Facing the issue of admitting privileges.

Recently I became the physician advisor for a critical access hospital, Cameron Memorial Community Memorial Hospital in Angola, Ind. It was a huge step for them and one that was met with total anticipation and acceptance.

This hospital has the mentality of a mid-size hospital in a small footprint. They did, however, have an outsourced physician advisor for a second-level review process from a well-known corporation. Realizing that a physician advisor can offer so much more than case reviews, the executive and leadership staff gave full support to me and hired me as their own.

During each edition of Talk Ten Tuesdays, I have a segment in which I share a journal entry on my experiences in this new venture as a physician advisor. So, for this journal entry I want to focus on just one of the many tasks that I am undertaking. For background purposes and methodology only, I wanted to share that my start was exactly the same process that I have done numerous times for my consulting projects. It is important to keep in mind that some of the projects can become cases studies and the topics are not limited to just this hospital.

For variable reasons and also when the Two-midnight rule came into existence, many hospital facilities gave admitting privileges to their ED physicians. Some of the main reasons given were the following:

  • To facilitate getting that first midnight on the record to satisfy the presumption, remembering that there are two components to the expectation of two midnights, the presumption and the benchmark
  • Improve throughput
  • Get care started as quickly as possible by using transition orders or occasionally termed “tuck in orders”

This has and does raise quite a debate that has gone on for several years since the institution of this practice. The American College of Emergency physicians has a definite policy regarding this topic:

Therefore, ACEP endorses the following principles:   Patients are best served when there is a clear delineation of which clinician has patient care responsibility.   The best practice for patients admitted through the ED is to have the admitting physician (or designee) evaluate and write admitting orders for ED patients requiring hospitalization at the time of admission or as soon as possible thereafter.   The admitting physician (or designee) is responsible for ongoing care of the patient after accepting responsibility for the patient’s care whether verbally, by policy, or by writing admission orders, regardless of the patient’s physical location within the hospital.   The emergency clinician is responsible for ongoing care of the patient only while the patient is physically present in the ED and under his/her exclusive care.

A link is provided below for a survey to delineate more about how prevalent is the practice of ED physicians having admitting privileges. It is not designed to influence how facilities handle this issue but provide information on the extent of this practice and maybe some of the consequences thereof. I am asking you to take 10 minutes of your valuable time to contribute to this survey and the results will be presented in next week’s “Journaling John MD.”


Programming Note: Listen to Dr. John Zelem every Tuesday on Talk Ten Tuesdays, 10 Eastern. 

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