Peds bucked at me for these admissions, was I overly cautious?

[pootcarr]

Case 1: 7 y/o with cough and fever x2 days. temp 103 VS otherwise wnl, physical exam normal. CXR shows small R infiltrate.

PMH: on methotrexate for JRA, autistic

patient looks great, CBC and CMP normal, received 20 cc bolus. Parents are very concerned taking her home due to the immunosuprresion and fever (101 down from 103).

Case 2: 32 day old female with 2 d history of cough and congestion. Born at 37.5 weeks to a first time mom. Eval at pcp with cxr, flu, and rsv. RSV is +. sent home. comes into ED several hours later as mom is concerned that patient isn't eating as well. Besides for congestion, pt looks and sounds great. o2 sat 100% RA and afebrile. Called for admission due to this is the second time patient has been seen today, she is 32 d old, this is d 2 of symptoms so expect further progression, and first time mom is nervous and feels like things are getting worse.

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[GeneralVeers]

Case 1: Yes, that definitely could have been admitted, especially if parents are concerned.

Case 2: No reason for admission, especially since you have RSV + (a source) and VS are good and she's in no respiratory distress.

 

[pootcarr]

Yeah, I felt bad about the 2nd one, but she was so little and the mom was about to lose it

 

[turkeyjerky]

Yeah, I felt bad about the 2nd one, but she was so little and the mom was about to lose it

Honestly I think either of those would probably be fine for either admission or discharge depending on parental preference. I'm actually more surprised they balked at the second one, given the risk for apnea.

 

[Birdstrike]

Both are reasonable. 1, due to immunosuppression and parental issue, and 2, due to age combined with concern of apnea in RSV <3 mos (admittedly small risk) & bounce back.

Neither would be like sending home a missed STEMI or unstable c-spine fracture, but through hindsight you and only you would be blamed if 1 got septic and died or 2 was found dead due to apnea. "But the Peds service is soooo craaaaaby!" would be accepted by no one. You'd be notified later with papers served by a uniformed process server, and the subpoena would list you and only you as the target of the wrongful death/malpractice suit, with no empathy extended to you, only to the parents of the dead kid.

 

[Daiphon]

Both of these are easy obs cases, like Birdstrike said.

There's nothing you could've done better. Residents often look to minimize work, but these are both slam dunk 23h obs cases.

Carry on, young Padawan.

-d

 

[deleted480308]

cya. cover the patient's "a" as well, but for real cya

 

[Arcan57]

Whatever the resident tells you, the peds floor is full of pts that are only in the hospital because the parents aren't comfortable with going home yet. When they have the cojones to kick out those kids, I'll be more willing to listen to them minimize parental concern in potential admits.

 

[Birdstrike]

Case 1: 7 y/o with cough and fever x2 days. temp 103 VS otherwise wnl, physical exam normal. CXR shows small R infiltrate.

PMH: on methotrexate for JRA, autistic

patient looks great, CBC and CMP normal, received 20 cc bolus. Parents are very concerned taking her home due to the immunosuprresion and fever (101 down from 103).

Case 2: 32 day old female with 2 d history of cough and congestion. Born at 37.5 weeks to a first time mom. Eval at pcp with cxr, flu, and rsv. RSV is +. sent home. comes into ED several hours later as mom is concerned that patient isn't eating as well. Besides for congestion, pt looks and sounds great. o2 sat 100% RA and afebrile. Called for admission due to this is the second time patient has been seen today, she is 32 d old, this is d 2 of symptoms so expect further progression, and first time mom is nervous and feels like things are getting worse.

You're a resident, right?

Seriously, ---- these -------s that are "bucking" admissions. ---- 'em.

 

[WilcoWorld]

Totally reasonable admissions.

 

[Hair Police]

Residency got a whole lot easier when I realized that the patient getting the best care was more important than my pride or what other people thought of me.

 

[gro2001]

Case 1: 7 y/o with cough and fever x2 days. temp 103 VS otherwise wnl, physical exam normal. CXR shows small R infiltrate.

PMH: on methotrexate for JRA, autistic

patient looks great, CBC and CMP normal, received 20 cc bolus. Parents are very concerned taking her home due to the immunosuprresion and fever (101 down from 103).

Case 2: 32 day old female with 2 d history of cough and congestion. Born at 37.5 weeks to a first time mom. Eval at pcp with cxr, flu, and rsv. RSV is +. sent home. comes into ED several hours later as mom is concerned that patient isn't eating as well. Besides for congestion, pt looks and sounds great. o2 sat 100% RA and afebrile. Called for admission due to this is the second time patient has been seen today, she is 32 d old, this is d 2 of symptoms so expect further progression, and first time mom is nervous and feels like things are getting worse.

Both cases are borderline, not unreasonable to admit or discharge. Not unreasonable to have shared decision making with parents.

Alternative to admission with 1) could have been a dose of IV abx and mandatory re-eval in the ER or with PMD in 24 hours (but only if truly normal vital signs other than temp).

2) I would not hesitate to admit for observation as so young they are at risk of apnea with RSV, but it largely depends on how closely the parents can observe them at home. But I would probably admit anyway.

 

[WalkingCorpse]

Both would have been admitted without pushback at my shop, but our pediatric service is pretty light so the peds residents will admit most everything that we're not comfortable with discharging.

 

[two guys]

This is typical to residency. It will get easier in the "real world"

My general rule is no one can disagree with my decision until they've seen the patient and talked with the family. That alone fixed 99% of any discussions when I was in residency. Usually they come down and see the situation a little more clearly and admit. Some of that is bc both parties are still learning how to give and receive admissions. Maybe you're not giving a presentation that paints the pisture that you see, maybe they're not hearing it. Maybe there is some work avoidance as well. Either way, my answer was always "I have seen and evaluated the patient and think they require X. You're on call for y, when can I tell the patient you'll be here to see them?"

I haven't had to do this much outside of residency but it is a good mindset to have. You're not asking them to come down. You've seen the patient and think they need something, no one can disagree if they haven't seen the patient. There are some rare exceptions (it's someones private clinic patient and they know the patient well or provide some specific information that changes YOUR mind on what you think the patient needs).

 

[Mighty Mouse]

i find its all in the sales pitch. if you're wishy-washy in how you discuss the case, the admitting team is going to push back. i find if you lead with diagnosis first and then go with story, you're going to hook them sooner. convoluted medical student type histories that make them lose attention and then hitting them with the admission reason last will result in failure. if you're up front and state you recognize this is a softer admit but you want the patient observed and here's why, you'll also likely get what you're looking for. particularly in pediatrics.....if the kid doesn't pass the mom test that needs to be relayed to the admitting team. making it clear that the mother is a reasonable person, she is not being a scardy cat, and she is very uncomfortable taking the child home in this condition will often get you what you're looking for. i go in with the mindset that i'm going to get what I want. I speak confidently and make it clear I know what the heck I'm doing. My calls are typically very one sided. I don't give them the opportunity to say anything but "yes I will admit this patient" because I've anticipated what they will want to know by imaging I was on their side of the phone call.

and perhaps the biggest take home point -- and this is acknowledging throughput and LOS pressures, etc -- is just because the admitting service doesn't want to admit the patient, doesn't mean you have to discharge the patient. you are the only one clicking the discharge button. don't do it until you are totally sure you feel comfortable with the plan to discharge and you're not going to have nightmares about this patient tonight. if you think the patient needs longer observation and nobody else will do it, then observe them in the ER until you and mom are happy. again, not saying its going to be awesome, or that your colleagues will be thrilled, but sometimes this happens. Handle the obs treatment or come up with an alternative plan. slam dunk criticals won't get bucked, its only the softies anyway.

 

[alpinism]

I'm no expert on Bronchiolitis (or anything for that matter) but all the research i've read says that for healthy term infants with no risk factors (NM disease, LBW, tachypnea, increased WOB, low O2 sat) the risk of apnea is <<1%.

Sounds like the mom just needed some reassurance and education.

At the same time I realize this is mostly CYA medicine.

 

[Birdstrike]

... I realize this is mostly CYA medicine.

qft

 

[Daiphon]

I'm no expert on Bronchiolitis (or anything for that matter) but all the research i've read says that for healthy term infants with no risk factors (NM disease, LBW, tachypnea, increased WOB, low O2 sat) the risk of apnea is <<1%.

Sounds like the mom just needed some reassurance and education.

At the same time I realize this is mostly CYA medicine.

True... but reassuring mom is a key point of therapy.

Peds, in many ways, is about treating the parents. I see these situations as the corollary to the "LOL who's not safe to go home" for whatever reason.

Agree with the post above that it's all about the sales pitch... but, ultimately, it's an easy 23h obs admit; and in terms of CYA, if I get pushback, I talk with the attending. If still pushed back, I document that the admitting service declined to keep the patient despite my concerns and inform them as such.

Very few admits get blocked after that point, but the nuclear option can pose problems so only invoke when absolutely necessary.

-d

 

[gman33]

I try to have a reasonable interaction with the admitting services.
If I have a strong feeling about disposition, I will sometimes change my mind.
This will only happen if the consultant physically sees the patient and leaves a written consult.
If residents are involved, the case must be discussed with an attending.
In some cases, the attending must see the patient and sign the consult for me to change dispo.

In my mind, an OBS is just that. Extra time to watch the patient while getting them out of the ED to free up a bed.

I don't dig in every time, but if I really am not comfortable, I am not sending the person home.
Worst case, I'll just keep them in the ED.

 

[Xerxes1729]

i find if you lead with diagnosis first and then go with story, you're going to hook them sooner. convoluted medical student type histories that make them lose attention and then hitting them with the admission reason last will result in failure.

This is good advice for talking to anyone else for any reason.

2 AM consult call:
"Hi Dr. Bones, I have a consult for you. Last name Unsteady, first name Verri. DOB 2/16/1922. She lives in a third floor walk-up by herself. She was going downstairs to empty out her cat's litter box. The back steps were icy and she slipped and fell. She landed on her right side. She wasn't able to get up. She says she did not strike her head or lose consciousness. A neighbor called EMS. On arrival, vitals were stable, and there were no signs of trauma except for a shortened and externally rotated right leg. Her labs looked good, except for a creatinine of 2.2, which is her baseline. She has CKD. The rest of her medical history is notable for DM2 on metformin, hypertension, hyperlipidemia, and psoriasis. Also mild depression, for which she takes citalopram. EKG was normal sinus rhythm. Her films show a right intertrochanteric hip fracture, which is why I'm calling you."

versus

"Hi Dr. Bones. I have a hip fracture for you. 93yo F fell and has a right intertroch. No other injuries. She's got a fair number of comorbidities, so I'd be happy to admit her to medicine if you don't want her on your service."