For patients being admitted into the hospital, hospital admission may be the first and most significant care transition that they will experience in their medical care. The number of inpatients being cared for by their primary care physicians has decreased significantly in the last several years. In a study reported in JAMA in 2009, outpatient to inpatient continuity with a primary care physician decreased from 44.3% in 1996 to 31.9% in 2006, correlating with the growth of hospital medicine during the same time period. As a result, patients are frequently cared for by physicians who are meeting them for for the first time in the hospital, and who are unfamiliar with their medical history, past hospitalizations, or family and social support network. In addition, due to the “shift” structuring of many hospital medicine groups, patients are likely to be cared for by multiple physicians during a single hospital stay, each one having to learn anew the subtleties of their history.
Patients may be admitted to the hospital through the Emergency Department (ED), directly from an outpatient office, or transferred from an outside facility such as another hospital, a Skilled Nursing Facility (SNF) or a Subacute Rehabilitation Facility (SAR). While these transitions have much in common, they also have unique challenges in care transitions that are specific to their sites. We will discuss these challenges as well as potential solutions here.
ADMISSIONS FROM THE EMERGENCY DEPARTMENT
The majority of unscheduled admissions to the hospital come through the Emergency Department. The American College of Emergency Physicians estimates that over the past decade the percent of admissions through the ED has increased from 64% to over 80% while at the same time there was a decline in the percentage of unscheduled admissions from clinics or doctor’s offices. Patients admitted through the Emergency Department experience two transitions—the transition into the ED and the transition from the ED into the hospital. As patients’ transition from the ED to the hospital the need to not only transfer information but also to clarify who is primarily responsible for the patients’ care is critical as there is often a delay between the exchange of information and the physical relocation of patients. Admissions that occur during shift changes may be particularly problematic as they result in multiple transfers of information and responsibility. In the ED, patients may be admitted at a shift change with data pending rather than be signed out to a new ED provider. These transitions can result in ambiguity and conflicting expectations between ED providers and hospitalists specifically regarding patient care responsibilities and can contribute to dropped information, delays in treatment, and other errors that threaten the safety of patients. Strategies to improve the transitions are discussed below and outlined in Table 12-1.
TABLE 12-1Strategies to Improve ED to Hospital Transitions