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Dynamic Chiropractic – July 30, 2007, Vol. 25, Issue 16

Hospital Admission Criteria

By John Cerf, DC

One of the many benefits enjoyed by chiropractors with hospital privileges is the opportunity to maintain contact with their patients who require inpatient hospitalization. The chiropractor has the ability to both communicate with the patient and coordinate care with the hospital's allopathic physicians.

The hospitalized patient benefits by the additional treatment alternatives available only when a chiropractor is on staff. The hospital and the third-party payer benefit by the opportunity to reduce the length of the patient's stay.

The composition of the chiropractor's patient population affects the number of potential hospital admissions. Chiropractors whose patient population includes people suffering from a wide variety of medical conditions, with no other source of medical monitoring, have a greater opportunity to admit patients suffering from potentially critical organic disorders. While the chiropractor will not be treating these organic disorders, they will have the opportunity to provide uninterrupted musculoskeletal care during the hospital stay. The extent to which the chiropractor will provide care for the inpatient depends on the nature of the patient's condition. Even more important, the medical physicians and nursing staff will have the opportunity to witness both the benefits of chiropractic care and the good judgment of the chiropractor, who knows when to perform treatment and when to withdraw from offering care.

Chiropractors occasionally discover urgent medical concerns in patients who present for treatment of musculoskeletal complaints. The chiropractor without hospital privileges has the responsibility of referring the patient for medical evaluation, with no guarantee that the medical provider will recommend a return to chiropractic care. Many of us have had a patient return following referral to a medical physician, only to hear the patient describe the medical physician's lack of support for chiropractic care. The chiropractor with hospital privileges has the opportunity to develop a congenial medical referral network with doctors' private offices and with the hospital.

On occasion, most chiropractors have encountered a patient who is unable to walk without assistance or walks insufficiently to handle basic daily activities (e.g., making meals or getting to the bathroom). If the severity of pain prevents chiropractic care, referral to the emergency department (ED) is reasonable. The chiropractor should call the ED and alert the attending physician of the referral. The chiropractor will need to ask that the physician call back if they determine that the patient will require hospitalization. If, following treatment in the ED, the patient remains in severe pain, then the patient is considered unstable. According to the Emergency Medical Treatment and Active Labor Act, the patient must not be transferred home (i.e., discharged from the hospital).

A patient recently presented to my office for treatment of mid-back pain that began gradually following exercise. The patient's diastolic blood pressure was in excess of 120 mm Hg. I immediately referred the patient to the ED for urgent reduction of hypertension. The attending physician ran routine laboratory tests and became suspicious of underlying pathology. The physician called me back to advise that this unstable patient required hospitalization for ongoing treatment and further evaluation. During the patient's hospitalization, I was able to maintain uninterrupted chiropractic treatment of the spinal complaint, with the added benefit of helping the patient avoid additional pain medication, which has the attendant risk of an adverse event/interaction.

The attending ED physician may summon the on-call chiropractor in an attempt to avoid hospitalizing a patient. If the application of chiropractic techniques is unable to prevent hospitalization, the chiropractor may then become involved as a co-admitting physician. Hospitals and third-party payers desire to limit the duration of hospitalization for back pain. The chiropractor's role as a co-admitting physician will be to use chiropractic techniques to help shorten the hospital stay, and to offer an alternative to additional and/or prolonged narcotic analgesia.

On one occasion, the ED physician called on me to offer chiropractic care, with the goal of relieving enough of the patient's low back pain to allow for discharge. Unfortunately, in spite of narcotic analgesia, the patient was unable to tolerate spinal manipulation. He was unable to walk without assistance. His inability to perform basic activities of daily living was obvious. I co-admitted the patient for severe low back pain. When the hospitalized patient presents with contraindications to spinal manipulation, the co-admitting chiropractor's role will remain one of evaluation. In the first 24 hours, I was only able to evaluate the patient and order physical therapy modalities performed by members of the physical therapy department. During this initial period, a MRI examination ruled out significant discopathy and underlying pathology. During the second day of hospitalization, the patient was able to tolerate gentle, carefully applied manipulation without complication and with increased mobility. I then ordered ambulation training, performed by physical therapy. I arranged for discharge and outpatient treatment once the patient was able to demonstrate sufficient improvement by performing minimum daily activities and avoiding narcotic analgesia for greater than three hours.

A chiropractor who co-admits is responsible for orders and consultation requests as they relate to those aspects of care that fall within the chiropractor's scope of practice. Depending on the rules and regulations that govern chiropractic in a particular hospital, the chiropractor may request orthopedic, neurologic or other specialist consultations. If allowed in that state, the chiropractor may request treatment administered by a hospital physical therapist. The medical physician co-admitter will be the primary admitting physician. The medical physician will be responsible for the medical aspects of the admission orders. The medical physician is responsible for ordering medications, types of meals (e.g., low salt), specialist consultations, etc.

One of my patients returned to my office for continued treatment of low back pain. On this visit, he presented with a contused left eye. He advised that someone had assaulted him the previous day, but that he had not received emergency medical attention. He was unable to read all but the large "E" at the top of my eye chart from only a few feet away. I called the ED and alerted the attending physician that I would be referring this patient for evaluation of his eye. The physician called back to advise that a CT scan revealed a fracture of the orbit. I told him that I would be co-admitting with a staff medical physician. I then called a co-admitting medical physician, who in turn called the ED to provide admission instructions that included neurological monitoring and neurological, ophthalmology and ENT consultations. During the patient's three-day hospital stay, I was able to visit him daily to continue chiropractic care of his lower back condition. When all consultations and testing were complete and it was determined that the patient was stable, he was discharged.

You should contact the co-admitting medical physician when you believe your patient has improved sufficiently to be able to receive treatment on an outpatient basis. The patient should no longer require injections of intramuscular or IV narcotic analgesia. The patient should not be in need of constant traction. The patient should be able to walk without assistance, although they still may require the use of a cane or walker. The patient should be able to move from the bed to a chair or be able to use bathroom facilities without assistance. You need to have a reasonable expectation that the patient will be able to perform essential daily activities upon discharge.

While we strive to use our chiropractic skills to help patients avoid hospitalization, admission is sometimes necessary to properly treat and evaluate a small percentage of patients. Once the patient is admitted, the goal of chiropractic should always be to help limit the length of the patient's hospital stay and to help them avoid unnecessary analgesic medication. For patients who present with contraindications to manipulation, the co-admitting chiropractor retains the ability to contribute to treatment and diagnostic planning. By maintaining contact during hospitalization, the chiropractor is available to provide care for those patients whose contraindications resolve. A pleasant side effect of providing chiropractic care in the hospital is the ability of the hospital staff to observe both the professional manner of the chiropractor and the benefits of chiropractic care for select hospital patients. Rules governing hospital admissions, discharges, and the appropriate role of the chiropractor will vary according to state regulations governing the practice of chiropractic, as well as individual hospital rules and bylaws.


Click here for previous articles by John Cerf, DC.

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