Emergency and Hospital Medicine: A Call for Collaboration
Emergency and Hospital Medicine: A Call for Collaboration
Improved Efficiency, Optimization of Hospital Use, and Avoidance of Hospital Readmissions Boarding time for patients awaiting hospital admission is a primary indicator of ED and hospital efficiency. Median time from the admission decision to ED departure is one of the voluntary core quality measures of the Centers for Medicare and Medicaid Services (CMS). Prolonged boarding ties up ED resources, leads to delays in care for new and existing patients, and results in increased patient elopement, ambulance diversion, and decreased surge capacity. It has been associated with increased hospital length of stay, adverse events, errors, and lost revenue. Effective strategies to reduce boarding time largely rely on enhanced teamwork and communication between ED and admitting staff control of non-ED hospital use. Increasingly, hospitalists govern hospital capacity by their management of hospital admissions, inter-unit transfers, and discharges. Coordinated involvement of the hospitalist earlier in the management of ED-boarded patients can help ensure safer care and avoid wasted time in completing patient work-ups. Within some EDs, hospitalists expedite admissions or facilitate safe and timely ED discharge of patients, just as they coordinate care of inpatients to expedite their safe discharge. Emergency physicians can start treatment plans early in an admitted patient's care (e.g., by ordering relevant studies, starting antibiotics) to improve the efficiency of inpatient care.
Improved decision-making about the need for hospital admission also enhances ED capacity. Hospitalization is the most expensive medical decision made in the context of ED care. Critically evaluating need for hospitalization and identifying outpatient alternative plans for care can substantially reduce costs. Hospitalists are the link to the community's primary care network and can be of tremendous assistance in identifying effective outpatient care plans as alternatives to admission. Hospitalists are often knowledgeable about outpatient care strategies not typically utilized by emergency physicians, such as peripherally inserted central catheter (PICC) lines, outpatient parenteral antibiotic therapy, and transfers to skilled nursing facilities and hospice settings. Collaboration on the management of patients in clinical decision units allows a short-term ED care plan to help further determine need for hospital care. Avoidance of unnecessary admissions will be increasingly important as the CMS and other payers continue to focus on both 1-day admissions and "inappropriate" admissions.
CMS and other payers are moving to a reimbursement model that reinforces coordinated care, such as through bundled payments. Hospitals will be penalized for same-diagnosis readmissions within a specific time period; the most widely deployed penalties to date are for readmission for heart failure, myocardial infarction, or pneumonia within 30 days of hospital discharge. The first way to avoid hospital readmission is to avoid an index hospital admission; many strategies apply to both. Enhanced emergency physician and hospitalist coordination of effective outpatient management provides an alternative to hospital readmission for patients who return to the ED. Protocolization and consistency in hospitalist discharges back to primary care physicians or rehabilitation facilities that maximize necessary patient and caregiver support, medication adherence, and appropriate follow-up will be instrumental in reducing avoidable admissions and readmissions.
Quality and Safety Goals Many established hospital quality and safety goals can be promoted through better emergency physician and hospitalist collaboration. The Joint Commission's National Patient Safety Goals emphasize improved staff communication (e.g., through transitions of care from emergency physicians to hospitalist), and medication safety (e.g., developing systems for medication reconciliation). In addition to ED boarding time, core quality measures developed by The Joint Commission and CMS include many items for which shared responsibility exists between emergency physicians and hospitalists, such as management of community-acquired pneumonia, acute myocardial infarction, congestive heart failure, and stroke. Hospitalists increasingly manage intensive care unit (ICU) patients and, like emergency physicians, utilize procedural sedation, perform bedside ultrasound and invasive procedures, and manage mechanically ventilated patients. Coordination of efforts between specialists would help to establish best practice protocols, identify common equipment needs, and develop improved credentialing and safety monitoring processes.
Transitions of Care/Communications Issues In addition to the emergency physician–hospitalist patient transition at the time of admission, patients benefit from clear communication across other information interfaces, including primary care physician (PCP)/nursing facility to ED during (or in advance of) ED care, hospitalist to PCP/nursing facility at the conclusion of inpatient care, and communication to facilitate care coordination outside the hospital. Systematic transfer of information across these interfaces is critical to good continuity of care and reduces the likelihood of near-term rehospitalization. Emergency physicians and hospitalists should work more closely together with information services and hospital administration to maximize the efficiency of such information transfers, to identify and strengthen weak links in the communication chain, and improve patient care across the continuum.
Risk Stratification Several clinical risk-stratification tools are used in the management of acutely ill patients, which may better inform the need for inpatient care and monitoring. Examples of validated scoring systems include the Thrombolysis in Myocardial Infarction Risk Score for Non-ST-Segment-Elevation Acute Coronary Syndrome; the Pneumonia Severity Index (PSI), CURB-65, and SMART-COP scores for pneumonia; and various assessments for the likelihood of venous thromboembolism. The ED-to-hospital transition affords many opportunities for developing consensus on risk assessment and patient disposition protocols. These scoring systems offer a consistent platform across which communication between emergency physicians and hospitalists about a patient's need for hospital admission and the level of care required can be improved.
Future of Bundled Payments/Diagnosis-Related Group Payments As the payment mechanism for inpatient stays shifts from case rates and per diem payments to a bundled or diagnosis-related group payment model, inpatient services will need to work together to optimize resource use and throughput to protect revenue. Improved collaboration between emergency physicians and hospitalists is critical to achieving this success and providing optimal, evidence-based care in a manner that facilitates efficiency and improves the payer's bottom line.
Regulatory/Public Reporting Requirements As public reporting of hospital data becomes more widespread and sophisticated, and patients, payers, and competing hospitals analyze them, the motivation for change in basic processes—such as the transition from the ED to the hospital—will increase. Organizations are already competing for better reporting of performance measures, while internally linking employee and provider incentive payments to achieving better scorecards. Examples of such parameters include the core measures for myocardial infarction, heart failure, pneumonia, and post-operative venous thromboembolism. Many times one specialty acting alone cannot meet all the requirements for a specific disease target. Core measures for community-acquired pneumonia are illustrative, because the timing of blood cultures and initial antibiotic therapy is largely the responsibility of emergency physicians, whereas ensuring that smoking cessation education and pneumococcal or influenza vaccine are given are in the domain of hospitalists.
Staffing Support/Hospital Administration Comprehension of Mission Staffing support for hospital-based specialties such as Emergency and Hospital Medicine is similar in that most have moved to a shift-based scheduling model, as used in nurse staffing. Over the years, Emergency and Hospital Medicine have developed their own guidelines for staffing, but as needs increase to meet aggressive quality, service, and outcomes goals, engagement of hospital administration is important. Further, hospitalists are often teamed with nurse practitioners, case managers, pharmacists, social workers, and nurses to meet the needs of throughput, quality, and error reduction. Multidisciplinary staffing must also be factored into the support requirements for Emergency and Hospital Medicine groups.
Organized Collaboration As hospital-based physicians, it is reasonable to expect emergency physicians and hospitalists to collaborate effectively and in an ongoing manner. There is much to be gained from regularly scheduled group interactions, with discussion of specific issues—such as "the pneumonia pathway," "how to facilitate work-ups from the clinical decision unit," "deployment of resources in sepsis patients"—for which both groups can be prepared in advance. It is also useful to regularly review difficult cases or circumstances encountered by the two services. Such regular collaboration fosters improved communication and promotes personal investment in making the system work better.
Training Opportunities Several opportunities exist for training to help practitioners better understand each other's needs. Once in practice, hospitalists have a disproportionate experience in being contacted about patients presorted by emergency physicians thought to require hospital admission, but may be deficient in their experience evaluating the full spectrum of patients and factors that may affect disposition decisions. Internal Medicine residency rotations in the ED facilitate learning how to decide which patients should be admitted and which can be managed as outpatients, and how to start management of patients early in the ED.
Emergency Medicine residents are spending time on ward medicine and ICU rotations, gaining an understanding of hospitalists' many duties, ongoing management of patients, discharge planning, and quality-of-care issues. They also benefit from learning—from the inpatient perspective—common deficiencies in ED management of hospitalized patients and novel options for outpatient disposition. Some combined Emergency Medicine-Internal Medicine residency programs exist, which present natural opportunities for training of "super-hospitalists," who work in both capacities and further promote coordination of services within centers. In teaching hospitals, joint educational sessions such as grand rounds and morbidity-and-mortality conferences between Emergency and Hospital Medicine groups foster an improved working relationship that optimizes the quality and efficiency of patient management. Opportunities exist for joint development of skills in leadership, teaching, research, and quality.
Diagnosis-Specific Opportunities to Deliver Evidence-Based Care Although the number and types of patients crossing the Emergency Medicine-Hospital Medicine interface continue to increase, there are some specific diagnoses for which guidelines help guide collaboration. We would expect that tighter adherence to guidelines would result in better patient outcomes, shorter lengths of stay, and fewer avoidable readmissions.
Non-ST-segment Elevation Acute Coronary Syndrome Unlike ST-segment elevation myocardial infarction, which is typically managed briefly by emergency physicians and then by cardiologists, the more common non-ST-segment-elevation acute coronary syndrome is now often managed after admission by hospitalists, whether or not the patient undergoes catheterization while an inpatient. Published guidelines call for a number of diagnostic and therapeutic actions that readily lend themselves to inclusion in a protocol initiated in the ED and continued by hospitalists. Previous work has validated the success of quality-focused, guidelines-supported acute coronary syndrome care across this transition.
Heart Failure Many measures have been demonstrated to improve symptoms, decrease length of stay, and reduce the likelihood of costly short-term readmission for this increasingly common diagnosis. Initiation of "triple therapy" (diuretics, beta-adrenergic blockers, and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker agents) is essential to quality heart failure care and can be driven by an Emergency and Hospital Medicine protocol, which, when followed, can be expected to improve both clinical and economic outcomes.
Community-Acquired Pneumonia Risk-stratification and disposition strategies for patients with community-acquired pneumonia are perhaps the best studied of any infectious disease diagnosis. The Agency for Healthcare Research and Quality-funded Pneumonia Patient Outcomes Research Team group developed and validated the PSI, a risk-stratification scoring system to identify patients with low 30-day mortality risk who may be safe to discharge for outpatient care or, alternatively, are higher risk and may require hospitalization. PSI use has been demonstrated to reduce pneumonia hospital admission rates safely. A simpler score used for this purpose is called CURB-65. SMART-COP and the Infectious Diseases Society of America guidelines are other tools developed to discriminate among higher-risk patients and guide the decision for ICU admission. Common awareness and consistent use of these schemes has the potential to ensure efficiencies in management and more optimal hospital resource utilization.
Skin and Skin Structure Infections With greater coordination among emergency and hospitalist physicians, and wound care resources, many more hospitalized patients with skin and soft tissue, and bone infections, could be treated effectively as outpatients. A long-acting antibiotic regimen could be initiated in the ED with arranged 24–48-h follow-up, with patients subsequently assessed for transition to oral antibiotics. For patients requiring a longer course of parenteral therapy, PICC and outpatient parenteral antibiotic therapy can be initiated from the ED.
Sepsis Quality standards for management of sepsis and septic shock are being promoted in hospitals. This movement is related to the dramatic mortality reduction demonstrated in a randomized trial comparing early goal-directed therapy (EGDT) to standard resuscitation. EGDT includes central venous and arterial pressure monitoring to guide fluid resuscitation and pressor use; its unique feature is sequential therapeutic interventions, including anemia-correcting blood transfusion, dobutamine, and mechanical ventilation, to increase sub-threshold central venous oxygen saturation (or, more recently, lactate clearance). Quality standards also include time posts for severe sepsis recognition and administration of appropriate antimicrobials. Because these standards are being applied to both ED-presenting and in-hospital-onset sepsis patients, development of a common management protocol represents an important opportunity for Emergency and Hospital Medicine collaboration. Although successful ED-based strategies have been described, EGDT can be labor intensive and may be difficult to institute in busy EDs. Hospitalists can assist with expedited ICU transfer. Another model proposes an on-call sepsis management team. Emergency physicians and hospitalists should develop team-based management strategies for these and other critically ill patients.
Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD) COPD is a common ED presentation that often results in admission and significantly contributes to readmissions. Emergency physicians and hospitalists should jointly develop pathways for COPD management so that appropriate therapy is started in the ED and seamlessly continued in the hospital. Hospitalist adoption of therapeutic strategies at discharge to lessen the risk of near-term exacerbation and ED re-visit should also be encouraged.
Transient Ischemic Attack (TIA) TIA is a diagnosis that in the not-too-distant past was an automatic admission to Neurology. Now these patients are often managed by hospitalists and do not always require an inpatient Neurology consultation. Emergency physicians and hospitalists can jointly develop pathways for TIA that allow expeditious disposition. The logistics of prompt scheduling of, for example, Holter monitoring, echocardiograms, computed tomographic scanning, and carotid Doppler studies lend themselves to protocolization. Avoidance of admission may be achieved for many patients with a well-defined pathway initiated in the ED and continued by the Hospital Medicine service.
Pain Management and Palliative Care Pain is the most common reason patients present to EDs. Patients who require hospital admission for intractable pain are particularly challenging for both emergency physicians and hospitalists. An attitude of suspicion, lack of objective knowledge about underlying medical or surgical problems, and suboptimal transitions between ED and hospital and between hospital and continuing care combine to present formidable obstacles for effective pain management in the acute care setting. A consistent approach to analgesia by emergency physicians and hospitalists aimed both at improved understanding of patient needs and expectations for pain relief, and at patient education regarding pain, can improve outcomes and satisfaction.
Likewise, patients who might best be managed with a palliative or hospice-based approach are often encountered at the emergency physician-hospitalist interface. Improved pain management strategies, early involvement of case managers, and protocol-driven, smooth transitions from hospital to hospice, or even from ED to hospice, would help decrease the inordinate expense of end-of-life care and reduce the frustration experienced by providers, patients, and caregivers in those difficult times. Hospitalists are often more familiar with hospice services than are emergency physicians, and closer collaboration for the development of a consistent approach to palliative care would be beneficial to all.
Prophylaxis for Venous Thromboembolism Venous thromboembolism (VTE) prevention is a national quality issue endorsed by The Joint Commission, Surgeon General, and many professional organizations. Well under one-half of hospitalized patients in the United States currently receive appropriate VTE prevention. Emergency physicians and hospitalists should work closely together to help ensure VTE prevention processes occur within the hospital setting, not only to promote better clinical outcomes, but also to avoid payment penalties and adverse public-reporting issues. This may lead to initiation of prophylaxis by emergency physicians, especially when ED boarding times delay initiation of routine inpatient orders. When evidence-based prophylaxis is not provided, patients with "preventable" VTE complications are readmitted to the hospital, thus leading to un-reimbursed "never events."
Discussion
Shared Interests
Improved Efficiency, Optimization of Hospital Use, and Avoidance of Hospital Readmissions Boarding time for patients awaiting hospital admission is a primary indicator of ED and hospital efficiency. Median time from the admission decision to ED departure is one of the voluntary core quality measures of the Centers for Medicare and Medicaid Services (CMS). Prolonged boarding ties up ED resources, leads to delays in care for new and existing patients, and results in increased patient elopement, ambulance diversion, and decreased surge capacity. It has been associated with increased hospital length of stay, adverse events, errors, and lost revenue. Effective strategies to reduce boarding time largely rely on enhanced teamwork and communication between ED and admitting staff control of non-ED hospital use. Increasingly, hospitalists govern hospital capacity by their management of hospital admissions, inter-unit transfers, and discharges. Coordinated involvement of the hospitalist earlier in the management of ED-boarded patients can help ensure safer care and avoid wasted time in completing patient work-ups. Within some EDs, hospitalists expedite admissions or facilitate safe and timely ED discharge of patients, just as they coordinate care of inpatients to expedite their safe discharge. Emergency physicians can start treatment plans early in an admitted patient's care (e.g., by ordering relevant studies, starting antibiotics) to improve the efficiency of inpatient care.
Improved decision-making about the need for hospital admission also enhances ED capacity. Hospitalization is the most expensive medical decision made in the context of ED care. Critically evaluating need for hospitalization and identifying outpatient alternative plans for care can substantially reduce costs. Hospitalists are the link to the community's primary care network and can be of tremendous assistance in identifying effective outpatient care plans as alternatives to admission. Hospitalists are often knowledgeable about outpatient care strategies not typically utilized by emergency physicians, such as peripherally inserted central catheter (PICC) lines, outpatient parenteral antibiotic therapy, and transfers to skilled nursing facilities and hospice settings. Collaboration on the management of patients in clinical decision units allows a short-term ED care plan to help further determine need for hospital care. Avoidance of unnecessary admissions will be increasingly important as the CMS and other payers continue to focus on both 1-day admissions and "inappropriate" admissions.
CMS and other payers are moving to a reimbursement model that reinforces coordinated care, such as through bundled payments. Hospitals will be penalized for same-diagnosis readmissions within a specific time period; the most widely deployed penalties to date are for readmission for heart failure, myocardial infarction, or pneumonia within 30 days of hospital discharge. The first way to avoid hospital readmission is to avoid an index hospital admission; many strategies apply to both. Enhanced emergency physician and hospitalist coordination of effective outpatient management provides an alternative to hospital readmission for patients who return to the ED. Protocolization and consistency in hospitalist discharges back to primary care physicians or rehabilitation facilities that maximize necessary patient and caregiver support, medication adherence, and appropriate follow-up will be instrumental in reducing avoidable admissions and readmissions.
Quality and Safety Goals Many established hospital quality and safety goals can be promoted through better emergency physician and hospitalist collaboration. The Joint Commission's National Patient Safety Goals emphasize improved staff communication (e.g., through transitions of care from emergency physicians to hospitalist), and medication safety (e.g., developing systems for medication reconciliation). In addition to ED boarding time, core quality measures developed by The Joint Commission and CMS include many items for which shared responsibility exists between emergency physicians and hospitalists, such as management of community-acquired pneumonia, acute myocardial infarction, congestive heart failure, and stroke. Hospitalists increasingly manage intensive care unit (ICU) patients and, like emergency physicians, utilize procedural sedation, perform bedside ultrasound and invasive procedures, and manage mechanically ventilated patients. Coordination of efforts between specialists would help to establish best practice protocols, identify common equipment needs, and develop improved credentialing and safety monitoring processes.
Transitions of Care/Communications Issues In addition to the emergency physician–hospitalist patient transition at the time of admission, patients benefit from clear communication across other information interfaces, including primary care physician (PCP)/nursing facility to ED during (or in advance of) ED care, hospitalist to PCP/nursing facility at the conclusion of inpatient care, and communication to facilitate care coordination outside the hospital. Systematic transfer of information across these interfaces is critical to good continuity of care and reduces the likelihood of near-term rehospitalization. Emergency physicians and hospitalists should work more closely together with information services and hospital administration to maximize the efficiency of such information transfers, to identify and strengthen weak links in the communication chain, and improve patient care across the continuum.
Risk Stratification Several clinical risk-stratification tools are used in the management of acutely ill patients, which may better inform the need for inpatient care and monitoring. Examples of validated scoring systems include the Thrombolysis in Myocardial Infarction Risk Score for Non-ST-Segment-Elevation Acute Coronary Syndrome; the Pneumonia Severity Index (PSI), CURB-65, and SMART-COP scores for pneumonia; and various assessments for the likelihood of venous thromboembolism. The ED-to-hospital transition affords many opportunities for developing consensus on risk assessment and patient disposition protocols. These scoring systems offer a consistent platform across which communication between emergency physicians and hospitalists about a patient's need for hospital admission and the level of care required can be improved.
Future of Bundled Payments/Diagnosis-Related Group Payments As the payment mechanism for inpatient stays shifts from case rates and per diem payments to a bundled or diagnosis-related group payment model, inpatient services will need to work together to optimize resource use and throughput to protect revenue. Improved collaboration between emergency physicians and hospitalists is critical to achieving this success and providing optimal, evidence-based care in a manner that facilitates efficiency and improves the payer's bottom line.
Regulatory/Public Reporting Requirements As public reporting of hospital data becomes more widespread and sophisticated, and patients, payers, and competing hospitals analyze them, the motivation for change in basic processes—such as the transition from the ED to the hospital—will increase. Organizations are already competing for better reporting of performance measures, while internally linking employee and provider incentive payments to achieving better scorecards. Examples of such parameters include the core measures for myocardial infarction, heart failure, pneumonia, and post-operative venous thromboembolism. Many times one specialty acting alone cannot meet all the requirements for a specific disease target. Core measures for community-acquired pneumonia are illustrative, because the timing of blood cultures and initial antibiotic therapy is largely the responsibility of emergency physicians, whereas ensuring that smoking cessation education and pneumococcal or influenza vaccine are given are in the domain of hospitalists.
Staffing Support/Hospital Administration Comprehension of Mission Staffing support for hospital-based specialties such as Emergency and Hospital Medicine is similar in that most have moved to a shift-based scheduling model, as used in nurse staffing. Over the years, Emergency and Hospital Medicine have developed their own guidelines for staffing, but as needs increase to meet aggressive quality, service, and outcomes goals, engagement of hospital administration is important. Further, hospitalists are often teamed with nurse practitioners, case managers, pharmacists, social workers, and nurses to meet the needs of throughput, quality, and error reduction. Multidisciplinary staffing must also be factored into the support requirements for Emergency and Hospital Medicine groups.
Opportunities
Organized Collaboration As hospital-based physicians, it is reasonable to expect emergency physicians and hospitalists to collaborate effectively and in an ongoing manner. There is much to be gained from regularly scheduled group interactions, with discussion of specific issues—such as "the pneumonia pathway," "how to facilitate work-ups from the clinical decision unit," "deployment of resources in sepsis patients"—for which both groups can be prepared in advance. It is also useful to regularly review difficult cases or circumstances encountered by the two services. Such regular collaboration fosters improved communication and promotes personal investment in making the system work better.
Training Opportunities Several opportunities exist for training to help practitioners better understand each other's needs. Once in practice, hospitalists have a disproportionate experience in being contacted about patients presorted by emergency physicians thought to require hospital admission, but may be deficient in their experience evaluating the full spectrum of patients and factors that may affect disposition decisions. Internal Medicine residency rotations in the ED facilitate learning how to decide which patients should be admitted and which can be managed as outpatients, and how to start management of patients early in the ED.
Emergency Medicine residents are spending time on ward medicine and ICU rotations, gaining an understanding of hospitalists' many duties, ongoing management of patients, discharge planning, and quality-of-care issues. They also benefit from learning—from the inpatient perspective—common deficiencies in ED management of hospitalized patients and novel options for outpatient disposition. Some combined Emergency Medicine-Internal Medicine residency programs exist, which present natural opportunities for training of "super-hospitalists," who work in both capacities and further promote coordination of services within centers. In teaching hospitals, joint educational sessions such as grand rounds and morbidity-and-mortality conferences between Emergency and Hospital Medicine groups foster an improved working relationship that optimizes the quality and efficiency of patient management. Opportunities exist for joint development of skills in leadership, teaching, research, and quality.
Diagnosis-Specific Opportunities to Deliver Evidence-Based Care Although the number and types of patients crossing the Emergency Medicine-Hospital Medicine interface continue to increase, there are some specific diagnoses for which guidelines help guide collaboration. We would expect that tighter adherence to guidelines would result in better patient outcomes, shorter lengths of stay, and fewer avoidable readmissions.
Non-ST-segment Elevation Acute Coronary Syndrome Unlike ST-segment elevation myocardial infarction, which is typically managed briefly by emergency physicians and then by cardiologists, the more common non-ST-segment-elevation acute coronary syndrome is now often managed after admission by hospitalists, whether or not the patient undergoes catheterization while an inpatient. Published guidelines call for a number of diagnostic and therapeutic actions that readily lend themselves to inclusion in a protocol initiated in the ED and continued by hospitalists. Previous work has validated the success of quality-focused, guidelines-supported acute coronary syndrome care across this transition.
Heart Failure Many measures have been demonstrated to improve symptoms, decrease length of stay, and reduce the likelihood of costly short-term readmission for this increasingly common diagnosis. Initiation of "triple therapy" (diuretics, beta-adrenergic blockers, and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker agents) is essential to quality heart failure care and can be driven by an Emergency and Hospital Medicine protocol, which, when followed, can be expected to improve both clinical and economic outcomes.
Community-Acquired Pneumonia Risk-stratification and disposition strategies for patients with community-acquired pneumonia are perhaps the best studied of any infectious disease diagnosis. The Agency for Healthcare Research and Quality-funded Pneumonia Patient Outcomes Research Team group developed and validated the PSI, a risk-stratification scoring system to identify patients with low 30-day mortality risk who may be safe to discharge for outpatient care or, alternatively, are higher risk and may require hospitalization. PSI use has been demonstrated to reduce pneumonia hospital admission rates safely. A simpler score used for this purpose is called CURB-65. SMART-COP and the Infectious Diseases Society of America guidelines are other tools developed to discriminate among higher-risk patients and guide the decision for ICU admission. Common awareness and consistent use of these schemes has the potential to ensure efficiencies in management and more optimal hospital resource utilization.
Skin and Skin Structure Infections With greater coordination among emergency and hospitalist physicians, and wound care resources, many more hospitalized patients with skin and soft tissue, and bone infections, could be treated effectively as outpatients. A long-acting antibiotic regimen could be initiated in the ED with arranged 24–48-h follow-up, with patients subsequently assessed for transition to oral antibiotics. For patients requiring a longer course of parenteral therapy, PICC and outpatient parenteral antibiotic therapy can be initiated from the ED.
Sepsis Quality standards for management of sepsis and septic shock are being promoted in hospitals. This movement is related to the dramatic mortality reduction demonstrated in a randomized trial comparing early goal-directed therapy (EGDT) to standard resuscitation. EGDT includes central venous and arterial pressure monitoring to guide fluid resuscitation and pressor use; its unique feature is sequential therapeutic interventions, including anemia-correcting blood transfusion, dobutamine, and mechanical ventilation, to increase sub-threshold central venous oxygen saturation (or, more recently, lactate clearance). Quality standards also include time posts for severe sepsis recognition and administration of appropriate antimicrobials. Because these standards are being applied to both ED-presenting and in-hospital-onset sepsis patients, development of a common management protocol represents an important opportunity for Emergency and Hospital Medicine collaboration. Although successful ED-based strategies have been described, EGDT can be labor intensive and may be difficult to institute in busy EDs. Hospitalists can assist with expedited ICU transfer. Another model proposes an on-call sepsis management team. Emergency physicians and hospitalists should develop team-based management strategies for these and other critically ill patients.
Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD) COPD is a common ED presentation that often results in admission and significantly contributes to readmissions. Emergency physicians and hospitalists should jointly develop pathways for COPD management so that appropriate therapy is started in the ED and seamlessly continued in the hospital. Hospitalist adoption of therapeutic strategies at discharge to lessen the risk of near-term exacerbation and ED re-visit should also be encouraged.
Transient Ischemic Attack (TIA) TIA is a diagnosis that in the not-too-distant past was an automatic admission to Neurology. Now these patients are often managed by hospitalists and do not always require an inpatient Neurology consultation. Emergency physicians and hospitalists can jointly develop pathways for TIA that allow expeditious disposition. The logistics of prompt scheduling of, for example, Holter monitoring, echocardiograms, computed tomographic scanning, and carotid Doppler studies lend themselves to protocolization. Avoidance of admission may be achieved for many patients with a well-defined pathway initiated in the ED and continued by the Hospital Medicine service.
Pain Management and Palliative Care Pain is the most common reason patients present to EDs. Patients who require hospital admission for intractable pain are particularly challenging for both emergency physicians and hospitalists. An attitude of suspicion, lack of objective knowledge about underlying medical or surgical problems, and suboptimal transitions between ED and hospital and between hospital and continuing care combine to present formidable obstacles for effective pain management in the acute care setting. A consistent approach to analgesia by emergency physicians and hospitalists aimed both at improved understanding of patient needs and expectations for pain relief, and at patient education regarding pain, can improve outcomes and satisfaction.
Likewise, patients who might best be managed with a palliative or hospice-based approach are often encountered at the emergency physician-hospitalist interface. Improved pain management strategies, early involvement of case managers, and protocol-driven, smooth transitions from hospital to hospice, or even from ED to hospice, would help decrease the inordinate expense of end-of-life care and reduce the frustration experienced by providers, patients, and caregivers in those difficult times. Hospitalists are often more familiar with hospice services than are emergency physicians, and closer collaboration for the development of a consistent approach to palliative care would be beneficial to all.
Prophylaxis for Venous Thromboembolism Venous thromboembolism (VTE) prevention is a national quality issue endorsed by The Joint Commission, Surgeon General, and many professional organizations. Well under one-half of hospitalized patients in the United States currently receive appropriate VTE prevention. Emergency physicians and hospitalists should work closely together to help ensure VTE prevention processes occur within the hospital setting, not only to promote better clinical outcomes, but also to avoid payment penalties and adverse public-reporting issues. This may lead to initiation of prophylaxis by emergency physicians, especially when ED boarding times delay initiation of routine inpatient orders. When evidence-based prophylaxis is not provided, patients with "preventable" VTE complications are readmitted to the hospital, thus leading to un-reimbursed "never events."