Cases & Commentaries
Is It Safe to Be Direct?
A 92-year-old man with hypertension and heart failure (HF) was evaluated by his primary care physician (PCP) for progressive shortness of breath and lower extremity edema. An electrocardiogram (EKG) in the office showed no acute evidence of ischemia, and the patient's vital signs were normal, including pulse oximetry. Given a suspected HF exacerbation, the PCP arranged for a direct admission to the hospital and contacted the hospitalist on call to report the clinical history. The patient was sent to the admitting office to await an available bed, thus avoiding a prolonged emergency department (ED) stay.
Three hours later, a bed opened and the patient was taken to the floor. His vital signs now demonstrated significant instability, with a heart rate of 144 beats per minute, respiratory rate of 30, and pulse oximetry of 90% on room air. The admitting hospitalist was notified, the rapid response team was activated, and the patient received treatment for tachyarrhythmia and hypoxia. The patient's condition rapidly stabilized, and, after 3 days of treatment for his fluid overload and adjustments to his diuretic regimen, he returned home safely. The case prompted the hospital to consider the safety of admitting patients directly from outpatient clinics.
For the patient, a direct admission to the hospital may seem attractive compared to a potentially long wait in the ED. However, as this case illustrates, a direct admission may not always be the safest option, particularly when associated with significant delays in patient registration and unmonitored observation. Furthermore, decreased bed availability, ED overcrowding, and hospitals operating at full capacity often result in increased waiting time for inpatient beds (1), even for patients who are directly admitted. Finally, factors such as inadequate systems for triaging and observing patients awaiting an inpatient bed, loss of information transfer during the handoff, and a complicated admission process itself may hamper the safety of the directly admitted patient, as seen in this case.
The direct admission process can be complex and, like all complex systems, can be aggravated by inherent gaps, or discontinuities of care, that result in patient safety problems.(2) For the patient in this case, waiting 3 hours in the admitting office before a bed became available while also not receiving evaluation and treatment likely represented the biggest gap in care. A previous AHRQ WebM&M commentary noted that a patient in an ED waiting area should be reassessed at regular intervals as "acuity level is not necessarily static."(3) As evident here, the same approach should be applied to the patient in a hospital admitting office waiting for an available bed. The patient in this case aptly demonstrated just how dynamic a patient's clinical condition can be and the rapidity with which it can deteriorate. While presumptively "stable" in the doctor's office, this patient required urgent treatment and restabilization upon eventual evaluation by the hospitalist. One potential solution might be to establish a role for an admission intake nurse who would triage direct admissions based on their diagnoses, vital signs, clinical status, and any preadmission labs or radiology results. Patients who require more urgent care would be transferred to the ED for further management. In addition, providing this safeguard could decrease inappropriate ED referrals from outpatient physicians who may be reluctant to directly admit a relatively stable patient when the typical waiting time for a bed is several hours.
As hospital occupancy increases, so does "boarding time," or the time that admitted patients wait for a bed.(4) One study found that increased boarding time in the ED due to lack of available beds may lead to increased patient morbidity from factors such as missing doses of key medications while waiting.(5) Boarding a patient in an admitting office may pose an even greater hazard given the absence of medical staff and monitoring in this location. In addition to a trained triage nurse as suggested above, another solution might be to board patients in a nurse-supervised "care initiation unit" in which physicians' admission orders such as routine lab work, x-rays, and medication administration could be followed while the patient is waiting for an available bed. The directly admitted patient, who has often been evaluated by a physician and carries a presumptive diagnosis (either based on an office visit or a phone consultation), is an ideal candidate for such a unit. The benefits of a care initiation unit would be threefold: (i) increase patient safety by providing nurse supervision, (ii) improve patient flow by expediting the admission process (i.e., RN assessment, IV placement, phlebotomy) even before a bed becomes available, and (iii) help the inpatient physician through ready access to completed radiology and laboratory testing.
In addition to providing prompt and appropriate care for the directly admitted patient, the process should ensure a complete transfer of key information. A recent systematic review revealed the frequent failure of information transfer that occurs during hospital discharge (6); a similar loss of information may occur during the admission process. Although the patient in this case had an EKG performed in the office, it was not available for the admitting hospitalist to review when the patient arrived on the floor. For the hospitalist, lack of access to outpatient clinic notes, labs, and other significant data impedes the care of a directly admitted patient. Development of a brief "transition record" with listing of diagnoses and medications would facilitate this handoff.
Errors that may compromise patient safety are more likely to occur in complex systems such as a large hospital.(7) At our institution, the direct admission process (to the hospitalist service) requires multiple steps and handoffs: (i) the PCP notifies the senior triage resident about an admission from clinic, (ii) the resident requests a bed from the admitting office, (iii) the bed assignment clerk alerts the hospitalist about the pending admission, (iv) the PCP then calls a report to the hospitalist on call, and (v) this hospitalist passes on the report to the admitting hospitalist once the patient arrives on the floor. In many cases, the admitting hospitalist may not have an opportunity to speak to the PCP directly and commonly meets the patient before doing so. Potential for errors and delays abound in this multi-tiered process. Reducing complexity by simplifying protocols and operations can decrease errors and prevent adverse effects.(7) For example, initially connecting the PCP directly to the actual admitting hospitalist and providing access to a shared electronic health record could mitigate the likelihood of a "voltage drop" in information transfer. Although communication failures are at the root of many of the problems that arise during the direct admission process, the complexity of the system itself may also be partly at fault. A better system (Figure) would eliminate redundant steps and multiple handoffs while implementing safeguards to facilitate the transition to the hospital.
Direct admissions to the hospital can be a frustrating experience for both the physician and the patient. While some PCPs may overuse the direct admission process to help their patients avoid the chaos of the ED, others may shy away from it given the potential safety concerns. Revamping the process would not only address the safety issues but also improve patient throughput by decreasing inappropriate ED referrals. Efficient coordination among different care settings is a key component of a patient-centered health system that strives to meet the needs and expectations of patients.(8) Hospitals can enhance the process of direct admission while optimizing patient safety and preserving a patient-centered approach. Overall, improving coordination of care between PCPs and hospitalists, expediting the initial admission evaluation, eliminating unsupervised boarding time, and implementing safeguards such as a triage protocol will allow for a smoother transition of the patient from the outpatient to inpatient setting.
Steps to improve the direct admission process include:
- Simplify the process by eliminating redundant steps and avoiding multiple handoffs.
- Ensure prompt evaluation or triage of patients upon their initial arrival at the hospital to determine if urgent care is needed.
- Create a nurse-supervised care initiation unit, or its equivalent, to expedite the initial admission evaluation.
- Minimize loss of information transfer by increasing hospitalists' access to outpatient medical records.
Nita S. Kulkarni, MD Instructor, Division of Hospital Medicine Northwestern University Feinberg School of Medicine
Mark V. Williams, MD Professor & Chief, Division of Hospital Medicine Northwestern University Feinberg School of Medicine
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Figure. A Safer Pathway to Direct Admission.