Hallway Four

In my hospital, Hallway Four is where the crazy people go. This is a glimpse of their lives and mine.

“My doctor told me to come get admitted”

Posted by Amy on March 13, 2007

Almost every shift I work, I get a patient who was “sent by my primary care doctor to get admitted”.  These are often extremely frustrating situations, for both me and the patient, if poorly executed by the PCP.  There is definitely a right and a wrong way to refer a patient to the ED. 

Some PCP’s do it right.  Maybe they saw the patient in their office earlier in the day and thought the patient needed more tests/xrays/labs and possible admission so they call ahead to the ED to give us a heads-up.  Or, maybe the patient called the PCP and couldn’t be seen, but clearly had a life-threatening emergency (chest pain, shortness of breath, left arm hanging off) and so was told to go directly to the ED. 

Then there’s the wrong way to do it.  The PCP is too busy to deal with the patient in person, so they tell them to go to the ER.  Okay, I’m fine with that.  What I’m not fine with is when the same PCP, after having never layed eyes on the patient, tells him “to go to the ER to get admitted”.  Why would they do this?  They haven’t seen the patient.  They have no idea if the patient is sick enough to get admitted.  And, they invariably don’t admit their own patients (they let the hospitalist admit for them). 

For example, last week I saw a middle-aged Type II (adult onset) diabetic patient who said his PCP’s office had called him because his sugar was high on a previous blood-draw and told him to go to the ED to get admitted.  He had spent the previous day in our ED, ruling out a blood clot in the leg, and was not happy to be back, but had followed his PCP’s instructions and returned.  He waited for an hour or two in triage.  He waited to see me.  He waited as I did more blood tests to rule out serious salt or acid/base imbalances.   And then I got to tell him that he didn’t, in fact, need to be admitted.  Yes, his sugar was high (400’s) but everything else was just fine.  I talked to his PCP on the phone and she agreed that the patient didn’t actually need to stay in the hospital.  But, I’m the one who had to break the news to the patient.  He got really upset (understandably) and demanded to be admitted.    Great, now I’m the bad guy. 

In the end, no amount of explaining or reasoning could make my patient understand.  He started crying and I finally broke down and admitted him.  When the hospitalist asked the reason, all I could say was “hyperglycemia and tears”. 

13 Responses to ““My doctor told me to come get admitted””

  1. Heather said

    What about telling the PCP’s to go down the street to the State Hospital to be admitted themselves?

  2. Charity said

    Just because a patient demands to be admitted to the hospital doesn’t mean that we have to appease them. I’m not sure what your patient’s healthcare coverage status is, but as you probably know already, there has to be clear indications for admissions otherwise some, especially medicare and medicaid, will not reimburse. If we bend and allow every patient who demands to be admitted a bed upstairs, we might as well just run a hotel service and act as the glamorized concierge, because they’ll be knocking down our front doors in droves, especially the homeless folks, to get a warm bed, 3 squares meals, and be waited on hands and foot.

    Sure our Press-Ganey scores will suffer for not kowtowing to patients’ demand, but damn it I’m still going to do the right thing every time. They’ve come to my ED for my expertise and specialized care, not for me to hold their hands and sing Kumbaya with them. Unless their doctors provide them with admit orders, I will be the sole person who will make such a determination.

    Not to sound preachy but if you abuse your hospitalists and consultants too many times by making them see/admit bullshit cases, not only will they lose confidence in you, they’ll lose their respect for you. Developing a trusting relationship in your consultants is of vital importance for an EM doc. You wanna be able to call up a surgeon or any specialists and have them not vaccillate and trust you without question.

  3. Charity Doc,

    I know that you are absolutely right, that’s why I left that shift feeling upset – with everyone (especially myself). This lady wasn’t homeless or looking for hand-outs. She just felt like she was sicker than she really was and wanted it to be fixed like her doctor had told her it would be. I argued with her and discussed with her for over an hour and in the end I just couldn’t get rid of her. Next time, I’ll have to push harder.

  4. Charity said

    Sometimes when I can’t convince a patient to be admitted or go home, I get their primary care doc on the phone and tell him/her the situation and punt the ball into their court. Let them talk to each other on the phone and straighten out the situation among themselves. After all, as the ER doc we have no admitting privileges (unless you also do HBOT).

    As a rule, whenever faced with a disposition problem, apply the big circle or umbrella approach. Draw a big circle/open an umbrella, get everyone (medicine, surgery, all the specialty consultants) involved inside the circle or under the umbrella for a powwow, then you step outside and let them handle it. Our job as the EM doc is to recognize medical emergencies, stablilize and punt.

  5. 911doc said

    well doc, one arrow you have in your quiver, and one of the few that you do have, is to call the doc in question and tell them that their patient is in the ED waiting for them. when they opt out you can explain that there is something called a ‘direct admission’ that he or she may want to employ in the future, and that in the meantime you would be happy to evaluate their patient. also, you will be sure to explain to the patient why they will get a big bill from the ED in their primary physician’s absence.

    then there’s the 2am “just calling you to update you on mr smith” call, but i digress.

  6. I like the idea of having the patient and the PCP hash it out over the phone. The big circle/umbrella protection plan is also a great one – Keep the good ideas coming!

  7. DementedM said

    This post was actually very helpful. I had a bad asthma episode last year that, of course, hit over the weekend. Back to back ER visits ensued. Along with begging to get squeezed into a pulmonologists’ schedule. Then PCP visits. PCP wanted me admitted, but didn’t have priveleges. Just told me to go to the ER and get admitted, never mentioning calling ahead.

    I couldn’t face it. The ER staff had not been friendly. Care had been slow enough (after putting me in a room and seeing the doc who didn’t think much of my reappearance) that I was using my rescue inhaler and self-medicating. No call button either.

    Instead of dealing with that again, I just went home and took my chances. I could just picture the Er docs’ faces when I gasped out “My pcp sent me to be admitted.” Particularly, after they had tried to contact PCP before to admit and couldn’t get a hold of them. It wasn’t a pretty picture and one I was too sick to contemplate dealing with.

    Fortunately, I’m pretty good at staying calm and keeping the lungs going. I made it through until the pulmonolgist could see me. 24 hours after the first Avelox (sp?) dose, I was on the mend.

    Those ER visits have haunted me though. There is nothing worse than being legitmately sick (audible wheezing, some dips in O2 sats, skin retracted) and being treated as if you are scummier than a drug seeker.And when you can’t breathe, you don’t argue, you don’t advocate, you’re just trying to make it to the next breath.

    But knowing what my PCP should be doing is helpful. Hopefully there won’t be a next time (I did have a 7 year gap between ER asthma visits) but if there is, I’ll have a better idea of how things need to be coordinated.

    So if you made it to the end of this long comment, thanks.


  8. M

    Thanks for the post. I’m sure that as a patient, nothing about the ER makes any sense or is in anyway a fun experience. I had to wait for like 20 minutes at my vet’s office yesterday and was like “what’s taking them so long?”, when my patients often wait hours to see me. Hopefully you won’t have to deal with many more ER visits in the future!

  9. scalpel said

    Not trying to be a link-whore, but I thought you might be interested in this. We all have to deal with this problem, unfortunately. As usual, Charity is right on the money. Compromising your integrity is making a deal with the devil.

    If you feel like a patient really needs to be admitted, don’t take no for an answer no matter how many calls you have to make. If you are sure that the patient does not need to be admitted, let the PCP or cross-covering MD make the decision whether they want to do a courtesy admission. If they decline, then dump the blame on them explain to the patient why they don’t really require admission.

    I just tell them “Look, if you are admitted, it will be to an overworked hospitalist who doesn’t know you at all and whose primary goal is to discharge you from the hospital as soon as possible. That will likely be right after morning rounds. Why not go home and sleep in your own bed, then discuss the situation with your own doctor when you can?”

  10. scalpel said

    Not sure if my link worked, sorry:


  11. I actually did talk to the hospitalist about this patient and he said that he was happy to admit him. Granted, this particular hospitalist is a really nice guy, but I approached him with the story and he said he was fine with keeping him. Interestingly, I just looked back at the guy’s hospital course and he was actually here for 3 days. Hmmmm.

  12. Thanks for the link, Scalpel. It’s a sad and all-too-often true story.

  13. Peeny said

    Good God, what kind of crazy person wants to be sick enough to be admitted? I should think they’d be thrilled to get to go home. People is craaazy.

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