New Attending, How to Deal With Pushback?

[Mount Asclepius]

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.

I agree with you that the odds of deterioration are low for BIG 1. It does happen even if uncommonly, because I’ve seen it. I don’t think your comparison is great as a head bleed is a mostly confirmed diagnosis with potentially serious pathology, where as the low risk chest pain patient with negative workup doesn’t have a confirmed diagnosis. Odds are 98-99% it’s GERD, musculoskeletal pain, anxiety, etc.

A phone consult, hospital policy or even close outpatient follow up won’t fully protect you as you can be sued for anything. They are all just risk mitigation techniques. You won’t win every time, but the goal is to lose as infrequently as possible. That’s also interestingly enough the same goal as our patients, although in terms of their morbidity/mortality vs. our liability. None of us get out alive though.

Great discussion overall. I think I’ll bring the BIG up with our group to see what they think, but mainly just to put it on their radar. I doubt we’re ready for implementation.

P.S. I can’t claim credit as someone else on SDN once made this observation, but it’s worth repeating as it’s interesting that they want us to send people home after they’ve had the BIG 1!

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[turkeyjerky]

Just read that followup analysis of the BIG. Their modification seems pretty reasonable to me. Notable changes include NSG consultation for any EDH and mandatory trauma consults for all BIG1. Even though the latter is likely unnecessary, I think it's a better thought out pathway. Obviously, this doesn't really help out non-trauma centers and it would be nice if they published a modified pathway where all BIG2 patients get transferred, and BIG1 get admitted to the ICU overnight under a non-trauma intensivist for monitoring.

 

[Groove]

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.

That's still limited evidence and certainly doesn't reflect standard of care across the nation. Don't get me wrong, I'm sure the data looks good and I support any evidence that empowers our specialty but from what I can see thus far, it doesn't look ready for prime time across the nation.

Funny, I call ortho for virtually any unstable fracture. Why wouldn't I? It's unstable. I almost always want to document their refusal to admit for urgent ORIF after I tell them on a recorded line that the ankle is unstable and was "very loose" on reduction. We all know the mortise shifts after discharge on those floppy ankles and the longer it's non anatomic, the greater the pt's risk of long term arthropathy. I've never had ortho even remotely get upset for a call about a trimal. I also call them for the hip fractures for the same reasons @Mount Asclepius mentioned. It gives them a heads up for a potential surgical case for the next day and allows them enough time to re-arrange their OR schedule.

 

[Groove]

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.

Yeah but the difference is that you have overwhelming data to support your disposition regarding the chest pain pt. The data supporting d/c a "trivial" head bleed is anything but overwhelming at the moment. Phone consults absolutely add liability protection in court.

 

[B52forU]

What everyone else said above. I trained in a conservative high med malpractice environment in Cook County during residency and transitioning to my first physician gig as an attending elsewhere in the US was a big change. Things that I learned quickly was though ACS is real, the literature is out there on low cardiac risk and while I practiced a certain way in residency, it did NOT mean it was well substantiated or that the culture was the same elsewhere.

Things to consider are whether the patient actually even wants to stay in the fist place. You have your reasons for wanting to maybe keep him however the patient NEEDS to be on board with the plan. If you find yourself in the grey area that no one wishes to be, you can reach for help with the patient's established cardiologist (if he has one) to weigh in, often times their recommendations can sway things one way or another. I.e. he's a moderate cardiac risk per heart score but has had negative workups not TOO long ago and has been seen several times but has risk factors/age that you can document that you spoke with his physicians who wanted him to go home OR his own cardiologist found it concerning and wanted him admitted AND the cardiologist will see him in the hospital. Another is the patient just doesn't look good and doesn't have good follow up. He might be from out of state and just moved here, has risk factors and has no established PCP or cardiologist and lives alone and cannot reasonably follow up or cannot reliably return to the ED (not a safe discharge). Do not burn your bridges as a new attending with your hospitalists because this is your life line and once you cry wolf once or too many times, you really lose your credibility.

Ways to often establish a good rapport with your hospitalist teams is to make conversation with them sometimes when they come down to see your admits or offer help when they need it (at my smaller hospitals this meant intubating their crashing patients and as a courtesy, running their code afterward when asked if it was reasonable/I was free to) or placing the order on their patients and making sure things were carried out by my staff or making that extra call to a consultant or doing xyz if it wasn't a herculean task or took me away from my own duties for too long. I had a notoriously difficult hospitalist who would push back on most admissions and cause a regular nuisance to even reasonable admissions at a smaller site I was contracted to staff from time to time and that all evaporated after the 6:30 AM code blue in a crashing obese patient that arrested and needed an airway and then a code to be run after w/ crash central line. We are required to do the intubation, but everything else is not mandatory and by going the extra mile at the expense of 10-15 extra minutes of overtime paid dividends later on. Mutual respect established.

 

[TeddyBoomBoom]

I dunno… I’m a (new) ER doc and I send a LOT of ppl home. Probably more than anyone else in my group. I hate admitting nonsense and if the admission isn’t going to effectively accomplish anything, then in my view o/p follow up is fine.

However… I’m not super excited about sending new PE’s home. I’ll do it if the patient looks well, has few comorbidities, has a support network, and can assure follow up. But let’s face it that’s a small percentage of our patients.

I totally get that there is a population that can just be dc’d on a DOAC, but imho that patient is pretty rare.

🤷

 

[Splenda88]

Maybe I am a weird hospitalist. My motto is that if the EM doc thinks the patient needs to be admitted, I say fine. It usually take 20-25 minutes to take care of these "soft" admits. Since my place is open ICU, I rather deal with these soft admits than the trainwrecks

If it is a soft admit, I just let the EM doc know that and why. I usually discharge the patient the following day.

I guess it's the culture at your place. Our boss told us to NEVER refuse an admission from the ED.