New Attending, How to Deal With Pushback?

[cardsperson]

If we learned anything, if it isn't the fluff that comes into the hospital, then we are ****ed as a profession. Our salaries basically depend on admitting and dispoing softballs. Look what happened in EM when all those soft walk-ins stopped coming. I'm a cardiology fellow (who moonlights as a hospitalist/nocturnist) and during the height of the lockdown, we were doing a handful of consults (like 2-3 vs 15 during normal operations), our inpatient services were like 2-3 patients, zero heart transplants/LVADs, <10 echos/day, 0 TEEs for months, basically zero EP procedures, <1 cath/day. You can't justify 400k salaries on that volume. We were doing basically what was necessary and nothing more. If you cut out all the unnecessary/borderline consults, procedures, we actually don't have all that much to do.

A lot of inpatient echos and cards consults are unnecessary, but the other things you listed didn't dwindle down because people stopped ordering unnecessary tests, but because we stopped doing "elective" procedures. There's really nothing "elective" about a heart transplant or LVAD implantation, given that the alternative is a miserable death from cardiogenic shock or non-stop ICD shocks. Also, when the STEMI patients stopped seeking care because they were scared of contracting COVID, their MIs didn't magically fix themselves, and we started to see all the electromechanical complications that we thought were things of the past.

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[TheComebacKid]

I'll be honest I think one of my biggest issues with discharging patients is that I wasn't well trained in much of the primary care that we see the vast majority of the time. Maybe my residency failed me in that regard. I'm not sure how it is at residency programs across the country, but I trained at a very high acuity program that made me comfortable to handle critically ill patients and acute problems, not chronic disease. I think the vast majority of EM docs can line and tube people day and night, resuscitate all day everyday.

But starting anticoagulation for a DVT, which is clearly something that can be managed in the outpatient primary care setting, is not something that is ingrained in our training the same way as say, airway management.

I've read that it's reasonable for EM physicians to start patients on long acting insulin on discharge for new onset diabetes. Again, unless they are on an insulin drip, this feels out of my wheelhouse. This is the type of stuff which all the hospitalists and PCPs do in their sleep, but not me. I hate admitting these non-DKA hyperglycemia patients. But I'm just simply not trained well in calculating their daily dose requirements and starting them on outpatient therapy.

The training paradigm for EM, at least for me, is honestly broken. I was really exceptionally well trained to take care of the minority of sick and dying people or those with acute medical complaints i.e. fracture/dislocation, PTA, paronychia etc. For everyone else, I was trained to make a dispo which is either admit to a hospitalist/consultant or discharge home to PCP follow up. But discharge home with long acting insulin, xarelto, new BP meds, gabapentin or lyrica for neuropathy, antidepressants, OCPs, risperidone for agitation, new seizure meds etc...? Sometimes if I'm not comfortable with it, I'm going to defer to someone who manages this stuff regularly and that may mean bringing them into the hospital on a "soft" admit or calling a "soft" consult. It's very easy if you are an endocrinologist and have spent your entire residency/fellowship managing thyroid medication, but for me it feels like foreign territory where I'm bound to goof up and get into trouble for both the patient and myself.

I wish hospitalists and PCPs understood that "an easy discharge" for them from their inpatient service or their clinic sometimes feels for me like I'm almost practicing a different specialty that I wasn't trained in.

 

[southerndoc]

Hey; you got a link for a good read on the BIG1/2/3 guidelines? My google-fu isn't quite cutting it. I get abstracts, but nothing good.

PM me your email address and I'll send them to you.

I find it hilarious that neurosurgeons want us to discharge head bleeds based on a retrospective study. Sorry mister important consultant, but you have to see the boring BS too, just like the rest of us.

The original study was retrospective, yes. However, it's been prospectively validated.

We run all of our protocols for discharging patients (BIG, PE, 0,1-hr hsTrop, etc.) by MEC for approval for official hospital protocol buy-in.

We all live in our comfort zones. Sometimes you have to step outside of it to progress. There was a time when ER docs were scared to tPA STEMI's. We still see it in being afraid of tPA'ing strokes. Trying to admit everything that should go home will worsen job dissatisfaction as you'll be arguing with every hospitalist. One of the posters was correct: you admit on a heparin drip, they change to a NOAC, and then discharge the patient. If their sPESI, PESI, or HESTIA score (whichever you use) is appropriate for discharge, then they can go home.

However, I recognize that a scoring system is just that... a risk stratification system. Not every BIG1 goes home. Sometimes there are social issues, frequent falls, etc. that I might admit to a hospitalist for. We have a modified BIG algorithm. We have excluded epidural hematomas from BIG1 and also require a repeat head CT at 6 hours. If it's worse, it's an automatic neurosurgery consult (we have neurosurgery APP's in-house 24/7). If it's stable, they go home.

 

[thegenius]

I'm a relatively new attending in my first year out (did a fellowship last year with some moonlighting, but this is my first big boy job). I, like many new attendings tend to be on the more conservative side. At least once or twice on a shift, you get that patient that you know is going to be a soft admit, but you don't feel comfortable sending home. It sort of builds up over the next few hours as you prepare for the inevitable dreadful battle with the hospitalist, and sometimes I (regretfully) end up hoping I find something so I can keep them in the hospital. It's not that I have an issue discharging patients, but it's just that some people give you a high risk story, or have risk factors, or just look terrible despite what their numbers show. Sometimes, I just want them to be watched for awhile, but I know it's a soft admit and I'm going to get reamed by the hospitalist.

Yup I was there. I've been out for 7 years...and the first 1-2 years was hard. I remember admitting all sorts of stuff in residency. Over time I've learned a few things:
- you end up adopting the admission culture of your institution (for better or for worse). If it's really bothersome to you and you feel the hospitalists practice bad medicine, then you should leave. While I'm not a fan of our hospitalist group it's more due to their competency and not their admission criteria.
- I slowly realized that ER residency academia is not at all real world. And while I don't think it's a problem because I learned a lot of theory in residency...often that theory doesn't play out in the real world. Academia ER is fraught with conservatism and that's the right way to train. You have to make ER residents think about and consider all the emergencies before settling in on benign stuff like vaso-vagal syncope or acute gastroenteritis.
- For what it's worth...I work at two different hospital systems and I work up and dispo the same complaint totally differently at both systems. We practice system medicine and not ER Residency / Rosen / Tintinalli's medicine.

We really live by a doctrine of ensuring outpatient follow up for our patients. Well, if it takes 6 months to get in to see a cardiologist for a chest pain workup, I don't feel comfortable sending them home to just wait it out.

Maybe I'm wrong...but I feel like the patient needs to do some work to see a doctor. The way I practice is the following: if a patient has a diagnosis that REQUIRES a specialist, or even their PCP, to be followed-up in ~2-3 days, then I consider admitting them. It's near impossible to get an appointment like that in just about any system.

However, if they have a diagnosis that can be seen in 1-2 weeks or even more, then it's the patient's job to get that appointment. I used to go out of my way to make them appointments and it got me nowhere besides heartache and a waste of time. 1/2 the time patients wouldn't even go. Example diagnoses in this category are stable pneumonia, diverticulitis, non-arrhythmogenic syncope, stable pyelonephritis, asthma exacerbation, etc. You get my drift.

I really dread these "low risk" chest pain patients. At my hospital I have a hard time coordinating outpatient follow up for them. They say all the bad things. They have all the risk factors. But sometimes they lack objective data i.e. EKG changes or enzyme leak etc. Pitching these patients to the hospitalist is a nightmare, and I hate the phone call. "They have two negative troponins and a unchanged EKG, what are we going to do for them in the hospital?" or "They presented for the same thing 2 months ago and had a negative workup." These points and questions are valid on part of the hospitalist, and I do think avoiding unnecessary admissions is a good thing. HEART scores, while I love them, IMO seem very conservative and probably lead to many unnecessary admissions and stress tests. But I think my risk tolerance is exceedingly low, and when patients are old, or tell a good story, I just get nervous and err on the side of wanting to keep them. I'm not particularly proud of this, and don't think it makes me a great doctor, and sometimes I feel like a wuss.

I know the intent of this is NOT to discuss disposition of low risk chest pain, but this is one area where I felt academia ER taught us poorly. The data showing 30-day adverse outcomes in low-risk chest pain (HEART SCORE <=3) is exceedingly low. It's less than 1%. It's not ~2.5% as we were taught. Even HEART SCORE = 4 has a < 1% of 30-day adverse outcome per the Kaiser study that looked at like 50K - 100K patients.

Simply put, if you correctly apply a HEART Score and they are low risk, and they have two neg troponins, normal EKGs, and no chest pain at discharge, the chance of those patients having an adverse outcome in 30 days is < 1%. It doesn't get much better than that.

This has been one major change in the way I practice and it took about 5 years for me to get comfortable doing it. I basically either discharge or admit chest pain. I never keep them in the ED and get a stress test, nor do I discharge them with arrangements to get an outpatient stress test. Their doctors can arrange for that.

For what it's worth, the emerging data shows that stress tests in low risk chest pain is meaningless and shouldn't be done. Too bad there are old time cardiologists who will stress every 4-limbed thing that walks into their office. Seriously...if an alligator came into their office and said it had chest pain, they would get a twelve lead and then do a treadmill stress test on the giant lizard.

2 nights ago I had a patient: 83 year old male, history of atrial fibrillation not on anticoagulation. Syncopized in the kitchen while cooking, broke his mandible on the kitchen counter. EKG just revealed atrial fibrillation (rate controlled). Troponin was negative. He just looked terrible. And he looked old. And I didn't have a reason for why he syncopized. His CHADS-2 score was 3. He was recommended by cardiology years ago to start anticoagulation, but for some reason, never did. He just looked awful, and I wanted to keep him despite any objective data, he seemed like a high risk person to me, and the hospitalist was having none of it.

I would admit that patient! Make the hospitalist do a consult on the patient.

My admits are probably overkill, and I fully concede that. But how do I become less conservative? Is it just time? How do I not get that patient that I am going to dread calling the hospitalist the entire time? I want to be a good steward of healthcare resources, the hospitalists time, etc but I also want to sleep at night. All of these things seem to be at odds with each other.

It's just time. I find ER doctors, over time, do one of two things (there are obvious exceptions though): they become very conservative and test and admit everything, or become liberal and do limited testing and admit little.

You know what? I bet the pertinent outcomes of interest in both groups is about the same too.

Some pointers:

- Most docs will tell you ITS NOT YOUR JOB TO BE A STEWARD OF HEALTH CARE RESOURCES. You know what? I believe it. But I'm like you in that I don't like over testing and I think about things like the bill they are going to get, if the hospital is full or not, etc. I don't think that's bad either. First and foremost always do what's best for the patient.

- Over time you'll pick your battles. You'll probably learn to let soft stuff slide a little. But if you are confident that a patient needs to be admitted then have the hospitalist see the patient. Ask for a consult. They need to consult. They have to. I think over time you'll settle into a groove.

 

[thegenius]

I find hospitalists want me to tell them what to do. Hospitalists are consult jockeys - many of them act more as a mid-level than practice true medicine. Just tell them what to do. That old guy with risk factors and concerning story for syncope = tell hospitalist that he needs tele and observation for cardiac arrhythmia or if the dude is on meds that alter mentation (heavy blood pressure meds and his pressures are semi soft) tell the hospitalist he needs observation for medication metabolism and maximizing outpatient blood pressure control in addition to the tele.

Agree....I can't imagine being a hospitalist is fun. They just want to admit the patient, put some orders in, and go to the next patient. They don't care about the vast majority of patients and I wouldn't either if I were in their position.

They just want to know what antibiotics to give, what's the next test to order, and if it's a semi-emergency condition requiring a specialist that the specialist "is on board" so to speak. I hate that last part, but I think 1/3 of my consults from the ED are just to facilitate admitting the patient.

 

[Rekt]

I'll be honest I think one of my biggest issues with discharging patients is that I wasn't well trained in much of the primary care that we see the vast majority of the time. Maybe my residency failed me in that regard. I'm not sure how it is at residency programs across the country, but I trained at a very high acuity program that made me comfortable to handle critically ill patients and acute problems, not chronic disease. I think the vast majority of EM docs can line and tube people day and night, resuscitate all day everyday.

But starting anticoagulation for a DVT, which is clearly something that can be managed in the outpatient primary care setting, is not something that is ingrained in our training the same way as say, airway management.

I've read that it's reasonable for EM physicians to start patients on long acting insulin on discharge for new onset diabetes. Again, unless they are on an insulin drip, this feels out of my wheelhouse. This is the type of stuff which all the hospitalists and PCPs do in their sleep, but not me. I hate admitting these non-DKA hyperglycemia patients. But I'm just simply not trained well in calculating their daily dose requirements and starting them on outpatient therapy.

The training paradigm for EM, at least for me, is honestly broken. I was really exceptionally well trained to take care of the minority of sick and dying people or those with acute medical complaints i.e. fracture/dislocation, PTA, paronychia etc. For everyone else, I was trained to make a dispo which is either admit to a hospitalist/consultant or discharge home to PCP follow up. But discharge home with long acting insulin, xarelto, new BP meds, gabapentin or lyrica for neuropathy, antidepressants, OCPs, risperidone for agitation, new seizure meds etc...? Sometimes if I'm not comfortable with it, I'm going to defer to someone who manages this stuff regularly and that may mean bringing them into the hospital on a "soft" admit or calling a "soft" consult. It's very easy if you are an endocrinologist and have spent your entire residency/fellowship managing thyroid medication, but for me it feels like foreign territory where I'm bound to goof up and get into trouble for both the patient and myself.

I wish hospitalists and PCPs understood that "an easy discharge" for them from their inpatient service or their clinic sometimes feels for me like I'm almost practicing a different specialty that I wasn't trained in.

You're over complicating things.

"You don't have an emergency today, follow up with X".

Very simple. I don't do any of that. That's not my problem. You're job is to determine if they have an acute emergency that is life or limb threatening. Someone who is a little more sad than normal? Discharge. SSRI/SNRI needs follow up to determine efficacy regardless. You can start one and be nice if you want. Close your eyes and pick one. Next. Hyperglycemia? There's never any reason to admit a hyperglycemia without other metabolic derrangements. They likely don't even need insulin if this is a new dx. Metformin and home. Follow up A1c at PCP. DVT/PE? Xarelto or Eliquis and discharge. No insurance/transportation/etc admit with magic words of they can' afford it or get it. Heparin bridge to coumadin - bye. First time seizure gets no anti-epileptics. F/u with neuro. 2nd time sz didn't bother following up? Keppra - bye. Thyroid? Unless thyrotoxicosis or myxedema - bye. OCPS? forget it. Not your responsibility. Respiradone for agitation? What? that's borderline malpractice if you're sending them home. Psych pts that go home get nothing. Not your problem.

etc etc etc etc

I start all my encounters telling patients this is an emergency room and I don't manage chronic complaints. Anything that isn't imminetely threatening can be followed up. You aren't there to be their friend and especially not be their PCP or specialist.


Hospitalist doesn't want a patient? I document "Dr. XY of hospitalist refused patient for admission at Z time despite my continued recommendations". Screw them. They'll throw you under the bus any day of the week.

 

[bravotwozero]

One day, I came home from a shift and called up a buddy of mine who understands me very well.
I said to him: "My job would be better if they just created a hologram of me that smiled and told patients the things that they wanted to hear; it would free me up to do the actual brain-bending work of the medicine itself."

Like the floating head doc in scrubs…

EDIT: as for people, I find them more pleasant outside the ED as a whole, but inside the ED it will get anyone jaded.

I’m transitioning out of a hospital system right now that is notorious for patients having epic levels of entitlement.

Every second patient knows the bloody hospital CEO. ‘I’m Marc Boom’s baby mommas niece so you have to spend 20 minutes kissing my ass and admit me for my acute rhinovirus infection’…

 

[thegenius]

I partially agree with what you're saying. We as emergency physicians are often too uncomfortable discharging someone that doesn't need admission: low risk PE's, BIG1 minor head bleeds, moderate risk chest pain (hsTrops for the win), diverticulitis just because they have pain, etc.

Just as STEMI's once were in the hospital for a week, cardiology has changed to discharge them 24 hours after their cath. DKA has transitioned to an observation admission even if going to the ICU. The low risk stuff that I mentioned previously should go home. The hospital loses money because of DRG's or worse, the patient gets stuck with a bill for an unnecessary admission. Before anybody asks, no, you don't need a neurosurgery consultation to discharge a BIG1 patient.

BIG1?

 

[larpleston]

PM me your email address and I'll send them to you.

The original study was retrospective, yes. However, it's been prospectively validated.

We run all of our protocols for discharging patients (BIG, PE, 0,1-hr hsTrop, etc.) by MEC for approval for official hospital protocol buy-in.

We all live in our comfort zones. Sometimes you have to step outside of it to progress. There was a time when ER docs were scared to tPA STEMI's. We still see it in being afraid of tPA'ing strokes. Trying to admit everything that should go home will worsen job dissatisfaction as you'll be arguing with every hospitalist. One of the posters was correct: you admit on a heparin drip, they change to a NOAC, and then discharge the patient. If their sPESI, PESI, or HESTIA score (whichever you use) is appropriate for discharge, then they can go home.

However, I recognize that a scoring system is just that... a risk stratification system. Not every BIG1 goes home. Sometimes there are social issues, frequent falls, etc. that I might admit to a hospitalist for. We have a modified BIG algorithm. We have excluded epidural hematomas from BIG1 and also require a repeat head CT at 6 hours. If it's worse, it's an automatic neurosurgery consult (we have neurosurgery APP's in-house 24/7). If it's stable, they go home.

I'm definitely not comfortable assuming 100% of the risk for a head bleed. If you do, more power to you, but it's still not the standard of care to discharge these patients anywhere I've been. The guidelines also showed that some of the BIG1 patients deteriorated, right? At the end of the day I don't see what there is to gain by sending these patients home. They might have a bad outcome, and bad = catastrophic not a minor bounceback, and its main impetus was to decrease the amount of consults for neurosurgeons. Why would I take on all of the liability for that when we're only talking about a few extra obs admits a month. Don't get me wrong I wish we lived in a medicolegal climate where I could send these people home but alas my being sued for crazy $#*@! tolerance is too low.

 

[thegenius]

I'll be honest I think one of my biggest issues with discharging patients is that I wasn't well trained in much of the primary care that we see the vast majority of the time. Maybe my residency failed me in that regard. I'm not sure how it is at residency programs across the country, (1) but I trained at a very high acuity program that made me comfortable to handle critically ill patients and acute problems, not chronic disease. I think the vast majority of EM docs can line and tube people day and night, resuscitate all day everyday.

But starting anticoagulation for a DVT, which is clearly something that can be managed in the outpatient primary care setting, is not something that is ingrained in our training the same way as say, airway management.

(2) I've read that it's reasonable for EM physicians to start patients on long acting insulin on discharge for new onset diabetes. Again, unless they are on an insulin drip, this feels out of my wheelhouse. This is the type of stuff which all the hospitalists and PCPs do in their sleep, but not me. I hate admitting these non-DKA hyperglycemia patients. But I'm just simply not trained well in calculating their daily dose requirements and starting them on outpatient therapy.

(3) The training paradigm for EM, at least for me, is honestly broken. I was really exceptionally well trained to take care of the minority of sick and dying people or those with acute medical complaints i.e. fracture/dislocation, PTA, paronychia etc. For everyone else, I was trained to make a dispo which is either admit to a hospitalist/consultant or discharge home to PCP follow up. But discharge home with long acting insulin, xarelto, new BP meds, gabapentin or lyrica for neuropathy, antidepressants, OCPs, risperidone for agitation, new seizure meds etc...? Sometimes if I'm not comfortable with it, I'm going to defer to someone who manages this stuff regularly and that may mean bringing them into the hospital on a "soft" admit or calling a "soft" consult. It's very easy if you are an endocrinologist and have spent your entire residency/fellowship managing thyroid medication, but for me it feels like foreign territory where I'm bound to goof up and get into trouble for both the patient and myself.

1) Yep homey....80% of what we are chronic exacerbations of chronic conditions. How many COPDers do we see who are not that bad? Literally they get better with two duonebs. And they have a nebulizer at home. Why can't they just give themselves duonebs. It's silly. Heart failure is another. The vast majority of heart failure "exacerbations" as we call them can just go home with better BP and diuretic mgmt. Literally 85-90% of them. They come in becuase they had two days of pizza and wendys and Popeyes and then be like "I can't breathe!!!" LOL

2) I send home hyperglycemia ALL THE TIME. 100% of the time. It's simply not an emergency. I never start them on insulin. Start them on metformin. Or don't start them on metformin. By definition diabetes is a chronic disease. It's rarely an emergency.

3) I hear what you are getting at. I struggle with this...but ultimately ERs are for emergencies and not for delivering medical care for chronic conditions. Otherwise it would just be called "Outpatient 24hr Room." I think ER training is fine for emergencies...but the system we have is so bad we see like 1 emergency per 15 patients in the ED.

 

[southerndoc]

I'm definitely not comfortable assuming 100% of the risk for a head bleed. If you do, more power to you, but it's still not the standard of care to discharge these patients anywhere I've been. The guidelines also showed that some of the BIG1 patients deteriorated, right? At the end of the day I don't see what there is to gain by sending these patients home. They might have a bad outcome, and bad = catastrophic not a minor bounceback, and its main impetus was to decrease the amount of consults for neurosurgeons. Why would I take on all of the liability for that when we're only talking about a few extra obs admits a month. Don't get me wrong I wish we lived in a medicolegal climate where I could send these people home but alas my being sued for crazy $#*@! tolerance is too low.

30% of ER's are discharging BIG1 patients now according to a recent poll I did through the ACEP ED Directors Academy listserv.

Do you also not follow clinical stratification rules for head injuries or cervical spine injuries? Do you CT all of them? It's the same thing. A minor head bleed + 6-hour ED observation + repeat head CT at 6 hours = would be extremely rare to miss progression of a headbleed.

 

[larpleston]

30% of ER's are discharging BIG1 patients now according to a recent poll I did through the ACEP ED Directors Academy listserv.

Do you also not follow clinical stratification rules for head injuries or cervical spine injuries? Do you CT all of them? It's the same thing. A minor head bleed + 6-hour ED observation + repeat head CT at 6 hours = would be extremely rare to miss progression of a headbleed.

30% means practicing in a way that deviates from the majority of emergency physicians - a bad outcome when practicing that way is very hard to defend against. I follow pecarn, canadian head ct, use heart scores, etc, because these are decision rules that are used by the majority of EPs and have extensive validation but I don't think the same can be said for BIG yet. It would be great if they could be adopted more widely and I could admit less BS and call fewer pointless consults, but I don't think it's there yet in my neck of the woods.

 

[Mount Asclepius]

If you work in a busy community eat what you kill shop working 8 hour shifts where you don’t sign out you aren’t going to sit on a patient for 6 hours and repeat a head CT. That’s an observation admit. You have 2-3 hours for a patient to sit in the ED. Busy community shops are significantly different than big academic centers.

30% is too early on the technology adoption curve for something with the risk of catastrophic outcome. You’re much better off being in the late majority.

You CT most head injuries, because that’s what patients expect. They unfortunately don’t care about your education, nor your decision rules.

 

[thegenius]

If you work in a busy community eat what you kill shop working 8 hour shifts where you don’t sign out you aren’t going to sit on a patient for 6 hours and repeat a head CT. That’s an observation admit. You have 2-3 hours for a patient to sit in the ED. Busy community shops are significantly different than big academic centers.

30% is too early on the technology adoption curve for something with the risk of catastrophic outcome. You’re much better off being in the late majority.

You CT most head injuries, because that’s what patients expect. They unfortunately don’t care about your education, nor your decision rules.

I don't even know the BIG1 criteria, but the risk of catastrophic outcome is extraordinarily small. That's why people are investigating sending them home from the ER in the first place.

I'm not gonna get into this discussion about whether it's right or not right to admit or send home these head bleeds...but I can't wait to do it. It's kind of like PE's. There is a risk of catastrophic outcome but these tiny PE's with no red flags should just go home with a DOAC. I've done it a few times. In fact I would do it more often but there are often problems having my pt's medicaid insurance approve the DOAC.

 

[Mount Asclepius]

I don't even know the BIG1 criteria, but the risk of catastrophic outcome is extraordinarily small. That's why people are investigating sending them home from the ER in the first place.

I'm not gonna get into this discussion about whether it's right or not right to admit or send home these head bleeds...but I can't wait to do it. It's kind of like PE's. There is a risk of catastrophic outcome but these tiny PE's with no red flags should just go home with a DOAC. I've done it a few times. In fact I would do it more often but there are often problems having my pt's medicaid insurance approve the DOAC.

Not to be overly argumentative, but you should know or look up the criteria before you argue that the risk isn’t potentially catastrophic. The risk is lower. The risk of catastrophe isn’t negligible. This isn’t sending home intractable vomiting.

I don’t know the full history and background behind the BIG in full transparency, but have heard and feel some of the motivation is for Neurosurgeons to decrease consultations. I suspect that’s partially why they are looking into. The whole system also wants to decrease admissions and LOS that don’t pay as much. Follow the money.

Agree with you on sending people home. I work predominantly in our high acuity zone and yet have a lower admit rate than most. Head bleeds are not my hill to die on in our current environment. Admit, bill critical care, and move on to the next patient.

 

[thegenius]

Not to be overly argumentative, but you should know or look up the criteria before you argue that the risk isn’t potentially catastrophic. The risk is lower. The risk of catastrophe isn’t negligible. This isn’t sending home intractable vomiting.

Just hear me out. This is very simple. Nobody is ever going to conduct a study sending home a submassive PE with strain and hypoxia. Nobody is ever going to attempt to do that study - ever. You hear me? And you know why too. A good number of these patients die or have severe morbidity if they survive.

Researchers are studying sending home these tiny head bleeds because there is a very low risk of having an adverse outcome. The mere fact that it's being studied suggests that IT COULD BE SAFE. It's worth studying. I have never seen any bad outcomes from these few ditzel traumatic IPHs. I admit all of them, I follow all of them, and they all go home the next day. Every single one.

And if there is a bad outcome, I'll give you 99 charts of good outcomes.

Did you know that the Canadian CT Head Rule deems the following conditions as "not clinically important brain injury?" This is straight from the paper. 2nd page, 2nd paragraph:

All brain injuries are judged clinically important unless the patient is neurologically intact and has one of these lesions on CT: solitary contusion less than 5 mm in diameter; localised subarachnoid blood less than 1mm thick; smear subdural haematoma less than 4 mm thick; isolated pneumocephaly, or closed depressed skull fracture not through the inner table.

So I don't have to know the details of the BIG1 paper to make the conclusion that there is enough evidence, either empiric or anecdotal or both that it's worth STUDYING whether it's safe to send these patients home. That's all. If there was a meaningful risk of an adverse outcome, it would never pass the IRB.

 

[southerndoc]

If you work in a busy community eat what you kill shop working 8 hour shifts where you don’t sign out you aren’t going to sit on a patient for 6 hours and repeat a head CT. That’s an observation admit. You have 2-3 hours for a patient to sit in the ED. Busy community shops are significantly different than big academic centers.

30% is too early on the technology adoption curve for something with the risk of catastrophic outcome. You’re much better off being in the late majority.

You CT most head injuries, because that’s what patients expect. They unfortunately don’t care about your education, nor your decision rules.

We're RVU based, and yes, we sign these out. Even with our 150,000/year volume, we only see 2-3 of these per month. Most of our head bleeds are on anticoagulants, so by definition they're BIG3's and get admitted.

 

[Jabbed]

PM me your email address and I'll send them to you.

The original study was retrospective, yes. However, it's been prospectively validated.

We run all of our protocols for discharging patients (BIG, PE, 0,1-hr hsTrop, etc.) by MEC for approval for official hospital protocol buy-in.

We all live in our comfort zones. Sometimes you have to step outside of it to progress. There was a time when ER docs were scared to tPA STEMI's. We still see it in being afraid of tPA'ing strokes. Trying to admit everything that should go home will worsen job dissatisfaction as you'll be arguing with every hospitalist. One of the posters was correct: you admit on a heparin drip, they change to a NOAC, and then discharge the patient. If their sPESI, PESI, or HESTIA score (whichever you use) is appropriate for discharge, then they can go home.

However, I recognize that a scoring system is just that... a risk stratification system. Not every BIG1 goes home. Sometimes there are social issues, frequent falls, etc. that I might admit to a hospitalist for. We have a modified BIG algorithm. We have excluded epidural hematomas from BIG1 and also require a repeat head CT at 6 hours. If it's worse, it's an automatic neurosurgery consult (we have neurosurgery APP's in-house 24/7). If it's stable, they go home.

Maybe it's my patient population, but I've very rarely if ever had this mythical sober SDH < 4 mm reliable for follow-up and return precautions patient. Even if I did, I'm tying up a bed for at least 8 hours between the initial workup and repeat CT.

I also don't routinely CTA patients that end up having an sPESI of 0 either. Patients that can be managed outpatient seem like patients that shouldn't even be getting scanned in the first place (ie, low risk, maybe even physiologic, sub-segmental PEs that ACCP is now recommending against anticoagulation).

 

[southerndoc]

I don’t know the full history and background behind the BIG in full transparency, but have heard and feel some of the motivation is for Neurosurgeons to decrease consultations. I suspect that’s partially why they are looking into. The whole system also wants to decrease admissions and LOS that don’t pay as much. Follow the money.

Maybe it is. However, non-surgical head bleeds don't need a neurosurgeon to see. Do you consult orthopaedic surgery on every fracture you send home? Do you consult surgery for every diverticulitis you send home? Do you consult urology for every kidney stone you send home? Or do you simply admit all of these patients?

 

[southerndoc]

Maybe it's my patient population, but I've very rarely if ever had this mythical sober SDH < 4 mm reliable for follow-up and return precautions patient. Even if I did, I'm tying up a bed for at least 8 hours between the initial workup and repeat CT.

With our current situation, if we admitted them to obs, they're going to be in our ER for >8 hours anyhow. We typically have 25-60 patients boarding in our ER thanks to COVID.

You're right, the qualifying cases are rare. Even 81 mg of aspirin within the past 7 days excludes you. This is primarily for the 20-year-old skateboarder who has trace tSAH on CT that almost always has resolved by the time the repeat CT is done in 6 hours.

These aren't people being discharged immediately. "Oh, you have a traumatic subarachnoid, peace out!" They're observed (including writing a note in your chart for getting reimbursed for observation billing in the ER if you so choose). A repeat head CT is performed (which is not what the studies did -- we added the extra step for provider comfort). Neurosurgery is available for consultation if needed, but I rarely consult them. Our data is limited due to the low volume of these types of patients, but so far we've had >30 patients without any progression of bleeding.

 

[thegenius]

@southerndoc Can you send me the BIG criteria?

 

[aafisahar]

A lot of inpatient echos and cards consults are unnecessary, but the other things you listed didn't dwindle down because people stopped ordering unnecessary tests, but because we stopped doing "elective" procedures. There's really nothing "elective" about a heart transplant or LVAD implantation, given that the alternative is a miserable death from cardiogenic shock or non-stop ICD shocks. Also, when the STEMI patients stopped seeking care because they were scared of contracting COVID, their MIs didn't magically fix themselves, and we started to see all the electromechanical complications that we thought were things of the past.

Sure I agree with most of what you said but if we applied strict appropriate use to cath, stress testing, and echos, we'd have half the volume. Expertise gets you the job, but the fluff buys you a Porsche.

 

[southerndoc]

Those wanting BIG info please PM me your email address.

 

[Jabbed]

 

[jw3600]

The only people I’ve ever seen quote BIG work in admin. Just saying….

 

[turkeyjerky]

I'm definitely not comfortable assuming 100% of the risk for a head bleed. If you do, more power to you, but it's still not the standard of care to discharge these patients anywhere I've been. The guidelines also showed that some of the BIG1 patients deteriorated, right? At the end of the day I don't see what there is to gain by sending these patients home. They might have a bad outcome, and bad = catastrophic not a minor bounceback, and its main impetus was to decrease the amount of consults for neurosurgeons. Why would I take on all of the liability for that when we're only talking about a few extra obs admits a month. Don't get me wrong I wish we lived in a medicolegal climate where I could send these people home but alas my being sued for crazy $#*@! tolerance is too low.

For me, the major value of the BIG criteria is to avoid unnecessary transfers to level I or II trauma centers.

My system uses these criteria. Frankly, I think it's applied poorly. It should be used to avoid admitting stable young people who didn't need a CT in the first place. Instead, it's used by the trauma service to refuse to admit old people who aren't safe to go home.

 

[Jabbed]

Worth noting that the only patients that had any sort of progression were epidural hematomas that were classified as BIG 2. If you get institutional buy-in to obs these patients +/- repeat CT (which makes me feel better personally) then that's great. Being the only doc in your shop that DCs head bleeds or tries to force them into obs without NSG consult is not going to win hearts and minds though..

 

[RustedFox]

Yeah, I found this too - but I'd like to see the data and such. I can dig around today. I wasn't at a spot yesterday where I could reasonably search and read.

 

[Birdstrike]

...it's applied poorly...

Classic pitfall: Take a study that looks promising, done in ideal academic conditions, with ideal inclusion and exclusion criteria, performed in a system with all the resources in the world. Then try to apply it in a real world system with sub-ideal conditions, sub-ideal patient selection, with a patient population that is significantly different than the study population, while relying on a healthcare team with priorities and motives different from the study researches.

Sometimes the bugs get worked out and it translates to the real world. Sometimes they don't, and what seemed like a great idea, dies in academia.

 

[Birdstrike]

Worth noting that the only patients that had any sort of progression were epidural hematomas that were classified as BIG 2. If you get institutional buy-in to obs these patients +/- repeat CT (which makes me feel better personally) then that's great. Being the only doc in your shop that DCs head bleeds or tries to force them into obs without NSG consult is not going to win hearts and minds though..

These BIG criteria seem like an interesting concept, with a worthy goal of more efficient resource utilization. But I call BS on the concept of having a patient in your ED for 6-7 hours and getting 2 head CTs, but nobody on the neurosurgical team, not even a PA, resident, or fellow can possibly find a minute to come by and give their blessing, and more importantly establish care to see the patient in follow up, before an overwhelmed ED discharges a patient with an ICH.

Sounds like a liability offload.

 

[namethatsmell]

Lots of excellent suggestions on here for the OP.

Here's another one that may help you defuse challenging situations with staff and other docs who you think are gaslighting you, giving you a hard time, or are simply acting like a jerk:

Ask them "Are you OK?"

Do it sincerely and take 30 seconds to listen. People rarely ask us how we're doing since most people think we're somehow invincible or they just don't care...so don't be surprised if you're met with shock or silence.

Docs (and RNs and techs etc) are humans with our own personal/family/life/work stressors that sometimes bleed through to professional interactions...and it doesn't help that right now is the most stressful time in our lives to be on the front lines of medicine. Few people went to med school to become an a$$hole, and under a hard candy shell (or several shells lol) is usually a decent person who wants to do the right thing...but they may happen to be struggling with things that nobody can imagine.

Anyway, taking a moment to show a colleague you actually care about them and humanize them may be the most important thing you'll do all week. And chances are good they won't forget it.

 

[BoardingDoc]

We used similar criteria where I trained for residency and developed a "pathway" for these minor ICH patients. Most got observed for 6 hrs and then DCed without any NSGY involvement. I now work in the community and we don't have NSGY but we have a neurosurgeon who works at the local tertiary care center that will take phone consults for very minor ICH, look at our NCHCT on the pt and then basically applies this chart. I'm now sending these ditzel SAHs home from my community ED shop with some frequency. Tertiary care center saves a transfer, neurosurgeon gets to write a simple remote consult note, patient saves an admission, and to the point of @thegenius, nothing bad ever happens to these patients. Everyone wins.

 

[BoardingDoc]

These BIG criteria seem like an interesting concept, with a worthy goal of more efficient resource utilization. But I call BS on the concept of having a patient in your ED for 6-7 hours and getting 2 head CTs, but nobody on the neurosurgical team, not even a PA, resident, or fellow can possibly find a minute to come by and give their blessing, and more importantly establish care to see the patient in follow up, before an overwhelmed ED discharges a patient with an ICH.

Sounds like a liability offload.

I may be misreading your post, but I don't think that what you're describing is what's being suggested. A BIG1 patient with a exceedingly minor bleed (e.g. that's either blood or a stray pixel or two) gets 6hr obs in the ED and NO repeat NCHCT and then a DC if their MS is unchanged.

Anything more involved gets admitted.

 

[Birdstrike]

I may be misreading your post, but I don't think that what you're describing is what's being suggested. A BIG1 patient with a exceedingly minor bleed (e.g. that's either blood or a stray pixel or two) gets 6hr obs in the ED and NO repeat NCHCT and then a DC if their MS is unchanged.

Anything more involved gets admitted.

My questions are:

-In that 6 hour obs time, why can't someone from the neurosurgical service can't see the patient in those 6 hours? A resident, attending, fellow? Not even a PA or NP? They're all in the OR, all day, everyday, all the time?

-Isn't a consult need to get someone to establish care to ensure out patient follow up? What's to prevent them from calling the neurosurg office the next day and being told, "Sorry, we can't see you for 3 months. Plus, you can't afford the _$___ copay and EMTALA doesn't apply. So...bye"?

 

[Jabbed]

My questions are:

-In that 6 hour obs time, why can't someone from the neurosurgical service can't see the patient in those 6 hours? A resident, attending, fellow? Not even a PA or NP? They're all in the OR, all day, everyday, all the time?

-Isn't a consult need to get someone to establish care to ensure out patient follow up? What's to prevent them from calling the neurosurg office the next day and being told, "Sorry, we can't see you for 3 months. Plus, you can't afford the _$___ copay and EMTALA doesn't apply. So...bye"?

They don't need any NSG evaluation at all and don't require any specific followup aside from normal post-concussion instructions.

The point is to reduce unnecessary consults and hospitalizations.

In reality it's time-intensive to board these patients in the ED for 6 hours. The inclusion criteria are also exceedingly narrow. If your system is setup such that patients are adequately screened and you can put them in an ED obs area it works fine and makes everybody happy.

I don't do this personally.

 

[southerndoc]

My questions are:

-In that 6 hour obs time, why can't someone from the neurosurgical service can't see the patient in those 6 hours? A resident, attending, fellow? Not even a PA or NP? They're all in the OR, all day, everyday, all the time?

-Isn't a consult need to get someone to establish care to ensure out patient follow up? What's to prevent them from calling the neurosurg office the next day and being told, "Sorry, we can't see you for 3 months. Plus, you can't afford the _$___ copay and EMTALA doesn't apply. So...bye"?

As @Jabbed pointed out, they don't need urgent neurosurgical consultation at all. However, our neurosurgeons are able to see them the next day (except weekends of course). One of their APP's sees the patient as a walk-in. We send an Epic inbox message to the neurosurgeon on call that day, and they forward to their coordinators to ensure the patient follows up.

Again, not your "peace out!" type situation. There is thought behind the process. We stray from original BIG criteria by repeating a head CT. We may ditch it in a year or two.

As someone else pointed out, most of these patients shouldn't have gotten head CT's to begin with if people had followed Canadian criteria.

 

[Mount Asclepius]

It's worth studying.

I agree it’s worth studying. I just don’t think it’s ready for prime time and broad rollout. The body of evidence is small and it’s not the standard of care in most places. I wouldn’t be surprised if some day it is more widely used. Brain bleeds are like MIs in the sense that they are never miss scenarios to patients. 1 bad outcome is all it takes. I think it’s worth proceeding slowly.

Maybe it is. However, non-surgical head bleeds don't need a neurosurgeon to see. Do you consult orthopaedic surgery on every fracture you send home? Do you consult surgery for every diverticulitis you send home? Do you consult urology for every kidney stone you send home? Or do you simply admit all of these patients?

They may not need neurosurgical consultation every time. A small SDH is a little different though than a metacarpal fracture, uncomplicated diverticulitis, and a noninfected kidney stone. Sure, they all have the potential for complications and bad outcomes. I just don’t think brain injuries are in the same category quite yet. It takes rolling out protocols at institutions with a lot of resources first. Then more studies are done. Then eventually the standard seeps into the rest of the community.

 

[thegenius]

As @Jabbed pointed out, they don't need urgent neurosurgical consultation at all. However, our neurosurgeons are able to see them the next day (except weekends of course). One of their APP's sees the patient as a walk-in. We send an Epic inbox message to the neurosurgeon on call that day, and they forward to their coordinators to ensure the patient follows up.

Again, not your "peace out!" type situation. There is thought behind the process. We stray from original BIG criteria by repeating a head CT. We may ditch it in a year or two.

As someone else pointed out, most of these patients shouldn't have gotten head CT's to begin with if people had followed Canadian criteria.

I agree, ER doctors are comfortable managing low (and even medium risk) chest pain without consulting cardiology. Theoretically a small percent of them can have a massive MI but in reality basically none of them do.

For some reason ER docs have eschewed any risk with head bleeds. No matter how small. We accept and deal with a small amount of bleeding just about anywhere else in the body. We deal with it and often don't call the specialist.

 

[Mount Asclepius]

I agree, ER doctors are comfortable managing low (and even medium risk) chest pain without consulting cardiology. Theoretically a small percent of them can have a massive MI but in reality basically none of them do.

For some reason ER docs have eschewed any risk with head bleeds. No matter how small. We accept and deal with a small amount of bleeding just about anywhere else in the body. We deal with it and often don't call the specialist.

According to our malpractice carrier, litigation for adults in our state is now trending significantly towards missed and mismanaged neurological conditions. High sensitivity troponins have made missing MIs exceedingly rare.

You know this as well, but bleeding into a closed box housing one of the most important organs in the body is different than bleeding somewhere else.

 

[southerndoc]

According to our malpractice carrier, litigation for adults in our state is now trending significantly towards missed and mismanaged neurological conditions. High sensitivity troponins have made missing MIs exceedingly rare.

You know this as well, but bleeding into a closed box housing one of the most important organs in the body is different than bleeding somewhere else.

Yes, you're partially correct. The mismanaged neurological conditions are mismanaged strokes (i.e., the ER doc didn't feel comfortable tPA'ing, didn't diagnose stroke timely enough, etc.). It's not missed head bleeds or mismanaged head bleeds. This is true across the nation. The other hot thing in litigation is sepsis, inappropriate transfers due to out-of-network insurance status, and incidental findings not managed correctly.

 

[Apollyon]

Lots of excellent suggestions on here for the OP.

Here's another one that may help you defuse challenging situations with staff and other docs who you think are gaslighting you, giving you a hard time, or are simply acting like a jerk:

Ask them "Are you OK?"

Do it sincerely and take 30 seconds to listen. People rarely ask us how we're doing since most people think we're somehow invincible or they just don't care...so don't be surprised if you're met with shock or silence.

Docs (and RNs and techs etc) are humans with our own personal/family/life/work stressors that sometimes bleed through to professional interactions...and it doesn't help that right now is the most stressful time in our lives to be on the front lines of medicine. Few people went to med school to become an a$$hole, and under a hard candy shell (or several shells lol) is usually a decent person who wants to do the right thing...but they may happen to be struggling with things that nobody can imagine.

Anyway, taking a moment to show a colleague you actually care about them and humanize them may be the most important thing you'll do all week. And chances are good they won't forget it.

"Are you OK?" A bit to unpack here. First, what does the person say? Especially if they don't know you, or know you well beyond having seen you, what are they going to say? Are you ready if they unload whatever it is on you? And, what would I think, if Joe ER doc asked me if I was OK? If I say anything that isn't "I'm fine" to this rando, that's a direct line to med exec.

You need something from this harried consultant. What do you say when they say, for example, "I'm salty because my spouse is cheating on me" or "my daughter is pregnant again" or "I am so hung over"? All they can think of is that your question is insincere, and out to get them. Then, they won't be able to do their job, because they're now inpatient somewhere.

So, in the abstract, "are you OK?" is meaningful and sensitive. But, in reality? There is no place for that, in the professional realm. IF you know the consultant, AND you can talk to them in the doctor's lounge, THEN you might ask the question with gravitas.

But, playing armchair psychiatrist with colleagues (even if they are not being collegial) - ain't nobody got time for that!

 

[Rekt]

A thread about how annoying it is arguing about admissions turned into arguing about admissions.

Classic.

 

[Birdstrike]

As @Jabbed pointed out, they don't need urgent neurosurgical consultation at all. However, our neurosurgeons are able to see them the next day (except weekends of course). One of their APP's sees the patient as a walk-in. We send an Epic inbox message to the neurosurgeon on call that day, and they forward to their coordinators to ensure the patient follows up.

Again, not your "peace out!" type situation. There is thought behind the process. We stray from original BIG criteria by repeating a head CT. We may ditch it in a year or two.

As someone else pointed out, most of these patients shouldn't have gotten head CT's to begin with if people had followed Canadian criteria.

That sounds like it works well at your facility. But it sounds like you're recommending it to be practiced everywhere. What percentage of hospitals nationwide have such quick, agreeable neurosurgery practices, where follow up is all but guaranteed?

 

[TheComebacKid]

Just out of curiosity... do institutional policies protect physicians when it comes to malpractice claims? Lets say your hospital, academic medical center, healthcare system, whatever put out an official policy that these small head bleeds can go home after a period of observation without neurosurgical consultation.

Patient goes home, condition worsens, develops irreversible neurological damage and is now bed bound, can't work and has lost wages for decades.

Are you going to get "bailed out" because you were following officially adopted policies by your employer, or do you still get thrown to the wolves?

I ask this because I've had hospitalists say, "this patient doesn't meet XYZ hospital guideline for admission for X condition, they can go home" on more than one occasion.

Somehow I feel like the lawyers are still coming for you.

 

[southerndoc]

There is some liability protection by a policy/protocol endorsed by an institution. You could put something like "Per XYZ Hospital protocol, patient was observed for 6 hours and discharged home with no change in neuro assessment."

 

[namethatsmell]

"Are you OK?" A bit to unpack here. First, what does the person say? Especially if they don't know you, or know you well beyond having seen you, what are they going to say? Are you ready if they unload whatever it is on you? And, what would I think, if Joe ER doc asked me if I was OK? If I say anything that isn't "I'm fine" to this rando, that's a direct line to med exec.

You need something from this harried consultant. What do you say when they say, for example, "I'm salty because my spouse is cheating on me" or "my daughter is pregnant again" or "I am so hung over"? All they can think of is that your question is insincere, and out to get them. Then, they won't be able to do their job, because they're now inpatient somewhere.

So, in the abstract, "are you OK?" is meaningful and sensitive. But, in reality? There is no place for that, in the professional realm. IF you know the consultant, AND you can talk to them in the doctor's lounge, THEN you might ask the question with gravitas.

But, playing armchair psychiatrist with colleagues (even if they are not being collegial) - ain't nobody got time for that!

You're right, it takes time away from other tasks I could be doing -- but if there's nothing else emergent going on I'll spare the time to help a colleague. I don't do this frequently (maybe a few times/year) and I don't do it if other staff will overhear or seem to do more harm than good. I rarely ask folks I've never spoken/met with before. I'm far from the Mother Teresa type and I only ask once so if people continue to be jerks things proceed along the traditional ways we all handle jerks. I don't pretend to be a therapist, just somebody who will listen.

The world can be a tough place and I'm a fan of trying to inject a little more kindness into it when possible. That said, I don't fault anybody who doesn't agree with the above.

 

[Groove]

Maybe it is. However, non-surgical head bleeds don't need a neurosurgeon to see. Do you consult orthopaedic surgery on every fracture you send home? Do you consult surgery for every diverticulitis you send home? Do you consult urology for every kidney stone you send home? Or do you simply admit all of these patients?

I really haven't researched much of these criteria as we don't send home any head bleeds in my neck of the woods. However, on the chance that you had an adverse outcome on an ICH where you did NOT consult a neurosurgeon. I can't imagine how you'd be anything but toast in court. On the chance you found a single BIG1 advocate expert witness, the plaintiff attorney would line up 10 expert neurosurgeons to drill you and the lay public jury is never going to understand why an emergency doctor didn't consult a neurosurgeon for bleeding within the brain, no matter how much your expert witness tries to "educate" them in court. I sincerely doubt an institutional policy would save you in that scenario.

Kudos to your neurosurgery team for pushing through a ballsy hospital policy aimed at reducing their non surgical consult rate so they could sleep longer at night and convincing the ED to send home head bleeds without calling them. That's incredible. From my initial research, those guidelines are based on very limited evidence that's only been validated at a single institution. N of 269 patients?

The BIG do have some drawbacks. The guidelines have only been validated at the institution at which they were developed. Although both prospective and retrospective analyses have been completed, further independent validation is required before the guidelines can be widely implemented.12 13 The BIG are often vague in defining specific aspects of the management algorithm. Any attempt to implement these guidelines would require speculation regarding several of the pertinent components making uniform, widespread, utilization impossible.

 

[southerndoc]

I really haven't researched much of these criteria as we don't send home any head bleeds in my neck of the woods. However, on the chance that you had an adverse outcome on an ICH where you did NOT consult a neurosurgeon. I can't imagine how you'd be anything but toast in court. On the chance you found a single BIG1 advocate expert witness, the plaintiff attorney would line up 10 expert neurosurgeons to drill you and the lay public jury is never going to understand why an emergency doctor didn't consult a neurosurgeon for bleeding within the brain, no matter how much your expert witness tries to "educate" them in court. I sincerely doubt an institutional policy would save you in that scenario.

Kudos to your neurosurgery team for pushing through a ballsy hospital policy aimed at reducing their non surgical consult rate so they could sleep longer at night and convincing the ED to send home head bleeds without calling them. That's incredible. From my initial research, those guidelines are based on very limited evidence that's only been validated at a single institution. N of 269 patients?

The BIG do have some drawbacks. The guidelines have only been validated at the institution at which they were developed. Although both prospective and retrospective analyses have been completed, further independent validation is required before the guidelines can be widely implemented.12 13 The BIG are often vague in defining specific aspects of the management algorithm. Any attempt to implement these guidelines would require speculation regarding several of the pertinent components making uniform, widespread, utilization impossible.

It has been validated at a nearby academic institution that is in the process of publishing their data. I have the manuscript and their results look pretty good.

The neurosurgical society (whatever their name is) endorsed it. In our case, which is unusual compared to others, we have 24/7 APP neurosurgery coverage. So I don't wake up a neurosurgeon in the middle of the night. We have an APP that's already up and he/she doesn't have to run everything by the neurosurgeon. I don't consult ortho for a trimal fracture before reducing and sending them home (our trauma ortho guys can see them within a few days), nor do I call ortho for a hip fracture I'm admitting. Hospitalist admits and they consult ortho as a non-stat consult.

 

[Mount Asclepius]

In our case, which is unusual compared to others, we have 24/7 APP neurosurgery coverage. So I don't wake up a neurosurgeon in the middle of the night. We have an APP that's already up and he/she doesn't have to run everything by the neurosurgeon. I don't consult ortho for a trimal fracture before reducing and sending them home (our trauma ortho guys can see them within a few days), nor do I call ortho for a hip fracture I'm admitting. Hospitalist admits and they consult ortho as a non-stat consult.

That sounds great. However, I don’t feel that it is easily generalizable to a lot of other institutions.

I work in a busy community hospital and trauma center with almost every specialist on call. I wake up the Neurosurgeon in the middle of the night as they don’t have midlevels taking their call. I consult ortho for every trimal fracture as sometimes they want to admit and fix immediately, and sometimes they want to see in clinic and fix later once the swelling is down. I’d love to not call them for admitted hip fractures, but they usually want a call so they can prepare for the next day.

 

[thegenius]

I really haven't researched much of these criteria as we don't send home any head bleeds in my neck of the woods. However, on the chance that you had an adverse outcome on an ICH where you did NOT consult a neurosurgeon. I can't imagine how you'd be anything but toast in court. On the chance you found a single BIG1 advocate expert witness, the plaintiff attorney would line up 10 expert neurosurgeons to drill you and the lay public jury is never going to understand why an emergency doctor didn't consult a neurosurgeon for bleeding within the brain, no matter how much your expert witness tries to "educate" them in court. I sincerely doubt an institutional policy would save you in that scenario.

Kudos to your neurosurgery team for pushing through a ballsy hospital policy aimed at reducing their non surgical consult rate so they could sleep longer at night and convincing the ED to send home head bleeds without calling them. That's incredible. From my initial research, those guidelines are based on very limited evidence that's only been validated at a single institution. N of 269 patients?

The BIG do have some drawbacks. The guidelines have only been validated at the institution at which they were developed. Although both prospective and retrospective analyses have been completed, further independent validation is required before the guidelines can be widely implemented.12 13 The BIG are often vague in defining specific aspects of the management algorithm. Any attempt to implement these guidelines would require speculation regarding several of the pertinent components making uniform, widespread, utilization impossible.

Again, the probability of something bad happening with these trivial head bleeds is exceedingly small.

It's more likely you'll get a bad outcome when you send home a 44 yr old CP with a negative workup and a HEART score of 2.

If you are unlucky enough that a bad outcome occurs...I think a phone consult to NSG won't help you (or NSG) all that much to the lawyers.