A reader asked me if her father's physician hospitalist was supposed to be available at all times in the hospital:
I've Googled to find an answer to my question but haven't found anything. I did find your blog and thought you might be able to provide one.
Are hospitals required to have at least one physician, on-site, 24 hours a day? I'm asking because my dad is currently in a 300-bed community hospital in Orlando that does not have a doctor on-site 24 hours a day. They have hospitalists that seem to come by once a day (I don't think they are hospital staff, they seem to be a private group of hospitalists that cover more than one hospital at a time), and they have doctors available by phone in the evenings and over the weekends.
Is this legal? A standard practice? If it is, it seems crazy. I feel that my dad is getting terrible medical care because it takes forever for a doctor to be contacted and then for that doctor to respond and take action when a complication happens. It also seems like the nurses are hesitant to call a doctor in the middle of the night unless it's a life-threatening emergency. My poor dad (who had surgery for a bowel obstruction) spent 12 hours violently vomiting bile overnight. No doctor was consulted. It was only when his heart rate became elevated was a doctor was called in and the vomiting addressed.
Thanks.
Here are the answers to your questions:
Question: Are hospitals required to have at least one physician on-site 24 hours a day?
Answer: That depends on what type of physician you need and what services the hospital is providing. The general answer to my question is no, there is no requirement that a physician be in the hospital 24 hours a day.
Question: Is this legal not to have a physician in house 24 hours a day?
Answer: Yes.
Question: Is this standard practice not to have a physician in house 24 hours a day?
Answer: In many hospitals, yes.
Physicians may either be employees of a hospital system or they may be independent and have their own private practice. Either way, physicians are given the right to take care of patients in the hospital by passing through the the hospital's
physician credentialing software process.
Let's say I'm a new hospitalist or surgeon in town and I would like to take care of patients at hospital X. I must apply for hospital privileges at hospital X. Physicians must submit proof of educational standing and hospitals may require proof of proficiency in procedures. Hospitals may require background checks, credit checks, or any other checks they desire. The application is then presented to a hospital credentials committee where a whole bunch folks decide whether the physician is worthy enough to take care of patients at the hospital. It is a rigorous process that is taken quite seriously. You'd better not get labeled as a
disruptive physician or you might find yourself unable to get credentialed at a hospital.
Once a physician is credentialed, they are often required to take emergency room call for unassigned patients who show up in the ER and need care. If you are an orthopaedic surgeon and you want to operate at hospital X, you have to rotate through the ER call and be available to see patients who present to the ER with a need in your specialty. You don't have to be physically present in the hospital, only available.
In Happy's hospital, if the ER physician determines the need is an emergency, the orthopaedic surgeon must evaluate the patient within an hour. For an emergency department to provide a full scope of care, they must have physicians available at all hours of the day and night to take care of in hospital medical issues. One of the benefits of being granted hospital privileges is the being given the right of taking care of 2 am gang banging uninsured gunshot wounds to the head. And you wonder why a lot of physicians are leaving hospital based medicine to practice elective outpatient based medicine.
Many smaller hospitals do not have subspecialty physicians on call. For example, if you get a brain bleed and you find yourself in a hospital with no neurosurgeons, you are going to get transferred to one that does. For hospitals to get designated as a stroke center or cardiac center or trauma center, they must have physicians on call and immediately available to manage certain medical conditions. If a hospital chooses not to offer certain services and a doctor is not available to provide those services, there is no rule that they must.
The patient will be transferred to another hospital that can provide the necessary services, either by transferring the patient to another emergency room or by finding a physician to directly accept the patient into an accepting hospital. Sometimes that's difficult, as I experienced on Christmas Eve last year when
I called a surgeon an ass.
There is no national standard or expectation that a physician be available 24 hours a day to provide in hospital bedside care to a patient or to answer all the family's questions at 2 am, then 3 am, then 4am. Having a physician in house 24 hours a day is expensive and few hospitals can afford to pay to have a physician staffed in house 24 hours a day. And even then, the expectation is not that they spend all their nights holding the hands of anxious family members. They are there admitting patients and taking care of urgent medical needs, not running midnight family conferences. I think, most families accept that premise.
Many hospitalist programs do have in house physicians 24 hours a day. My hospitalist program does. At least one of us are in house 24 hours a day, but we are not there for the convenience of family, nurses or even patients. We are there to take care of acute medical issues that may arise in the course of a patient's illness.
How a hospitalist program decides to set up their rules and what services they are contracted or subsidized to provide for a hospital is open to contractual negotiation. Happy's hospital provides 24 care because we respond to all
code blue in-hospital cardiac or pulmonary arrests. Many hospitals do not have physicians in house that provide that. Many hospitals have nurses or physician assistants or nurse practitioners that run the code with a physician available by phone. There is no national standard from which hospitals are required to follow.
While many hospitalist programs may offer 24 hour in-hospital care, to expect the physician to stop what they are doing and come to the bedside to answer the questions of multiple family members, multiple times a day is not reasonable or expected. I am often too busy taking care of acute medical needs of multiple other acutely ill patients, to return to the bedside to answer patient or family questions on folks I have already evaluated and made plans for the day.
If families wish to speak with a physician they should either
- Set up a defined conference at a reasonable time where all family members can meet once and discuss the plan of action with the physician or
- Establish one family member as the point of contact where all questions are funneled through that family member once a day.
They should not expect the hospitalist nor any other physician to drop what they are doing and run to the bed side at all hours of the day and night. That is unreasonable. Nor is it paid for. Under current
third party insurance rules, one visit per day is paid for by the Medicare National Bank. If you see the patient five times, you only get paid once, unless you pass the threshold for
prolonged service codes, which will often be denied unless aggressive documentation is provided.
When a nurse should call a physician is open to medical judgment. Some nurses will call the physician when their patient stubs their toe. Some nurses will only call when their patient is showing signs of decompensation. Many hospitals have defined objective lab values that require a nurse to call the physician, values that are often not critical when nurses are allowed to put on their critical thinking caps. A well trained nurse is worth their weight in gold, not only for patient safety but for the physician as well. They are irreplaceable.
Life threatening emergencies are a matter of medical debate. A 95 year old patient with septic shock and a troponin of 5 is not going to get a stat cardiology consult (CPT
99253,
99254, 99255) from me at 3 am. A 32 year old Sunday school teacher who develops crushing chest pain and a troponin of 5 will. It's all relative. When a nurse chooses to call the physician is also open to their decision making process. There are no hard defined rules on when a nurse should or shouldn't call the physician. A nurse who carries confidence in their skills and a hospital that believes in their skills (which they should since they hired them) should be given the latitude on when to call and when not to call the physician.
The nurse isn't going to get it right every time, just like the physician isn't going to get it right every time. What I find in today's legal landmine driven blaming game medical environment is that nurses will often error on the side of caution and call the physician far more often than is necessary. That's why I have written my own set of
hospitalist call parameters which I will be implementing at some point in the near future to trump hospital defined call parameters.
It seems like your father may have suffered with vomiting for a few hours. As a hospitalist, if I was called from a nurse telling me that a post op surgical bowel obstruction was vomiting uncontrollably, I would tell the nurse to call the surgeon. Medical hospitalists have no business managing vomiting in a post surgical belly patient. That is a surgeon's duty and responsibility. Why you are mad at the hospitalist is beyond me. If the surgeon or on call surgeon will not return their call or will not come evaluate the patient, then the
surgeon should quit and become a porn star. That's just obscene. Perhaps the hospital should hire their own 24 hour surgical hospitalist who is available to take calls when their surgeon abandons them. If the nurse won't call the surgeon, perhaps a
patient initiated rapid response team protocol needs to be implemented at your father's hospital.
and get efficient today.
