Defining appropriate ER visit

[chesca]

Hello,
I am currently a student intern working at a primary care clinic. I am trying to create a work flow that differentiates between an appropriate vs. inappropriate ER visit. One of the primary goal of the project is to create a list or guideline of symptoms/diagnosis that is warranted to be life threatening hence an appropriate ER visit. I have reviewed the literature quite extensively, however, it is difficult to identify what are life threatening symptoms and diagnosis without a clinical background.

My questions here are
1) Are there resources that you can direct me to in order to help me ascertain what symptoms are warranted to be life threatening?
2) What are your thoughts about using discharge plans as means to identify urgent vs nonurgent cases at a primary care setting? Although the information is limited, it is the most convenient and immediate resource that the clinic has access to.

Any ideas or thoughts would be greatly appreciated. Thank you for your time!

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[link2swim06]

It's going to be a case-by-case basis. And hard to make universal guidelines. In general the ER is good for acute issues or acute worsening of chronic issues. Chronic issues themselves are best managed in the primary care setting.

And half of the job of the ER is to figure out if there is something life-threatening going on. Just because we don't find anything doesn't mean the visit was inappropriate.

 

[Modafinil]

It's going to be a case-by-case basis. And hard to make universal guidelines. In general the ER is good for acute issues or acute worsening of chronic issues. Chronic issues themselves are best managed in the primary care setting.

And half of the job of the ER is to figure out if there is something life-threatening going on. Just because we don't find anything doesn't mean the visit was inappropriate.

Doc I've got the -itis.

 

[The White Coat Investor]

What you can't do is look at the discharge diagnosis- see, you just had costochondritis, that's not emergent, and determine it was inappropriate. The chief complaint of chest pain was appropriate to be worked up in the ED.

 

[SoCuteMD]

Can you explain what the use of this work flow once developed would be?

 

[RustedFox]

If a selfie is involved at any point...

 

[ccfccp]

One of my biggest pet peeves that gets sent to the ED from primary care offices is asymptomatic hypertension and asymptomatic hyperglycemia. I see at least one or two a shift. This is worse around the times clinics close, but can be any time. It's hard to tell a patient, "I don't really care that your blood pressure was apparently 200/110 at the clinic. It was probably that yesterday too. Your PCP should probably put you on blood pressure medication if it continues. It puts you at risk for bad things like heart attack and stroke. However, your blood pressure here is 140/100 and you still have no complaints. I don't feel comfortable enough without knowing your history and what your blood pressure has been running to start you on meds out of the ED with no close follow up. You should probably call your doctor." which is invariably answered with, "but my doctor sent me here for you to do it."

 

[RuralEDDoc]

One of my biggest pet peeves that gets sent to the ED from primary care offices is asymptomatic hypertension and asymptomatic hyperglycemia. I see at least one or two a shift. This is worse around the times clinics close, but can be any time. It's hard to tell a patient, "I don't really care that your blood pressure was apparently 200/110 at the clinic. It was probably that yesterday too. Your PCP should probably put you on blood pressure medication if it continues. It puts you at risk for bad things like heart attack and stroke. However, your blood pressure here is 140/100 and you still have no complaints. I don't feel comfortable enough without knowing your history and what your blood pressure has been running to start you on meds out of the ED with no close follow up. You should probably call your doctor." which is invariably answered with, "but my doctor sent me here for you to do it."

PCPs do not know or care about ACEPs asymptomatic HTN policy position. The patient was sent to the ED precisely because the PCP was not comfortable with the clinical scenario. Check a chem 7, start 25mg hydrochlorothiazide or 10mg lisinopril, tell them to buy a BP monitor, check daily, keep a log, 7 day PCP follow up. Door to dispo 60 minutes, easiest patient you'll ever see, and everyone including the PCP is happy. Don't burn bridges with your community PCPs, you need them and they need you.

As for the OP, I think this is unfortunately an impossibly difficult project. Too many variables. Even Kaiser (master of unnecessary ED visit avoidance) sends dozens of unnecessary visits to each Kaiser ED each day by advice nurses because this is a desperately complex issue that is impossible to place into a guideline or protocol.

 

[docdragon]

The standard definition of an appropriate, or emergent, ED visit is that a reasonable person would consider a symptom/symptoms concerning enough to need evaluation within 24 hours or less.

ACEP does a fair bit of research into this. The vast majority of patient presentations to the ED are actually quite reasonable within that framework, though many of the fast-track or urgent care type complaints become less reasonable if the primary care office has acute care visits available and can perform simple procedures like abscess drainage and sutures. None of these should be assumed to be true or available, though they are certainly possible. Look at the ACEP web page and poke around a little. Some of their easy-find, free publications (ACEP Now, for example) will publish summaries of these studies with references to the originals.

 

[Birdstrike]

You all should know by now, that
e v e r y t h i n g is an "appropriate ER visit."

 

[GeneralVeers]

PCPs do not know or care about ACEPs asymptomatic HTN policy position. The patient was sent to the ED precisely because the PCP was not comfortable with the clinical scenario. Check a chem 7, start 25mg hydrochlorothiazide or 10mg lisinopril, tell them to buy a BP monitor, check daily, keep a log, 7 day PCP follow up. Door to dispo 60 minutes, easiest patient you'll ever see, and everyone including the PCP is happy. Don't burn bridges with your community PCPs, you need them and they need you.

As for the OP, I think this is unfortunately an impossibly difficult project. Too many variables. Even Kaiser (master of unnecessary ED visit avoidance) sends dozens of unnecessary visits to each Kaiser ED each day by advice nurses because this is a desperately complex issue that is impossible to place into a guideline or protocol.

I disagree. It's dispo 5 minutes not 60. If they have hypertension with no other symptoms or signs of end organ damage, they get no labs, no meds, and are told to follow up with their PCP. I do tell them to keep a log of BP, but ONLY to show their PCP, not to panic and return to the ED if it's "high".

 

[RuralEDDoc]

I guess we'll have to agree to disagree. I just don't see the point of not addressing the reason someone was sent to the ED. The patient is going to have to pay their copay for ED visit no matter what you do. They'll get a level 3 bill regardless of whether you do labs or start meds. They will still have chronic hypertension regardless if you treat or not. Starting an oral antihypertensive provides a service. It reinforces to patients that hypertension matters (which it does) without creating the hysteria that patients need IV meds to bring down BP. Dispo without addressing the "problem" is kind of an f-you to the patient and PCP.

 

[ccfccp]

PCPs do not know or care about ACEPs asymptomatic HTN policy position. The patient was sent to the ED precisely because the PCP was not comfortable with the clinical scenario. Check a chem 7, start 25mg hydrochlorothiazide or 10mg lisinopril, tell them to buy a BP monitor, check daily, keep a log, 7 day PCP follow up. Door to dispo 60 minutes, easiest patient you'll ever see, and everyone including the PCP is happy. Don't burn bridges with your community PCPs, you need them and they need you.

As for the OP, I think this is unfortunately an impossibly difficult project. Too many variables. Even Kaiser (master of unnecessary ED visit avoidance) sends dozens of unnecessary visits to each Kaiser ED each day by advice nurses because this is a desperately complex issue that is impossible to place into a guideline or protocol.

This is actually what I typically do in cases where patients are still significantly hypertensive on presentation. However, lots of them aren't and I have no interest in treating their white-coat hypertension or "i just ran up the stairs because I was running late" hypertension. I just find it irritating. I also hate having to have the, "I'm not sure why your PCP sent you here (especially when they're expecting to be admitted for their BS blood pressure), probably all you need is BP meds. No, I'm not sure why you need to pay a $300 co-pay for me to tell you that" conversation. I usually end up seeing between 2.5-3 pph in a high acuity shop, and this seems like it is something that should be able to be cared for by the PCP. I'd rather be spending the time on someone who actually needed it. I'm actually pretty lenient on what I think is an "appropriate" ED visit. This is just one that irks me for some reason. (Same thing for asymptomatic hyperglycemia - which usually gets lab and I bring their sugar down somewhat knowing full well that it will be back to >400 when they're not taking their meds tomorrow, the same way that they were not taking their meds yesterday prompting the visit today.)

 

[Vandalia]

Defining an appropriate ER visit is a task on a par with finding a cure for cancer, peace in the Middle East, or creating an internal combustion engine that runs on water.

No matter what criteria you come up with, someone else will come up with an obvious flaw in seconds.

About a year or two ago, someone came up with a set of criteria: I pointed out that testicular torsion did not meet their definition. Which every male (at least) quickly agreed was in fact an emergency. The same thing applies with something like a kidney stone: in terms of physiology it is pretty minor. However, if you have every had one you are quickly heading for immediate care.

 

[GeneralVeers]

I guess we'll have to agree to disagree. I just don't see the point of not addressing the reason someone was sent to the ED. The patient is going to have to pay their copay for ED visit no matter what you do. They'll get a level 3 bill regardless of whether you do labs or start meds. They will still have chronic hypertension regardless if you treat or not. Starting an oral antihypertensive provides a service. It reinforces to patients that hypertension matters (which it does) without creating the hysteria that patients need IV meds to bring down BP. Dispo without addressing the "problem" is kind of an f-you to the patient and PCP.

It depends on volume. In my place where I'm typically at 2.5 pph or more, there simply isn't time. My job is to assess for an emergent medical condition, treat it, and either admit or discharge. These patients don't have an emergency. They get an MSE, and discharge told to f/u with their PCP. The fact that their PCP isn't smart enough or up-to-date enough to know when to send hypertension to the ED isn't my problem. The patient needs to ask their PCP why they wasted $300-$1000 on a copay coming in.

 

[Xerxes1729]

Refills of opiate medication for chronic non-cancer pain are never an appropriate reason for an ED visit. If you say that your pain is exactly the same pain that you've had constantly without change since 1992 and that you moved to my town eight weeks ago, but neglected to try to find a PCP to prescribe your chronic pain meds, you absolutely should not be in the ED.

On the flip side, there are things that are always appropriate reasons to visit the ED: massive bleeding, unconsciousness, new paralysis, apnea, etc.

Unfortunately, most things are in a gray area.

 

[linuxizer]

A recent NEJM piece argues not:
http://www.nejm.org/doi/full/10.1056/NEJMp1502627

even informed patients cannot necessarily trans- late their symptoms and history into a diagnosis, much less a prognosis. Patients present to the ED with symptoms that may sig- nal an emergency, such as chest pain, and clinicians are able to rule out an emergency only after performing an evaluation and di- agnostic tests. Indeed, 88% of all visits that are retrospectively de- termined to be for “nonemer- gency” (primary care treatable) di- agnoses cannot be distinguished from true emergencies at the time of admission on the basis of the patient’s chief complaint.4 It
is neither ethical nor prudent for clinicians to withhold care until they can determine whether a case is an emergency — and at that point opportunities for cost savings through diversion from the ED would probably be minimal.

 

[Birdstrike]

Like I said above, but I'll just say it again: Get the idea out of your head that there is anything such as an "inappropriate ER visit."

It doesn't exist. Any continued belief in this tooth fairy will just lead you down a rabbit hole of needless frustration.

 

[alpinism]

Yeaaah you all have it backwards...

There is no inappropriate ED visit because EDs don't exist any more in case you haven't noticed.

They've been replaced with hyper expensive urgent care clinics that also dabble in emergency medicine from time to time.

As for the OP, here's definition the NHS uses in the UK:

“A&E departments are there to treat critical or life-threatening illnesses and injuries"

(i.e. true emergencies)

From their Choose Well Campaign website:
http://choosewellmidlands.nhs.uk

And

Now obviously this is never going to happen in the US in the near future for a number of reasons that have been discussed ad naseum on this forum. But, since you asked the above is a basic example of how an ED is supposed to function.