The Admit Game
At times in my career, my job has become less about actually practicing medicine—especially at a small rural hospital. Instead of seeing patients, I often feel like the quarterback of the transfer game. This is not unique to my hospital or health system. Across the country, providers are doing the same thing on literally every shift. Even at medium-sized hospitals that lack certain specialties, a great deal of patient transferring still occurs. This is simply how the game is played.
My hospital’s inpatient unit can accommodate only about 8–10 patients and has no ICU capability. We have a fixed number of physical beds, and we usually have enough nurses to staff them safely. Sometimes, however, we don’t have sufficient nursing staff, which reduces the number of patients we can safely handle. Nursing shortages are nearly universal across the country and in most healthcare systems.
When a hospital says, “We have no beds,” it most often means, “We don’t have enough nurses.” This is usually a symptom of failing to treat nurses well enough—or pay them enough—to keep them from seeking employment elsewhere. Traveling nurses can sometimes earn twice as much by working at a hospital across town. In effect, nurses are simply swapping hospitals while making significantly 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 far more likely to be called out by administration for some seemingly inconsequential issue than to be praised for doing their job well.)
If I have a patient who needs admission, the “admit game” begins. If the admit game is successful, I don’t have to play the transfer game. Let me explain how both games work.
The goal: The patient needs to be admitted to a hospital and provider capable of adequately caring for their medical condition(s).
The players: The patient, myself, the hospitalist, EMS, the transfer center, the gatekeeper, and any needed specialists.
The length of the game: From the moment the decision is made to admit the patient until they are 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, the patient’s condition is relatively minor in the grand scheme of illnesses, our hospitalist can admit them, and our nursing staff can provide the appropriate level of care—assuming a bed is available. In theory, this requires just a single phone call or a few texts with the hospitalist. Presumably, the patient is also willing to be admitted, which is not always the case.
In reality, it is rarely that simple. Multiple factors come into play: beds held for elective surgeries scheduled that day, upcoming nursing shift changes, planned discharges, transportation arrangements for discharged patients, and hospitalist shift changes.
Outpatient surgical procedures generally proceed as scheduled, with the patient recovering and going home the same day. Occasionally, however, patients experience excessive pain, a complication, or take longer than expected to recover from anesthesia. For inpatient surgeries, it is assumed the patient will stay at least one night (sometimes more) to recover. The hospital must plan for both scenarios. Patients scheduled for same-day discharge after outpatient surgery usually do so; this is probably the least confounding factor in the admit game.
Far more often, nurse staffing is the biggest variable. The day shift may be fully staffed for a certain number of patients, but there may already be a sick call for the evening shift. Or the evening shift may already be short-staffed when another sick call comes in. (That “sick call” may actually be a nurse who is traveling across town to make twice the pay, or it may be a nurse taking PTO today so they can work an overtime shift later in the week. This is not a criticism of nurses. They have to make a living, and as long as the system allows them to adjust their hours, they cannot be blamed for being strategic about their time and compensation.)
Depending on the nursing supervisor or charge nurse—the senior nurse responsible for bed-flow decisions—a staffing shortage on a future shift can affect admissions hours in advance. I have worked at hospitals where the decision to admit a patient was based on projected nurse staffing 12 or more hours into the future. For example, we might have had adequate staffing at the moment, but because the day shift the following morning was projected to be short, the senior nurse would refuse the admission. This is absurd. I already have limited ability to admit the patients I’m currently caring for, and now I’m being constrained by a nursing problem half a day away.
During residency, I was taught that discharge planning begins the moment a patient is admitted. For relatively straightforward cases, this can be somewhat predictable. Certain conditions follow a fairly reliable timeline and expected hospital course. Patients with stable housing and a good support network usually return home. Many others, however, require discharge to a skilled nursing facility (SNF, commonly known as a nursing home). A social worker is often involved to help coordinate this transition.
Patients who arrive homeless generally leave homeless; that situation is rarely fixable in the ER or during a short hospital stay. The exception is when a patient is still too ill to go home safely (even if they had stable housing), in which case they may go to an SNF temporarily.
SNFs generally accept patients only during daytime hours when their administrative staff is available and staffing levels are highest. Like hospitals, they are also subject to personnel shortages and sick calls. Each SNF has its own capabilities and thresholds for how “sick” a patient can be and still be accepted. Two SNFs that appear identical on paper may make completely different decisions about the same patient. SNFs are under no legal obligation (unlike hospitals under EMTALA) to accept anyone. They choose which patients to take, and payer status often influences those decisions. Sometimes a previously arranged discharge to an SNF falls through at the last minute. All of these factors can create significant backlogs for patients waiting to be admitted from the ER.
If a patient is still too sick to go home, they often require medical transportation to the SNF. While EMS responds to 911 calls 24/7, medical transport agencies (including some BLS ambulances) typically operate only during business hours. Despite being part of the healthcare system, they are not obligated to accept every request. They decide when they operate, how many vehicles they run, and what level of transport they provide. They can become short-staffed, drivers may fail to show up, or vehicles may break down. They are juggling their own schedules, and if a patient’s discharge is delayed, the transport may be canceled entirely because they have other clients waiting. They cannot sit and wait any more than an Uber driver will wait for you to finish dinner if you called them before ordering dessert.
Finally, hospitalist shift changes add another layer of complexity. Hospitalists do not work 24-hour shifts; they typically cover day or night shifts, with some weekend rotation. Suppose I need to admit three patients from the ER toward the end of the day. The patients may have arrived at different times, but by around 5 p.m. it becomes clear they all require admission. When I call the hospitalist to give sign-out, we may run into a bottleneck if their shift ends at 6 p.m. It is extremely difficult to complete the workup and admission process for three patients in one hour. The hospitalist must review records, assess the patient’s current status, evaluate treatments already given, determine what remains to be done, coordinate with specialists if needed, speak with the patient, and perform their own history and physical. That is a lot to accomplish for three patients in a short window.
If the daytime hospitalist is efficient and the timing works out, they may admit two of the patients. I am then left speaking with the nighttime hospitalist about the third. The night hospitalist, however, may be more cautious and decide the patient should be transferred to a higher level of care. They might be trying to avoid extra work, or they may genuinely believe the patient would be safer or better served elsewhere. The former motivation is (I hope) rare, but everyone is human. Regardless, I only control what happens in my immediate sphere. I cannot force anyone to admit a patient against their judgment. If the nighttime hospitalist says no—even after a respectful discussion—they hold the final say. At that point, the transfer game begins.
Not only does the patient’s current condition affect their suitability for admission at my hospital, but their past medical history plays a major role as well. If a patient has a complicated history—especially recent events or conditions that required specialists at another facility—our hospitalist may understandably be reluctant to admit them. Their current issue may appear straightforward, but there is no guarantee the prior condition won’t flare up again, necessitating a transfer. In such cases, it may be better for the patient to be transferred from the outset.
The caveat, of course, is that nothing in medicine is 100% predictable. Patients are sometimes admitted to small hospitals based on the best judgment of the ER physician and hospitalist, only to require transfer later when their condition worsens. Other times, they are transferred out of caution, only for nothing to happen—and they could have safely stayed.
There are simply no guarantees.