Who should write admission orders?
Commentary
Mineral Springs Hospital, Banff, Alta.
CJEM 1999;1(1):21
Abstract
The rural hospital environment differs from the urban hospital environment in that there are fewer physicians available to share the workload and to help out in an emergency. When a rural physician on call for emergency writes admission orders rather than disturb the patient’s family physician, that rural physician accepts full responsibility for the patient until the patient’s physician actually examines the patient and assumes care.
Résumé
L’environnement hospitalier rural est différent de l’environnement urbain en ce sens qu’il y a moins de médecins disponibles pour partager la tâche de travail et pour aider à l’urgence. Lorsqu’un médecin en milieu rural de garde à l’urgence écrit les consignes lors de l’admission plutôt que de déranger le médecin de famille du patient, ce médecin accepte la pleine responsabilité de ce patient jusqu’à ce que le médecin de celui-ci l’examine et prenne ses soins en charge.
In a rural setting, physicians accept the responsibility of writing admission orders for another physician because they recognize that neither they nor their colleagues can be on call all the time. They also recognize and accept that they will be available and responsible for the patient's care until the family physician formally takes over.
By contrast, in an urban or community setting, where there are sufficient physicians to share the workload and the call schedule is thus not onerous, it is difficult to imagine a valid reason for the most responsible physician (MRP) on call not to see the patient promptly and write admission orders.
The problem with emergency physicians (EPs) writing admission orders is that once the patient leaves the ED and until that patient is seen by the MRP, there is no physician effectively overseeing the patient's care. Who does the ward nurse call to deal with problems after the patient leaves the ED? The physician who wrote the orders is now off shift and can't be reached; the physician who is currently on duty in the ED doesn't know anything about the patient; and the MRP may have heard a verbal account of the patient's problem but has not yet seen the patient.
When a patient suffers as a result of not having received prompt attention or appropriate care on the ward, and the MRP says to the court: "Of course I would have seen the patient right away if the EP had conveyed how sick the patient really was," who will the court find responsible - the physician who examined the patient and initiated care, or the MRP who has never seen the patient?
The EP's concern (and that of the hospital's medical advisory committee) should be that the patient receive timely and appropriate care. In an urban or community hospital, it is not the EP who will be overseeing the patient's care on the ward; it is the MRP. However, the baton of responsibility cannot change hands until the MRP sees and assesses the patient. When the EP writes admission orders and sends the patient to the ward, he or she is laying the baton on the track with the expectation that the MRP will later pick it up. The rules of the game should not permit such a sloppy hand-over.
Dr. Socransky1 and his colleagues shouldn't have to choose between antagonizing the consultant and putting the patient (and themselves) at risk. The issue of who writes admission orders should not be decided on a physician-by-physician basis. Unless EPs are willing to extend their patient care responsibilities beyond their own department and beyond their shift hours, they as a group should not be writing admission orders. It is in the interest of no one - not the hospital, not the EP, and certainly not the patient - for the possession of the "baton" to ever be in doubt.
Reference
- Socransky S. Admission orders [letter]. CJEM 1999;1(1):19.
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