Interactions with admitting or on-call physicians: Documenting discussions and utilizing physician extenders
by Robert A. Bitterman, MD, JD, FACEP, Contributing Editor
A host of medical and legal issues arise when the emergency physician contacts the patient's private physician or the hospital's on-call physician to get a patient admitted to the hospital. This article will address two of those issues: first, the everyday question of what constitutes appropriate and adequate documentation of the conversation with the admitting physician; and second, the relatively new but increasingly common issue of dealing with an on-call physician's physician extenders.
Documentation of conversations with admitting physicians
How much of the conversation with an admitting physician should the emergency physician document in the emergency department (ED) medical record? Everything — well, almost everything. The purpose of the discussion with the admitting physician is twofold: First, to transfer responsibility for the patient from the emergency physician to the admitting physician; and second, to provide sufficient clinical information necessary for the admitting physician to appropriately care for the patient from that point forward. Your job is to ensure the patient's safety, and consequently avoid liability, by effectively communicating to the admitting physician the relevant clinical data, your working diagnosis, and any concerns you harbor regarding the patient's condition. (See Table 1.)
Transfer of Responsibility. Document the time you initiated a call to the admitting physician and the time you discussed the case with him or her. You want to create a bright line, with no uncertainty, of the time you transferred responsibility and liability for the patient. You should place a note in the medical record stating, "Patient's care transferred to Dr. Smith at 1500 hours." (Incidentally, this applies equally for "change-of-shift turnovers" from one emergency physician to another.)
It doesn't matter if the transfer occurs by phone or to the admitting physician at the bedside in the ED. It also irrelevant if the patient remains boarded in the ED awaiting an inpatient bed; it is NOT true that emergency physicians remain responsible or liable for any patient still physically present in the ED. The admitting physician's hospital privileges and duty to the patient do not magically start after the patient leaves the confines of the ED; they begin when he accepts the patient from the emergency physician. (If the emergency physician writes the initial admitting orders, this becomes a much more complicated issue; the medical-legal issue of the emergency physician writing admitting orders is a topic for another time.)
The phone conversation with the admitting physician should also end with a mutual understanding of when the admitting physician will come to the ED or the hospital to see the patient. If a patient with routine pneumonia can be started on antibiotics and seen in the morning, then morning is a reasonable time for the admitting physician to be expected to come into the hospital to see the patient on the inpatient service. If the patient needs to go to the operating room ASAP, then ASAP is the time the physician should be expected to appear in the ED to assume care of the patient. Federal regulations require that the expected "response time" for an on-call physician to come to the ED when asked to see a patient with an emergency condition must be written down, in minutes, in the hospital rules and regulations or medical staff by-laws.1 State law also may govern an on-call physician's response time; Missouri, for example, requires the on-call physician to come to the ED within 30 minutes in certain circumstances.2
You want to avoid the scenario, for example, where you call the surgeon for a patient with acute appendicitis, he says he's on his way, but doesn't show up until many hours later; then, after examining the patient, screams to the family, "Why didn't the ED call me much sooner?"
If an admitting physician or surgeon gives you grief about agreeing to come to the ED within a set time frame, then document your request and the supporting facts in the ED record. Failure to consult the patient to a general surgeon in a timely fashion is a very common source of litigation against emergency physicians in appendicitis cases (or any other serious disease case); you want a clear record that you didn't cause the delay. Don't make inflammatory comments about the admitting or on-call physician in the record, but your notes should accurately reflect the conversation, your concerns, and the subsequent course of events. These are high-risk cases and litigation frequently follows if the patient's appendix ruptures and leads to complications or an adverse outcome, especially if after a prolonged stay in the ED without diagnostic and/or surgical intervention.
As an emergency physician, you must be willing to take heat from the difficult-to-deal-with or "incompetent" admitting or on-call physician on behalf of your patients.
Communication of Clinical Information. You want the admitting physician to appreciate the patient's clinical status at the time of the call, and assure that his understanding coincides with your impression of the patient's condition. Be sure to relate your diagnosis, any significant abnormal physical findings, and your clinical impression of the seriousness of the patient's condition. You should also inform the admitting physician of any abnormal laboratory or X-ray studies. The scenario you want to avoid here is an assertion by the admitting physician such as, "If the ED had only told me the glucose was 1,000 and the arterial pH 6.9, I'd have gone to the ED immediately to see the patient."
The medical record should reflect the full scope of your conversation about the patient. Document that you gave to the admitting physician the diagnosis, any abnormal physical findings, and the current condition of the patient. Also, specifically document which lab and X-ray data were provided to the admitting physician. Placing in the ED medical record that "told glucose over 1000 and pH 6.9" or "told potassium 8.5" eliminates misunderstandings and minimizes liability of the emergency physician; it also enhances patient safety. (See Table 2.)
If you don't think the admitting physician understands your concerns or appears somewhat confused at the moment, as often happens when you awake a physician in the middle of the night, then ask him or her to get a cup of coffee and call you back in few minutes. Also, it is wise to review the admitting orders of the physician to be sure the orders make sense, especially at night, since you have a much greater understanding of the patient's condition at that time.
Midlevel providers involved in on-call services to the ED
Physician assistants (PAs) and nurse practitioners (NPs), often called midlevel providers or physician extenders, are now commonly involved in providing emergency care. Many admitting physicians, including pediatricians, orthopedic surgeons, internists, and cardiologists, frequently use PAs or NPs in their practices and interactions with the ED. However, federal law, the Emergency Medical Treatment and Active Labor Act (EMTALA), and Center for Medicare and Medicaid Services (CMS) regulations distinctly require the hospital to provide on-call physicians, so it is clear that the hospital may not allow a midlevel provider to take ED call instead of a physician.3 Critical access hospitals (CAHs), however, as defined by federal regulations, while subject to EMTALA's requirements, may allow PAs or NPs to take ED call in certain circumstances.4
Additionally, all states, the District of Columbia, and the majority of U.S. territories have laws governing the practice of PAs and NPs.5,6 Each state defines and/or limits the scope of practice allowed by each type of provider and addresses the required level of supervision.5,7 Thus, state laws as well as federal law must be reviewed and considered before a hospital allows a midlevel provider to be involved in providing admitting or on-call services to the ED.
The real issue for emergency physicians, however, is whether the admitting on-call physicians may permit one of their associated midlevel providers to answer the call from the ED or evaluate the patient in the ED on their behalf. One of the government's "guidance" comments has confused the issue. CMS states that:
"…circumstances [exist] in which a physician assistant may be the appropriate practitioner to respond to a call from an emergency department … that is providing screening or stabilization mandated by EMTALA… . However, any decision as to whether to respond in person or direct the physician assistant to respond should be made by the responsible on-call physician, based on the individual's medical needs and the capabilities of the hospital, and would, of course, be appropriate only if it is consistent with applicable State scope of practice laws and hospital bylaws, rules, and regulations."8,9
This language has been misinterpreted by some to mean that the on-call physician may decide whether the midlevel provider can answer the page from the emergency department, or respond in person to the ED, instead of the on-call physician.
The decision of who to speak to by phone or who must present to the ED must be left to the emergency physician or other medical staff member requesting the services of the on-call specialists. The government agrees, stating:
"We believe any disagreement between the two [emergency physician and the on-call specialist] regarding the need for an on-call physician to come to the hospital and examine the individual must be resolved by deferring to the medical judgment of the emergency physician or other practitioner who has personally examined the individual and is currently treating the individual."9,10
Thus, it's perfectly appropriate to list the name of the on-call physician on the call panel and the name of the physician's midlevel provider. For routine admissions or follow-up care, the emergency physician can contact the midlevel provider to arrange the necessary services. However, for true emergencies or other instances where the emergency physician wants phone consultation from the on-call specialist directly, or needs the specialist to come to the ED to evaluate and treat the patient, the emergency physician must be able to contact the specialist directly at any time. The choice of which on-call individual to contact and which one must come to the ED must always rest with the physician examining the patient in the ED.
Every hospital needs its admitting medical staff and the emergency physicians to define the role of a PA or NP in providing on-call services to the ED and draft written policy and procedure regarding the admitting or on-call physicians' duties to supervise their midlevel providers and respond to the ED when requested by the emergency physicians.
Both the American College of Emergency Physicians and the American Medical Association offer policies and procedures regarding the role of PAs and NPs in the ED.11-13
1. 42 CRF 489.24; See reference #9: CMS Interpretive Guidelines, May 2004.
2. MO. 19 C.S.R.30-20.021.
3. 42 USC 1395cc(a)(1)(I)(iii); 42 CFR 489.20(r)(2).
4. 42 CFR 485.618(d)(1): Personnel Standards.
5. An extensive summary of each state's laws and regulations relating to physician assistants is available at www.aapa.org/gandp/StateLawsandRegulations.htm. Accessed February 6, 2007.
6. See also www.aanp.org for laws related to NPs. Accessed February 6, 2007.
7. For a list of PA regulatory agencies with addresses, phone numbers, and web links see www.aapa.org/gandp/statereg.html. Accessed February 6, 2007.
8. 68 Federal Register 53256 (2003).
9. CMS Interpretive Guidelines. Issued in May 2004 for state surveyors and CMS Regional offices regarding the enforcement of EMTALA. Available on line at http://www.cms.hhs.gov/manuals/Downloads/som107ap_v_emerg.pdf.
10. 68 Federal Register 53255 (2003).
11. ACEP Policy #400117, Guidelines on the Role of Physician Assistants in the Emergency Department, Approved by the ACEP Board of Directors February 2002. Accessed February 6, 2007 and available at: http://www.acep.org/webportal/PracticeResources/PolicyStatements/hlthwrkforce/guidelinespanursepract.htm.
12. ACEP Policy #400123, Guidelines on the Role of Nurse Practitioners in the Emergency Department, Approved by the ACEP Board of Directors June 2000. Accessed February 6, 2007 and available at: http://www.acep.org/webportal/PracticeResources/PolicyStatements/hlthwrkforce/guidelinespanursepract.htm.
13. AMA Policy H-35.989: Physician's Assistants; AMA Policy H-160.947: Physician Assistants and Nurse Practitioners; AMA Policy H-160.950: Guidelines for Integrated Practice of Physician and Nurse Practitioner; AMA Policy H-360.987: Principles Guiding AMA Policy Regarding Supervision of Medical Care Delivered by Advanced Practice Nurses in Integrated Practice. See also AMA Policies H-135.975; and H-425.997.