You Say Admit, Consultant Says Discharge? Do This

What if the emergency physician (EP) strongly believes a patient needs to be admitted, but a consultant gives a recommendation over the phone to discharge the patient? If a bad outcome occurs as a result, the EP will possibly share liability with the consultant, warns Debra J. Gradick, MD, FACEP, medical director of the ED at Avista Adventist Hospital in Louisville, CO, and vice president of operations at Serio Physician Management in Littleton, CO.

In this kind of situation, says Gradick, the EP should try to get a different physician to admit the patient, or go to the department head or chief medical officer.

"It is the nature of emergency medicine to rely heavily on consultants," says Chad Kessler, MD, FACEP, FAAEM, section chief of emergency medicine at Jesse Brown VA Hospital, and associate program director for the combined internal medicine/emergency medicine residency at the University of Illinois, Chicago. "Oftentimes, the EP will discharge a patient home based on a phone call from a consultant without a formal written consultation, and end up sleeping uneasy that night."

Rade B. Vukmir, MD, JD, FACEP, chief clinical officer of the National Guardian Risk Retention Group and chairman of education at Emergency Consultants, Inc., both based in Traverse City, MI, and adjunct professor of emergency medicine at Temple University Clinical Campus Pittsburgh, says that although the primary care physician and the specialist are the ones who technically have admitting privileges, the EP is the physician who has examined the patient and done the H&P and the decision-making. Therefore, he says, the EP is actually legally responsible for the patient.

"If you document, 'I wanted to admit the patient but the patient's doctor didn't want to admit them, so I'm sending them home,' you have clearly memorialized the potentially suboptimal decision-making that took place," says Vukmir.

A better option, says Vukmir, may be to take a five- or 10-minute break and then approach the primary care physician or specialist again, and sometimes even a third time.

Ask the patient and family what their preference is, and potentially involve nursing or administration in the decision-making, he says. Then, approach the physician again and say, 'This is our current set of circumstances. For all these reasons, admission would be the preferential pathway. Would you like to re-evaluate the admission process?'" he suggests.

"Oftentimes, that is enough to do it," says Vukmir. "An alternative is involving another specialist, or the patient's primary care physician. Approach the dilemma as the problem solver to assist the admitting physician in their care responsibilities as well."

If you believe a patient is truly at risk, says Vukmir, "from a medicolegal position, you are actually required to proceed up your chain of command." Typically, says Vukmir, the EP would contact the ED director, and if he or she is not available, then the administrator on duty or the chairman of the department.

Vukmir says that he has seen pleadings and allegations regarding the EP's failure to go up the chain of command, listing this as a point of alleged negligence.

"Continue your interventions while working on that process," advises Vukmir. "Just because the patient can't be admitted doesn't mean you can't observe him or her on your own until the next shift, or sometimes the next day," he says. "Never discharge the patient if it's not in their best interest."

Win the Battle

If you believe your patient should be admitted and the consultant disagrees, Frank Peacock, MD, vice chief of emergency medicine at The Cleveland (OH) Clinic Foundation, says, "Your diplomatic skills have to come out at this point. You need to win that battle," he says.

Hospitals that do not allow EPs to have admitting privileges have more bad outcomes than those that do, notes Peacock. "The reason for that is that the EP is more likely to be right than the guy at home talking on the phone," he says.

If you cannot force the admission, says Peacock, you'll need to transfer the patient and document that you believe the patient should be admitted but the hospital has refused. "You are the patient's advocate," says Peacock. "If you think they need to be admitted to the hospital, you are ethically and, generally, legally bound to do your best."

Here are strategies to reduce risks involving differences of opinion as to whether a patient should be admitted:

• Be familiar with your hospital's conflict resolution policy before this scenario occurs.

For instance, the policy may call for the department head to get involved if the emergency physician and specialist cannot agree on a course of action, says Gradick.

• Discuss the difference of opinion in a private area away from the patient.

"If your discussion doesn't really resolve the problem in the patient's best interest, you are still ultimately responsible for the patient," adds Gradick. "You've got to do what is right for the patient."

• Present both opinions to the patient or family and give them your advice.

"Document that there was a thorough discussion," says Gradick. "Should the patient opt to follow the consultant's treatment plan, then obviously you would have the consultant assume full responsibility for the patient."

By informing the patient of both opinions, says Gradick, the patient can make an informed decision about treatment. "It may be easier to disagree privately," she says. "But if the consultant is making a bad decision and your opinion differs, it's incumbent on you to be honest with the patient."

Stick to the facts, says Gradick, such as stating, "'Your physician would like you to be transferred to hospital A and we think you should stay here at Hospital B,' or, 'He would prefer you go home and I would prefer you stay.' You can make the decision."

Document the patient's response in quotes, advises Gradick, and avoid making statements to the patient like, "Well, he doesn't ever want to admit anybody."

• If necessary, obtain a second opinion.

"You can always consult a second physician," says Gradick. "You may have to go to through the chain of command or to the department chairman in order to resolve the issue. Always attempt to do what you feel is best for the patient."

• Document the difference of opinion without inflammatory remarks.

If a case goes to trial, you'll be asked to tell the jury what exactly you said to the consultant to the best of your recollection, says Gradick. "Documenting a brief synopsis of your discussion is the only way to protect yourself," she says.

Finger pointing is never appropriate in the chart, however. "If the record were ever to be subpoenaed, the plaintiff's attorney would have a heyday with inflammatory remarks," says Gradick. "They like nothing better than to pose a physician against another physician. It implies guilt on the part of another physician, which can never accomplish anything good."