and, prior to sending up, we'll get that X-ray if we can?”
3. Conduct Monthly Case Reviews about Outliers with the Doctors
While emergency physicians focus on discharging or admitting patients quickly, hospitalists often prefer to see patients in the emergency department, to ensure they are proper candidates for admission.
Every hospitalist can remember that one patient who came to the floor and crashed, and who had to be rushed to the ICU; or the few patients who came to the floor but were discharged immediately because they didn’t need to be there.
Because these cases tend to be anomalies, rather than routine, mandated monthly case reviews help provide context. Hospitalists and emergency physicians can put the anomalous anecdote in perspective, showing it to be ... what it truly is: an outlier and one that does not happen as often as perceived.
4. Develop Shared Performance Metrics
Shared clinical performance metrics are some of the most powerful tools for influencing cooperation and professional behavior, according to the two doctors. However, developing such metrics requires that hospitalists and emergency physicians work together to determine which are truly shared.
It’s recommended the two groups adopt the following measures:
- The time between the decision to admit and when the patient reaches the medical floor. The metric is a shared one because the hospitalist depends on ED efficiency to be able to accept those admissions; ED system issues can delay the patient from coming up, or the ED may have too many patients to see at one time.
- The quality of sepsis prevention and care. The ED is the best place to catch sepsis early and is instrumental in treating sepsis accurately. It is an important shared metric because the ED has a tremendous impact on what happens with that patient in the hospital.
- Readmission rates. Although traditionally a hospitalist metric, emergency physicians can assist by identifying patients that have been recently discharged and discussing them with the hospitalist before readmission.
5. Build Political Capital across Specialties
The medical directors of both teams can build “political capital” with each other through regularly scheduled meetings, and then arrange meetings between the entire hospitalist and ED groups, to cultivate social relationships and establish professional rapport.
The more capital built up between leaders over time, the easier it is for one to go to the other director and say, “I need help.” The more collegial the relationship, the less contentious exchanges will be during times of stress.
Ongoing collaboration between emergency physicians and hospitalists will not only help mitigate current conflicts but will also serve to address new issues that arise. None of these changes can be made in a vacuum, however; they require the willingness and engagement of the hospital administration, ED staff, and hospitalist staff to resolve them.