The Rapprochement of the Emergency Department and Hospitalists

Wesley Curry , MD, FACEP

President and CEO

Published May 18, 2012

We are at a critical juncture where the collaboration between emergency physicians and hospitalists is imperative for a hospital to achieve financial success in the future. These two hospital based specialties touch almost every one of the hospital’s entire patient population of hospital admissions each year. Yet there has in the past been an inherent conflict of interests in their clinical practices based on the drastically different priorities they each must manage.

This is no longer the way we can do things; there is a new paradigm of practice for both of these physician specialties. The integration of the clinical practices of emergency physicians and hospitalists is accelerating rapidly as hospitals increasingly seek shared financial and operational responsibility for patients and performance metrics across the Acute Care Continuum. As the healthcare crunch to reduce costs and increase revenue builds, perhaps Ben Franklin summed it up best when he said, “We must all hang together, or assuredly we shall all hang separately.”

The tensions and mistrust that can arise between the ED and hospitalist practices stem from their different responsibilities. In fact, this tension speaks to the very heart of a key challenge in healthcare: the need to treat each individual patient vs. the need to be efficient and plan for the long term. The ED must evaluate every patient who walks in the door and the goal becomes disposition with all due speed to empty beds for the next patient presenting to the ED, for the most trivial to the most major of medical or traumatic emergencies. Hospitalists must make decisions about admissions based on specific criteria (e.g. InterQual) which have financial consequences to the health plan or the hospital. To an ED doctor these requirements can appear like an unreasonable work-up, while a hospitalist faces the task of identifying the appropriate admissions and achieving the optimal length of stay with prudent lab, imaging, and medical inpatient treatment.

The strides made in this relationship show just how sensitive the ecosystem is as well as the results than can be accomplished through collaboration. To put in perspective how much is at stake, a program between the ED and hospitalists at Johns Hopkins Bayview Medical Center decreased ED throughput for admitted patients 98 minutes from the same period a year earlier, despite an 8.8% increase in ED census. Throughput also increased greatly when hospitalists and emergency physicians worked closely together through an active bed management system. Central Medical Center implemented a ‘let’s make a deal’ approach regarding the question if patients were leaving too fast or too slowly. Here hospitalists committed to getting to the ED in 30 minutes if the emergency physicians agreed to never move a patient to the floor without hospitalists giving the OK.

The concept of these two physician specialties working together rather than within their own “silo” of patient practice is still very new for physicians in long term practice. The challenges will only increase with changes such as InterQual criteria established by Medicare, which requires more documentation and can complicate admission, as well as bundled payments which are driving hospitals to further integrate the ED and hospitalists.

However it is done, there is no substitute for building closer relationships and a culture of collaboration among all hospital-based physicians, especially between the emergency and inpatient physicians. Pre-set agreed upon protocols are now common and in some hospitals, a full time hospitalist has now been placed in the ED to expedite admissions. The medical directors of the emergency medicine and hospitalist practices should sit in on each other’s monthly meetings and even department holiday parties should be shared to educate the other about how to best work together and build trust. Dr. Humayun Tufail, Medical Director with Galen Inpatient Physicians at Doctors Medical Center in San Pablo, California speaks of the strides he has recently seen between hospitalists and emergency physicians. He mentions the benefits he has experienced in having the two departments attend each other’s holiday parties and says, “This is all about the relationship, and the key to bringing us together has been the development of the Acute Care Continuum.” Even with all of the adjustments and new programs taking place to between these departments, there is no substitute for building personal relationships.

In this rapprochement, there is the opportunity to create a new and better practice paradigm, especially with new technologies that will make it easier for physicians to communicate and collaborate, achieving more cost effective patient care while preserving quality. The solutions that are being created right now are just the beginning of how rapidly the Acute Care Continuum is changing, and also how much more we will have to adapt for the future.

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