Social Admits

Who is a Social Admit Patient?

For the purposes of this resource page a "Social Admit" can be defined as a patient who has no medical diagnosis that requires hospitalization however they cannot be discharged safely from the hospital. The ED Observation unit serves an important role in housing such a patient while care management works to arrange a safe disposition, however there are limits to our obligations to house such patients when continuing to house them poses an increased risk to the patient or compromises the mission of ED obs.

Background

In ED observation we are proud to be able to treat and disposition patients more quickly than any other service in the hospital. When it comes to "social admit" patients, ED Observation can often find a safe disposition for patients more quickly, using fewer hospital resources and exposing patients to the hazards of hospitalization for a shorter period of time than if they had been on an inpatient unit. However our advantages to disposition a patient quickly fade after the first 48 hours, and the complexities of longitudinal care emerge, for which our service is not optimized. Recognizing this trade off, the ED Observation department has developed an agreement with other hospital services to help guide the care of these vulnerable patients.

The Agreement

The below process was developed with the CMO of St. Joseph Hospital (Dr. Tynes) and the Director of MIM / UM physician group (Dr. Chaudhuri) as well as the Director of Hospital Medicine (Dr. Morton) and the ED Observation Medical Director (Dr. Zeccola) in September of 2022.

Disposition from Initial ED Evaluation

  • Expected 24-48 hour stay remains the core criteria for ED Observation admissions

    • If there is a "social admit" patient in the ED and the expected stay for the patient is anticipated to be greater than 24-48 hours, the ED physician should involve Care Management early.

    • If the care manager also feels that a disposition is very unlikely within 48 hours (or if there is no care manager available), then the first call to disposition the patient should be to Hospital Medicine (KP or MIM).

    • If the ED Physician and the hospitalist agree that a safe disposition cannot be arranged within 48 hours, the patient should be assigned a bed on an inpatient unit under Observation Status, not in ED Observation.

    • If the hospitalist disagrees with the assessment of the care manager and/or ED physician, and that a disposition in the next 48 hours is possible, they may ask for the patient to be housed in ED observation. In this case, please document the conversation with the hospitalist and place the patient in ED Observation if there is a bed available. If no bed is available in ED Obs, the hospitalist will have to accept the patient.

    • If this exchange occurs during the hours of 8:00 AM to 6:00 PM the care manager should contact the UM physician as soon as possible to notify the UM physician of the patient. Care Management should know how to contact the UM physician. If they do not, the MIM triage doc should have their contact information.

Care in ED Observation

    • Each morning the ED Observation physician should review the census for patients that are unlikely to be dispositioned within 48 hours of admission to ED obs.

    • When such a patient is identified, the ED observation physician needs to discuss with care management, and confirm that the UM Physician is aware of the patient.

    • The care manager should update the ED observation physician regularly on progress towards a disposition.

    • As soon as three midnights have passed in ED observation, the care manager should take the first opportunity to contact the UM physician again, at which time the UM physician should direct the hospitalist to admit the patient to a bed in the inpatient unit under observation status.

    • If it is clear to the ED observation physician and Care Manager that there will be no disposition within three midnights, the care manager should request that the UM physician clear the admitting hospitalist to admit the patient to a bed on an inpatient unit under observation status before the three midnights have passed.

    • If a UM physician refuses to assign an inpatient bed for a patient after three midnights, despite the above efforts please compose an email with a HIPAA secure messaging service (KP or SCL/Intermountain email), include a one line summary of the patient, their MRN and the name and contact information for the UM physician and send this to the ED observation Director (Dr. Zeccola), Director of MIM (Dr. Chaudhuri) and CMO of St. Joseph hospital (Dr. Tynes). After sending please call the ED Observation medical director for further direction.