The Admission Game
At times in my career, my job has been less about actually practicing medicine, especially at a small, rural hospital. Instead of seeing patients, I am the quarterback of the transfer game. This is not unique to my hospital or system. Across the country, providers are doing this same thing literally every shift. Even at medium-sized hospitals that still don’t have all the specialties, there is still a lot of transferring going on. This is how the game is played.
My hospital’s inpatient unit can accommodate around 8-10 patients, and I have no ICU capability. We physically only have that number of beds, and usually, we have the nurses to staff them safely. Sometimes we don’t have enough nurses, so the actual number of patients we can handle is fewer. Nursing shortages are just about universal across the country and in most healthcare systems. When a hospital says, “We have no beds,” they most often mean, “We don’t have enough nurses.” This is usually a symptom of not treating them well enough and/or paying them enough to prevent them from seeking employment elsewhere. Traveling nurses can sometimes make twice as much money to go work at a hospital across town. Nurses are literally just swapping hospitals but making a lot more money. (I don’t blame them. If your own hospital treats you poorly and nitpicks everything you do because of regulatory issues, why would you stay? Most of the nurses I know and trust are more likely to come to the attention of administration for some seemingly inconsequential wrongdoing than to be applauded for doing their job well.)
If I have a patient who needs to be admitted, the admit game starts. If the admit game is successful, I don’t have to play the transfer game. Let me tell you about the admit and transfer games.
The goal: the patient needs to be admitted to a hospital and provider that can adequately care for their medical condition(s).
The players: the patient, myself, a hospitalist, EMS, the transfer center, a gatekeeper, and any needed specialists.
The length of the game: from the time of the decision to admit the patient until the patient is safely in their hospital bed.
The rules: infinitely changing. (This could also be called the infinite game, which is not dissimilar to my first marriage.)
Ideally, whatever the patient’s condition, it is a relatively minor issue in the grand scheme of illnesses, and my hospitalist can admit the patient, and nursing can provide the appropriate care. That is, assuming there is a bed available. In theory, that’s a single phone call or some texts with the hospitalist. Presumably, the patient is willing to be admitted, which is not always the case.
This is not nearly as simple as it sounds. Multiple other factors come into play: beds that are held for the elective surgeries happening that day, upcoming nursing shift changes, scheduled discharges, transportation for discharged patients, and hospitalist shift changes. Let me explain further.
Outpatient surgical procedures generally proceed as scheduled and with the desired outcome, i.e., the patient recovers and goes home. However, occasionally, they have excessive pain, a complication, or don’t recover from anesthesia as quickly as usual. It is assumed with other surgeries that the patient will spend a night or a few nights in the hospital to recover. The hospital needs to account for both. Patients scheduled to go home after an outpatient surgery generally do so; this is probably the least confounding factor at play in the admit game.
On the other hand, nurse staffing often becomes the biggest confounder. The day shift may be fully staffed to handle a certain number of patients, but perhaps there has already been a sick call for the evening shift. Or maybe the evening shift was already short-staffed, and now they have a sick call. (Granted, that sick call may be a nurse who is also traveling across town to make twice the money. Or the nurse is taking PTO today and will then work an extra shift later in the week and make overtime pay. This is not a judgment against nurses. They have to make a living, and as long as the system allows them to adjust their hours, they are not to blame for being savvy about their hours and pay.)
Depending on the nursing supervisor or charge nurse, i.e., the senior nurse tasked with making decisions about bed availability, a future shift that is short nurses can affect things hours ahead of time. I have worked at a hospital where the decision to admit patients is based on the projected nurse staffing 12 or more hours into the future. For example, there was currently adequate nurse staffing at the time I needed it, but since the day shift the next day was going to be short-staffed, the senior nurse determined we could not admit a patient. This is absurd! I have limited ability to admit the patients I currently take care of, and now I’m being hamstrung by a nursing problem half a day into the future.
During residency, I was taught that discharge planning for a patient starts as soon as they are admitted to the hospital. For relatively simple things, this can be somewhat predictable. Some conditions have a relatively predictable timeline and an expected hospital course. Patients with stable housing and a support network usually go home. However, many patients need to go to a skilled nursing facility, also known as an SNF (commonly known as a nursing home). A social worker is often involved to help navigate this transition. Patients who arrive homeless leave homeless. That is not a fixable problem in the ER or hospital most of the time. Exceptions include a patient who is still too sick to safely go home (even if they had one), so they go to an SNF temporarily.
SNFs generally only admit patients during daytime hours when their administrative-level personnel are available, and staffing is usually at its peak. However, they are subject to personnel shortages and sick calls as well. They all have their capabilities, and as discussed earlier, there is a lot of variability in just how “sick” a patient can be to be safely cared for. Two SNFs that on paper appear to provide the same level of care can independently decide if a patient is too sick to be accepted. SNFs are not under any obligation to accept patients. There is no EMTALA requirement. They accept which patients they want to accept, and depending on who’s paying the bill, two patients with the very same condition won’t necessarily be accepted at the same place. Sometimes a previously arranged discharge to an SNF falls through. All of this backlogs the patients being admitted from the ER in a timely fashion.
As you might expect, if you’re still too sick to go home, you very well might need medical transportation to get you from the hospital to the SNF. EMS answers 911 calls 24/7. Medical transport agencies, including some BLS ambulances, don’t operate 24/7. They operate during business hours because that’s what most businesses do. Again, despite being part of the medical system, they are under no obligation to come running when someone calls. They are not required by law to take any patient anywhere. They choose when they operate, how many vehicles, and which type of transportation they provide. Sometimes they end up short-staffed as well. Drivers don’t show up for work. A vehicle breaks down. That’s life. They are juggling their own workflow, and if a patient gets delayed for some reason, the ride may get canceled altogether because the medical transport service has other clients that need rides. They can’t always sit and wait any more than your Uber driver is going to sit and wait for you to finish dinner if you call them before you have even ordered dessert.
Wrapping up our discussion of confounders that influence the timing of admitting patients is the shift change for hospitalists. They don’t work 24-hour shifts. They often work the day shift or a night shift with some rotating weekend shifts. Let’s say I need to admit three patients from the ER toward the end of the day. This is going to create a potential bottleneck. The patients may have arrived at different times, but the treatment and diagnostics may have all progressed such that I know around 5 p.m. that they all need to be admitted. So, I call the hospitalist and give a sign-out regarding my patients. If the hospitalist is only scheduled to be on until 6 p.m., we may have a problem. It’s pretty hard for three patients to be admitted in one hour. As you recall from the discussion about hospitalists, they have a significant task in sorting through patient records, reviewing the current condition of the patient, considering what treatments have been done, what is left to do, who else they may need to contact, and, of course, talking to the patient and performing their own history and physical (H&P). That’s a lot to do for three patients in one hour.
So now, let’s say the hospitalist is efficient, and the stars align so that they are able to get their required work done and admit two of the patients. I’m now left talking to the nighttime hospitalist about the third patient. However, the nighttime hospitalist may be more cautious than the daytime hospitalist and thinks the patient should be transferred to a higher level of care. They may be trying to avoid work or legitimately thinking that the patient is not safe or would honestly get more appropriate care somewhere else. The former reason, I hope, is rare, but everyone is human. Regardless, I only control things in the small circle around my own two feet. I can’t twist anyone’s arm or make anyone do what I think should be done. If the nighttime hospitalist says no, even after we have a polite conversation and both express our concerns and desires for the patient, they hold the trump card. I can’t overrule their decision. Now the transfer game starts.
Not only does the patient’s current condition determine their suitability for admission at my hospital, but their prior conditions come into play. If a patient has a complicated past medical history, particularly recent events or conditions that have required specialists at another hospital, my hospitalist may be reluctant to admit them, and understandably so. Their current issue may seem simple, but there is no guarantee that their prior condition will not manifest again. That would require a transfer out of my hospital, so at times, it’s probably best for the patient to be transferred from the beginning. The caveat is that nothing is 100% predictable or guaranteed. Patients get admitted at small hospitals based on the best judgment of the ER doctor and hospitalist involved and still end up getting transferred later. Sometimes their condition worsens; that is just the nature of medical conditions. Other times, they may be transferred from my ER to a bigger hospital only to not have their condition or prior conditions manifest, and they could have just as well stayed at my hospital. Again, there are no guarantees.