Table 2.

Domains and themes emerging in deliberative discussions regarding systems and processes required for high quality direct admissions

Domain & associated themes	Summary of deliberative discussions	Representative quotations
Effective Multi-stakeholder Communication
Effective communication within inpatient healthcare teams	Importance of effective communication between inpatient physicians, nurses and residents about patients’ clinical and non-clinical needs, including anticipated arrival times, reasons for hospitalization, presence of chronic conditions, preadmission therapies, acuity, anticipated hospital management, family and social considerations	“Any other admission from any other place, PICU, ED, anywhere else, you would get a nurse to nurse report. That would be separate. With direct admissions, the onus is on us to describe adequately and there are always limitations in terms of timing and how busy you are, how busy they are…” “We’ve had a couple of occasions where there is a plan with the daytime doctor, and then the evening doctor has a totally different idea… One saying yes we will take this patient and then the other one saying no, I’m not going to take this patient. I think once the daytime doctor has discussed with the primary care doctor, this is the plan, that we shouldn’t be Monday morning quarterbacking them after the fact.”
Effective communication between inpatient and outpatient healthcare providers	Effective communication between referring and accepting healthcare providers facilitated by: (i) trust in referring healthcare provider and respect for their longitudinal relationships with families, (ii) respect for accepting healthcare providers’ roles in determining inpatient clinical management, and (iii) ongoing reciprocal communication	“[Direct admission] works so much better because I know them [referring provider]. I know them, I trust them. I ask them questions. …If things don’t go right, we can go back and talk about it….” “We have tried every possible means to treat the patient as an outpatient and when we get second guessed, that is the most frustrating situation. When you give vital signs… respiratory rate is this, oxygen saturation is this and I have given this treatment…I have kept him in the office with our rehydration protocol for the last 3 hours and he/she is not doing well. And somebody says, ‘Well, did you try clear liquids?’ What do you think? I was twiddling my thumbs?” “That handoff between physician and physician and nurse to nurse needs to be clear. And I think we fall short of that a lot…”
Purposeful communication with families	Communication with the family about plans and expectations for treatment and how those plans may differ when arriving on the floor, instructions regarding when and where to arrive at the hospital	“The dangers of direct admission is confusion for the parents sometimes where the doctor in the office says, ‘You are going to come over to the hospital, get an x-ray and an IV’ and kids change within hours sometimes. Look better and the fever goes away. So I think we have made gains in saying, ‘Please don’t tell them they are going to get a lumbar puncture…Just say the doctors there are going to evaluate you and they might do this, but they will come up with a plan.’ We’ve done a lot of communication about trying not to set up a specific plan.”
Resources needed for high quality direct admissions
Human resources within the hospital	The prompt and ready availability of the medical team including nurses, physicians, respiratory therapists, phlebotomists	“Have a little bit of a pop off valve in terms of staffing and in terms of somebody being readily available to see that patient immediately when they get there… You know, you are adding a patient to another 4 or 5 patient assignment, sometimes. And the inpatient setting right now, is that our typical day is like 8 to 10 kids go out. 8 to 10 kids come in. So there is a lot of activity and need for a little pop off valve or something to be another pair of hands, another set of eyes. And that is not always available to us.”
Triage system	Importance of consistent system to triage patients at the receiving hospital upon arrival; potential opportunity and challenges of triage in the ED without full ED registration	“It really depends on the capability of whoever that accepting person is or whatever system is in place, to be able to triage, so you can make a decision based on the clinical appearance of the case rather than diagnoses.” “If a patient is seen in the ED, they are registered in the ED and they are an ED patient. And it is because we see the patient, there is liability, there is responsibility and accountability for that patient… the patient should be registered, we feel, and the ED should get credit for that visit.”
Availability and limitations of nonhuman resources	The prompt and ready availability of beds, medications, and therapies; limitations of electronic medical records to allow for pre-admission placement of orders	“It is the availability of resources on our end. And it is a system problem of us not being able to access things for that child, if they get directly admitted because we have to go through the admission process…so we get held up on our ability to access resources. There are some system issues that could definitely be fixed and would make us feel better on the inpatient side of it.”
Resources available to referring providers to initiate patient care	Variation in capabilities and resources of referring healthcare providers to initiate diagnostic testing and therapies	“We can do a lot of stuff in our office, and for the families it is a nicer place to be than going to the ER where they may not know anybody and they do not know them.”
Systematic approach to preadmission data collection	Value of using a consistent approach to data collection, including a “one call” system to reach the inpatient team, and a data collection instrument to facilitate pre-admission assessment, including vital signs, pertinent medical history; may inform appropriateness of direct admission and facilitate communication within hospital team	“When somebody calls with a potential direct admission, not just calling the attending, but also talking with the charge nurse, having that be a joint phone call so that way, once you are off the phone with the attending, it doesn’t have to be ok, well, let me make sure we have a bed. If you have that in one phone call, then that might simplify that process…” “As hospitalists we have a written sign out and it [is] very structured. I wonder if we could create something structured to make sure we have vitals. ‘Cause sometime we will ask, and they’ll say, ‘Oh, he doesn’t look good.’ But then as an accepting provider, it is harder to know because that is a very subjective thing. So it is nice to have objective criteria… What is the respiratory rate? What is the oxygen saturation? ..Many times there is no blood pressure. Or maybe there is no oxygen saturation. And knowing what the meds are so we know what to anticipate.”
Quality reviews	Ongoing approach to evaluate direct admission processes and outcomes	“I’ve heard all these anecdotal stories of well, ‘We got this patient who comes in on a 6 liter non-re-breather.’ And why the hell didn’t I hear about it?…We need to talk about that. You know?” “Every month, we look at every patient who has come to our floor and needed to leave [transfer to higher level of care]…we are doing quality reviews, so it is very rare that someone slips through the cracks”
Written direct admission guidelines
Populations appropriate for and inappropriate for direct admission	Diagnoses, clinical conditions, and vital sign parameters to guide the appropriateness of direct admissions, to identify patients that may not require hospital admission as well as patients that may be too unstable for direct admission	“I think there are very few diagnoses that are black and white.” “Personally, I don’t think we can make a list with specific diagnoses. It would be more if the patient is stable and isn’t going to need immediate medical attention. Does the patient need an IV or resuscitation now? Does the patient need labs immediately?” “There are some conditions that should never go to the ED. Like hyperbilirubinemia should never go to the ED.”
Urgency of initial inpatient management	Need for diagnostic testing or interventions within a particular time window	“They have to be able to be up on the floor for up to 30 minutes before the resident or anyone is going to actually go in and assess them. And so…if they weren’t stable enough to be able to do that, then they had to come in through the ER.”
Pre-admission physician assessment	Time window in which an outpatient provider should have seen the patient to consider them as a direct admission, and locations from where direct admissions accepted	“We do have a specific policy for the hospital when referring from the office that they have to be seen by the physician in the office before they come over. One exception that is written in the policy, is that jaundice - you are home and you hear the lab results. But otherwise all other issues must be seen.”
Times when direct admissions accepted	Hours for accepting direct admissions might be limited	“I think a lot of times, as a senior resident at night, with no attending in house, you often get admissions that were billed very differently from what they come in as… complex cases that you are just not sure what to do with them. And so I do think, in a system where we don’t have attendings at night, you are running a little bit of a risk sometimes.”
Strengths and limitations of written guidelines	Application of guidelines should not override reciprocal communication between referring and accepting providers	“…One of the big hang-ups with guidelines and policies around this is nothing should ever trump the fact that I can say, ‘Well, [hospitalist], here is what I’m actually dealing with. And I’ve got this and this. You are like, Oh, well, you know. If you have this and this.’ There has to be a very clear pathway to say, ‘Let’s communicate about this and see what the situation is, you know?”
Family preferences and needs
Preference to avoid the ED	Primary care providers and parents described how and why they preferred to avoid ED utilization	“Being able to avoid the ER and going straight from the pediatrician to the hospital was fantastic…” “Mostly we have always gone through the ER and she just hates the ER. She just don’t like that. Cause I think everything is very hectic in there”.
Family-centered care	Importance of understanding families’ preferences regarding sites of care, emphasizing the importance families’ experiences of care	“If your patients have preferences, knowing what they want is helpful.” “But we get into the clinical technology of what we need to do and we forget that this is a person - a mom and a dad and a child - who are now being displaced. ”