What are the guidelines for a hospitalist service when a patient cannot be admitted to the current facility?

Guidelines for Hospitalist Consultation on Patient Non-Admission

When a patient cannot be admitted to a facility, the hospitalist should document a formal consultation note detailing the specific medical reasons for non-admission, available alternative care options, and coordination of transfer to an appropriate facility.

Medical Reasons for Non-Admission Documentation

• The consultation note should clearly identify why the patient's medical needs cannot be met at the current facility, focusing on specific resource limitations, specialized care requirements, or safety concerns 1
• Documentation should be based on formal risk assessment tools when available, as patients who have their risk formally assessed are more likely to receive appropriate level of care placement 1
• The note should specify which critical resources needed for the patient's care are unavailable at the current facility (e.g., specialized monitoring equipment, ICU beds, specialized surgical services) 1

Required Elements of the Non-Admission Consultation

• Patient identification and demographic information 1
• Detailed clinical assessment including vital signs, physical findings, and laboratory/imaging results that support the decision for non-admission 1
• Specific reason(s) the facility cannot safely or adequately care for the patient 1
• Documentation of communication with the receiving physician, including name, time of discussion, and agreed plan 1
• Risk assessment of transport and recommendations for appropriate monitoring during transfer 1

Coordination of Care and Transfer

• The hospitalist must identify and contact an accepting physician at the receiving hospital before initiating transfer 1
• The consultation should document that the receiving facility has confirmed availability of the necessary higher-level resources 1
• The note should specify the mode of transportation (ground vs. air) determined in consultation with the receiving physician, based on urgency, weather conditions, and interventions needed during transport 1
• For critically ill patients, the hospitalist should document recommendations for continuous monitoring during transport, including at minimum: ECG monitoring, pulse oximetry, and regular blood pressure measurement 1

Patient Stabilization Prior to Transfer

• The hospitalist should document that appropriate stabilization measures were initiated before transfer 1
• The note should confirm secure intravenous access has been established (central venous access if peripheral access unavailable) 1
• For patients with potential airway issues, documentation should confirm airway assessment and stabilization prior to transport 1
• The consultation should specify which medications and equipment should accompany the patient during transfer 1

Special Considerations

• For elderly patients (>65 years), the consultation should document consideration of geriatric-specific needs and risks associated with transfer 1
• For patients with high mortality risk (≥5% predicted mortality), the note should specifically address ICU admission needs at the receiving facility 1
• When ICU beds are unavailable at the receiving facility for high-risk patients, the hospitalist should document specific monitoring recommendations and protocols 1
• For patients with advance directives limiting care, the consultation should address how these directives impact the transfer decision 1

Common Pitfalls to Avoid

• Failing to document that the receiving facility has confirmed bed availability and acceptance of the patient before initiating transfer 1
• Incomplete documentation of the medical necessity for transfer, which may create EMTALA compliance issues 1
• Inadequate stabilization before transport, which significantly increases transport-related morbidity and mortality 1
• Failing to provide copies of relevant medical records, laboratory results, and imaging studies to accompany the patient 1
• Not documenting discussions with the patient/family regarding the reasons for transfer and obtaining informed consent when possible 1

Quality Improvement Considerations

• Hospitalists should participate in regular review of non-admission cases to identify system issues and improve transfer processes 1
• Documentation should facilitate tracking of transfer patterns, outcomes, and potential areas for service development at the referring facility 1
• The hospitalist service should maintain standardized protocols for common transfer scenarios to ensure consistent documentation and care 1