PookieMD's Blog: Where Physicians Learn About the Business of Medicine

As a hospitalist, I hate direct admits, especially from doctors I don’t know well.  The direct admits always seem to get called to me at 4:45, just as the busy clinic doc is wrapping up, and I’m throttling up for the admitting race. The clinic doc will call us with the patient info and ask us to go on faith that the patient is stable.  Cases that make me queasy and reject the patient as a direct admit:

• chest pain–I don’t care if the EKG is normal. Don’t ask me to direct admit a patient to tele, with the potential that they are having an acute coronary syndrome.  If the doc is concerned enough to admit someone with chest pain, they deserve a timely eval, something that may have to wait for several hours until I get to them.
• the physician hasn’t seen the patient, and is calling in based on a lab, or a report from a visiting nurse.  (I see this a lot with anemia–the patient will have a low hematocrit, and the PCP will assure me the patient is “stable.” How can you know the patient is stable if  you are not looking at them?)
• marginal vital signs.  Again with the assurance that the patient looks fine, “they not septic!”  Ha, I say.  My criteria is that a patient must be stable enough to wait two hours in a hospital bed before someone sees them to be a direct admit.  I will ask the PCP if the patient meets this criteria. 
• hypoxia–I hate admitting “stable” hypoxia.  If they are that stable, why do they need  to be admitted? I see this with chronic COPD patients on oxygen who are going up on their oxygen requirements.  The PCP will assure me that they are not in extremitis from their COPD exacerbation or pneumonia, but it takes a lot to convince me.  This type of patient can go down hill fast, and you can’t under rate breathing!
• TIA evaluation.  Patients like this may need a rapid CT scan and neuro exam before I am certain it’s “just a TIA.”

So why do PCPs direct admit? For a good reason–it saves the patient a lot of money and hassle not to have to go through the ED.  I’m all for cutting down costs, but only on verifiably stable patients.  I know that a direct admit gets labs and study results a lot slower than a patient in the ED.  Therefore, a direct admit patient may have treatment started much later than a patient that comes through the ED. This may be acceptable in very stable, slightly ill patient, but for many patients, the delay in diagnosis and treatment can lead to an extended stay and increased morbidity.  So, no, when I question the PCP, I’m not a lazy bum, I’m actually on medically solid ground.

My suggestion: develop a rock solid criteria for direct admits.  My proposed rules:

1. No chest pain or hypoxia direct admits.  Don’t care how stable the PCP says they are.
2. No one with marginal vital signs–and I get to be the arbiter of this.  If I think the patients is not stable enough, then they aren’t. It’s my name (and malpractice!) that is on the line, so, sorry, but I rule.
3. PCPs must have the patient physically in the office.  No one can get called in from home after a lab done yesterday, or last week, or last month.
4. Cellulitis is okay.
5. Social admits are okay.  Why waste all that ED time and money?  This is the one case I really think IS a direct admit.
6. No mental status change evals as a direct admit. C’mon, would you do that to your mom?

Lastly, my friendly PCP, I’m right there with you trying to take good care of patients, in a timely and cost effective manner.  My world is a little different than yours, and I hope you understand I’m not argumentative–I just see patients a little differently, and in a different time frame than you may.