At our institution we negotiate with the ICU all the time based on their bed
availability and the patients needs. The resident on call in the ICU can not
refuse our requests for admission. So the only person who over rides us is
the ICU attending but they have to see the patient and write a note. Our ICU
is is very good about accepting all sorts of patients since the floor are
limited in what they can do. A patient requring >40% O2, or albuterol nebs
more than every 4 hours, are two examples. They also take every intubated
patient, DKA patients with high risk cerebral edema( new onset , age < 3,
got fluid boluses,  Na < 130 meq, K<3.0, etc)
SO for the most part, we have an open admission policy for the ICU with a
very good working relationship. Unless they come to the ED and make a
consult note indicating that in their opinion the patient can go to the
floor, they take the kids we reccomend. We do negotiate but usually it is a
give and take. We hold patients for them while they make room, and the are
very good to send us nurses to help if we are short on RN's.
Seems you should be talking more.

One way we keep our lines of communication open is collaboration. One  of
the ICU attendings moonlight for us in the ED which helps give them a better
perspective regarding our needs. We have a conjoint education meeting the
first friday of every month and our fellows rotate through the ICU every
year. This gives our two departments lots of opportunities to interact. One
other aspect is that the ICU attending do take regular floor pediatric
rotations as admitting attendings for the resident staff so they get to know
the hospital florrs capabilities intimately.

Hope this helps,

Martin I. Herman,MD, FAAP,FACEP
Associate Professor of Pediatrics , UT College of Medicine
Fellow At-Large / West Tennessee, TN Chapter of the American
Academy of Pediatrics

-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]]On Behalf Of Julia Whitefield
Sent: Friday, December 06, 2002 7:54 AM
To: [log in to unmask]
Subject: [PED-EM-L] PICU admissions

I would greatly welcome your input regarding the rules and understandings at
your EDs regarding PICU admissions.
At our site we, the ED docs, seem to have issues regarding the 'screening
process' through our PICU attendings whether a PICU admission from ED is
warranted or not.
It is my belief and understanding, almost as if COBRA or EMTALA were to be
applied in-house, that we, the ED attendings make the decision where the
patient needs to go, knowing the patient best and taking the risk regarding
appropriate admission.
I also feel that we do not 'screen out' patients, an outside physician
wanting to send us a patient because he/she feels the patient is ill enough
to be seen in our tertiary care ED, is welcome to do so...
I am not used to such problems at all my other sites I worked at in the
The AAP has some screening documents for PICU admissions. Inspecting them
'under the microscope' makes it clear, that even with those documents, it is
left up to the ED doc deciding on where the patient needs to go.

Any suggestions on how to solve the issue? I'd welcome any input.

Julia Whitefield MD, Ph.D.
T.C. Thompson Children's Hospital
University of Tennessee
Erlanger Campus

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