Pushback in the community

[gman33]

Here's the abridged version. Chest pain, 31 year old male. Sweaty hispanic guy; no shortage of those in the summer in FL. No risk factors. EKG is benign except for what the cardiologist called a "persistent juvenile T-wave pattern" at the end of it all. Guy is pouring sweat, looks pale, looks... BAD, and has that fist tight over the precordium. If those ST-segments weren't up, they just weren't up... yet.

99% LAD. Boom goes the dynamite.

wellen's?
would be consistent with the t waves and location of lesion.

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[TooMuchResearch]

Hey, sounds good. I would have sent my HEART <3 guy right home... or to the cath lab...

Young people aren't healthy anymore. People who don't have risk factors, have undiagnosed risk factors. I never feel bed about admitting these guys for their 12-hour trops. Until "standard of care" changes, and we can't be sent up for (at least, a minimum) a "hit" on the database... eff that noise. Full gig; 12-hour trops... cardio consult... THEN home.

Our hospitalists don't trend trops for 12 hours. Our community standard doesn't match yours. We also send home our heart low risk folks, some without follow up stress.

 

[TooMuchResearch]

Here's the abridged version. Chest pain, 31 year old male. Sweaty hispanic guy; no shortage of those in the summer in FL. No risk factors. EKG is benign except for what the cardiologist called a "persistent juvenile T-wave pattern" at the end of it all. Guy is pouring sweat, looks pale, looks... BAD, and has that fist tight over the precordium. If those ST-segments weren't up, they just weren't up... yet.

99% LAD. Boom goes the dynamite.

Nobody is sending that guy home.

 

[Angry Birds]

If I get pushback from the hospitalist--and I usually don't any more since most of them are cool--I kindly request them to do a consult in the ER and to do shared medical liability with me to discharge a low-risk chest pain patient.

 

[The White Coat Investor]

Admitted a 2nd troponin positive patient yesterday with a flakey story. That's probably the 3rd one in the last year. Don't get too cavalier. History, physical, EKG and even troponin sucks for ACS. Be cautious but not ridiculous. A 2-3 hour trop doesn't mean much.

 

[RustedFox]

Fox, you're one of my favorite posters, but I gotta give you a little pushback on this, especially since you used this case to go after someone who was talking about decision rules.

I'm sure you're a great doc, but this wasn't some crazy catch. Per your own earlier post, dude was DIAPHORETIC, was PALE, looked TERRIBLE, and had his HAND CLENCHED OVER HIS CHEST. Come on, no one is sending that guy home with a decision rule. Everyone is admitting that guy. Everyone is STAT calling cardiology and/or sending him to cath lab, and/or scanning that guy for PE or dissection.

We use the HEART score at my shop regularly (if we didn't the hospital probably wouldn't have beds for anything but ACS obs), but when I use this decision rule I'm not using it on patients who look like they are going to die. I'm using it on patients who look well, have normal vitals, have a not terribly concerning story, have no active chest pain, etc. Which is what I think the earlier poster your were debating with was getting at. I'm sure he's not sending the diaphoretic, pale, "I'm obviously about to die guy" home because his HEART score is 2.

I'm all for pushback (I stir the pot regularly on here); but I think you're actually understanding my point better than you think you are. Point being: the academic argument is just that; an academic argument. You can HEART score and PORT score and PERC score and HI-SCORE! all you want... and that's good, on paper. In reality - you admit these patients, and you do the right thing. My original argument went something to the tune of "I used to love the academic argument, but then I was stunned when the "low-risk" guy on paper ended up needing the cath lab, pronto - and then all that went out the window."

Boys and girls, we're talking about how to disposition one of (if not, the most) high-risk complaint that we encounter. My point is this: if you're going to send chest pain home, you had better have a damn good reason why; and those clinical decision rules WILL betray you. The "young and healthy" crowd isn't young and healthy anymore. Patients with undiagnosed risk factors are everywhere; and those with risk factors... will still lie to you (out of ignorance, embarrassment, whatever) and tell you that they don't.

"Unstable angina" ? Sure, we collectively overdiagnose it; but its not really safe to do so otherwise.

- and McNinja: I checked my post history, I don't think that's a quote of mine, though I do love hyperbole for the sake of both humor and argument.

 

[RustedFox]

wellen's?
would be consistent with the t waves and location of lesion.

I wish I would have snapped a photo of the EKG (edited for HIPAA). I remember thinking to myself: "Wellens?" but they were tall/fat t-waves (and tall QRS complexes) without that distinct camelback look.

 

[Angry Birds]

Admitted a 2nd troponin positive patient yesterday with a flakey story. That's probably the 3rd one in the last year. Don't get too cavalier. History, physical, EKG and even troponin sucks for ACS. Be cautious but not ridiculous. A 2-3 hour trop doesn't mean much.

Nonsense. Just get two troponins at the same time, from two different IV sites.

 

[CanadianEM]

Admitted a 2nd troponin positive patient yesterday with a flakey story. That's probably the 3rd one in the last year. Don't get too cavalier. History, physical, EKG and even troponin sucks for ACS. Be cautious but not ridiculous. A 2-3 hour trop doesn't mean much.

I don't think there's anything wrong with a second trop, in fact, in the HEART pathway study from wake forest, which added a second 3 hr delta trop, it reduced the overall MACE to less than 1%.

At some point we have to decide what is an acceptable miss and discharge rate for things like chest pain. The notion of admitting or obsing anyone with a sniff of chest pain because they could potentially represent unstable angina is ridiculous.

 

[RustedFox]

I don't think there's anything wrong with a second trop, in fact, in the HEART pathway study from wake forest, which added a second 3 hr delta trop, it reduced the overall MACE to less than 1%.

At some point we have to decide what is an acceptable miss and discharge rate for things like chest pain. The notion of admitting or obsing anyone with a sniff of chest pain because they could potentially represent unstable angina is ridiculous.

You use this word "we". Like we docs can actually decide on something and make it happen with teeth.

 

[CanadianEM]

You use this word "we". Like we docs can actually decide on something and make it happen with teeth.

Fortunately, I don't work in a legal climate like Florida, so I can actually be a doctor and do doctory things.

 

[RustedFox]

Fortunately, I don't work in a legal climate like Florida, so I can actually be a doctor and do doctory things.

Judging by your handle; you're in the great white north. OldMil... you know this guy ?

I keed, I keeeed.

 

[emergentmd]

I still do not believe a second trop 2 hrs after presentation makes any sense. But whatever.

Admitted a 2nd troponin positive patient yesterday with a flakey story. That's probably the 3rd one in the last year. Don't get too cavalier. History, physical, EKG and even troponin sucks for ACS. Be cautious but not ridiculous. A 2-3 hour trop doesn't mean much.

I am not going to argue the point b/c everyone has to be comfortable with their practice style. Nothing that I do is cavalier. But by your statement, you seem to do a 2 -3 hr trop on most pts. I completely disagree with 2nd set on non cardiac presentation. If you are going to get a 2nd set on most CP pts, then I think this is poor medicine.

 

[Arcan57]

I still do not believe a second trop 2 hrs after presentation makes any sense. But whatever.


I am not going to argue the point b/c everyone has to be comfortable with their practice style. Nothing that I do is cavalier. But by your statement, you seem to do a 2 -3 hr trop on most pts. I completely disagree with 2nd set on non cardiac presentation. If you are going to get a 2nd set on most CP pts, then I think this is poor medicine.

Why get a 1st set on non-cardiac presentations? Either you're worried or you're not. If you're worried, why half ass it if symptoms started recently?

 

[gman33]

I wish I would have snapped a photo of the EKG (edited for HIPAA). I remember thinking to myself: "Wellens?" but they were tall/fat t-waves (and tall QRS complexes) without that distinct camelback look.

http://lifeinthefastlane.com/ecg-library/de-winters-t-waves/
Remembering an EKG is tough, but this would be another possibility.

I love how this thread went off the rails, but into an actual clinical discussion on how to workup CP.

I trained in one of the worst malpractice environments in the US.

We practiced something called the CAN protocol.
C = Chest pain. A=Admit. N=Next patient

If you had CP you got admitted.
The older attendings used to laugh at the young guys who would use a HEART score or something similar and send patients home.

It's not that the admit all guys were bad docs, most were actually excellent clinicians.
They just figured at some point they would send home a low risk guy and end up losing a suit.
And in that environment, I'm sure they were correct.

I don't go that far, but I do OBS a ton of CP.
They have to have a terrible story, minimal to no risk factors and obviously negative tests for me to think sending them out is a good idea.

I usually do some shared decision making with these folks.
I give them my best estimate of their risk of a missed event, and offer them obs, repeat trop in ED or just d/c.
I document the discussion, that they have capacity and dispo accordingly.

If I really feel like they have something going on, I will do my best to get them to stay in the hospital.
If they don't stay in these cases, I get them to AMA.

 

[gman33]

Why get a 1st set on non-cardiac presentations? Either you're worried or you're not. If you're worried, why half ass it if symptoms started recently?

That's an interesting point.
One of my attendings did a bunch of med mal.
He used to say that he'd rather try to defend a case with no trop vs an inadequate workup.

I work in a nursing protocol driven shop where everyone with CP, and I mean everyone, already has a trop ordered and maybe resulted by the time I see them.
This is kind of a funny situation.
Low risk, young patient with recent onset CP and 1 neg trop,
Likely I would have never gotten this test, but now it's out there.
I usually just d/c these people, but it's probably not the best from a med-mal standpoint.
Sometimes I'll do a delta trop at 2 or 3 hours.

I wish we would come up with more of a standardized way to workup CP at my shop.
I think some institutional guidelines would help defend a bad outcome if it occurs.

 

[exsanguination]

As a PGY2 based on this discussion I've already resigned myself to being sued at least 2-3 times as soon as I get out into practice. Our job is so hard and I'm really starting to feel it as PGY3 year rolls around the corner

 

[The White Coat Investor]

I still do not believe a second trop 2 hrs after presentation makes any sense. But whatever.


I am not going to argue the point b/c everyone has to be comfortable with their practice style. Nothing that I do is cavalier. But by your statement, you seem to do a 2 -3 hr trop on most pts. I completely disagree with 2nd set on non cardiac presentation. If you are going to get a 2nd set on most CP pts, then I think this is poor medicine.

Why do a 1st set on a "non-cardiac"presentation? If I knew it was non-cardiac, I wouldn't even do an EKG. The reason I'm doing tests is because I'M NOT SURE.

 

[Arcan57]

As a PGY2 based on this discussion I've already resigned myself to being sued at least 2-3 times as soon as I get out into practice. Our job is so hard and I'm really starting to feel it as PGY3 year rolls around the corner

It's unlikely your first taste of litigation is going to be a missed MI and most EPs don't get sued 3 times in their entire career. The job is hard though and an appropriate level of humility is important in presenting our opinions to our patients. Unfortunately as soon as we have a diagnosis really nailed down the disease spectrum expands to include ever more distant precursors to the event of interest.

 

[emergentmd]

The problem for cardiac evaluation is there is no accepted standard, it changes all the time. I have my own way of dealing with chest pain which works for me and can be defensible. Thus my charts are always clean and defensible b/c no protocol will protect me better than my benign chart when I discharge people with chest pain.

I have been doing this for 16 yrs. When I was in residency, I was told order Enzymes only if you think its cardiac and you will admit those pts for rule outs. If you think its not cardiac, do not order enzymes. In 16 yrs, it has fluctuated from this, to ordering 1 set and discharge. Order 1 set, and another in 2-4 hrs. Order 1 set, and do a stress test or admit.

I can present this to 5 cardiologist and they will have different opinions, have different opinions on different days, have different opinions depending how hungry they are, different opinions on the time of the day. What this tells me is no one knows how to deal with borderline cases which is 50% of the presentations. Anyone can deal with slam dunk chest pains.

Thus, a second set in 2 hrs (IMO) changes nothing for me. It may for someone else, it may make you sleep better. For me, not really. Thus if I send them home, my chart reads clear cut chest wall pain. If they get admitted, my chart reads unstable angina.

Heck, I can have 2 pts that have the exact same risk factors/history/exam and I could admit one (b/c of my gut) and he will have an anginal story. I could discharge another and he will have a chest wall pain story.

 

[Janders]

Just for clarity, we do the wake forest modified HEART score pathway, where the low risk people get two trops (we typically do 3hr delta).

The utility of 2-4hr delta troponin is real. It strongly depends on precisely WHICH assay you are using. But if you look at the literature on these assays, they do NOT need 8 hours to come positive. As an aside, when I think an acute CP is "Real" but the EKG isn't a STEMI or even close... and they come in with 30 minutes of CP... and the first troponin is flat... it can be hard to Xfer them to the cath lab facility unless the story / risk factors is SOLID. So I grab a second troponin as soon as that first one results negative. This is roughly at 80 minutes. And BOOM second troponin is weakly positive. Now its an easy, and still rapid, Xfer to a cath-capable facility. I see this type of case a few times a year.

Going back to the point at hand--
the REAL key to all of this is to have patient buy in with your discharge plan. I physically could not admit everyone >25yo with CP. I just can't. And I don't think its good medicine. So you explain to them that by doing the HEART score, and getting one trop I am getting them about 95-97% assurance they're "ok" for the time being. And with that second troponin, we're around 99%. That is NOT 100%! But for most people, that is good enough to get them home, have them see their PMD within 48 hours, and consider stress testing or further workup. So you document said discussion and your recommendations and that they should return if worsening.

Is this bullet proof against a malpractice claim? Of course not. But to me, it is very logical and very defensible. If I have REAL concerns about a patient, I wouldn't use this pathway. the same way I won't get a DDIMER if I REALLY think someone has a PE, or the same way I don't let a negative RUQ U/S dissuade me if I REALLY think the patient has acute/sub-acute cholecystitis.

 

[WilcoWorld]

Here's the abridged version. Chest pain, 31 year old male. Sweaty hispanic guy; no shortage of those in the summer in FL. No risk factors. EKG is benign except for what the cardiologist called a "persistent juvenile T-wave pattern" at the end of it all. Guy is pouring sweat, looks pale, looks... BAD, and has that fist tight over the precordium. If those ST-segments weren't up, they just weren't up... yet.

99% LAD. Boom goes the dynamite.

I appreciate your point, but I'd state it differently. (Also, I agree with Diaphon's assessment of the troponin stratification):

The HEART score doesn't need to be thrown out because of your case. Scoring systems are just like tests - they should only be applied in cases where you'll believe the answer. Got a patient who screams PE in every way that isn't on the PERC criteria - don't apply PERC! Got a patient who is obviously having an MI - don't calculate a HEART score!

So, you're totally correct to go Triumph the Insult Dog on applying scoring systems over clinical assessment, that's why we still need physicians. But if I'm sending home a 40 yo with atypical chest pain it does give me a warm fuzzy feeling to write "Considered PE and ACS, however patient is PERC negative, HEART score = 0" in my medical decision making.

 

[RustedFox]

I appreciate your point, but I'd state it differently. (Also, I agree with Diaphon's assessment of the troponin stratification):

The HEART score doesn't need to be thrown out because of your case. Scoring systems are just like tests - they should only be applied in cases where you'll believe the answer. Got a patient who screams PE in every way that isn't on the PERC criteria - don't apply PERC! Got a patient who is obviously having an MI - don't calculate a HEART score!

So, you're totally correct to go Triumph the Insult Dog on applying scoring systems over clinical assessment, that's why we still need physicians. But if I'm sending home a 40 yo with atypical chest pain it does give me a warm fuzzy feeling to write "Considered PE and ACS, however patient is PERC negative, HEART score = 0" in my medical decision making.

You get it. An academic argument is just that; an argument. The risk is real, so play it smart and play it safe. Admit.

 

[shoal]

I appreciate your point, but I'd state it differently. (Also, I agree with Diaphon's assessment of the troponin stratification):

The HEART score doesn't need to be thrown out because of your case. Scoring systems are just like tests - they should only be applied in cases where you'll believe the answer. Got a patient who screams PE in every way that isn't on the PERC criteria - don't apply PERC! Got a patient who is obviously having an MI - don't calculate a HEART score!

So, you're totally correct to go Triumph the Insult Dog on applying scoring systems over clinical assessment, that's why we still need physicians. But if I'm sending home a 40 yo with atypical chest pain it does give me a warm fuzzy feeling to write "Considered PE and ACS, however patient is PERC negative, HEART score = 0" in my medical decision making.

Make absolutely sure when u document decision rule numbers you have calculated them correctly. I have been taught and prefer to state facts, no tachypnea, tachycardia, hypoxia, evidence of dvt, recent travel, hospitalizations etc... Just in case you missed one. Otherwise your chart is wide open.

Sent from my VS986 using Tapatalk

 

[WilcoWorld]

Make absolutely sure when u document decision rule numbers you have calculated them correctly. I have been taught and prefer to state facts, no tachypnea, tachycardia, hypoxia, evidence of dvt, recent travel, hospitalizations etc... Just in case you missed one. Otherwise your chart is wide open.

Sent from my VS986 using Tapatalk

Agreed.

 

[Daiphon]

Agreed.

Seconded.

And thanks for the props. d=)

Semper Brunneis Pallium

 

[Old_Mil]

The easiest way I have found to do a decision rule is to go to Mdcalc, fill it out, and then copy and paste the result into the EMR.

(that is assuming your hospital's IT department is running a browser compatible with the website...many aren't).

 

[gman33]

Getting the decision rules linked into your EMR is even better.
Pick rule, click, click.
Done

I guess the only problem is if the clicks don't match other stuff in the chart.
Checking that is trickier.

Especially the old PERC neg, but somewhere they had a HR of 101 that you never saw.

 

[gman33]

Plus a lot of the rules may get you down to less than 1% miss, but the public excepts a 0% miss

 

[n2b8me]

6 hour troponin? In any community ER?! = LOLZ. Admit. I'd be fired if I did this more than twice.

CP + 8 hours of symptoms with any risk factors = unstable angina... Admit.

This is our standard of care. I know my system is different from most. I am in a community ER that is NOT fee for service, nor county/academic. Our ambulatory care is completely connected to our inpatient. We DO board patients in the ER for social work/discharge planners to place patient's in SNFs directly from the ER for complaints that do not need inpatient treatment. We do NOT board patient's in the ER that are waiting for hospital admission. One of our core 'metrics' is consult rate... for better or worse.

 

[GeneralVeers]

This is our standard of care. I know my system is different from most. I am in a community ER that is NOT fee for service, nor county/academic. Our ambulatory care is completely connected to our inpatient. We DO board patients in the ER for social work/discharge planners to place patient's in SNFs directly from the ER for complaints that do not need inpatient treatment. We do NOT board patient's in the ER that are waiting for hospital admission. One of our core 'metrics' is consult rate... for better or worse.

Always be careful with saying "Standard of Care" especially in front of a medical board or in litigation. That being said how you treat these intermediate risk chest pains is dependent on your system. If you don't have a holding problem, and easily have space to treat all of your new patients in the ED, then ideally a quick ED rule-out with 6-8 hr troponin would be the best for the patient. Unfortunately most of us work in places with severely limited bed space/staffing. Yesterday 6 nurses showed up rather than the usual 12 we have to staff our 50 beds. It's a unique situation whereby we have beds available upstairs, but are extremely limited in ED throughput due to staffing. Anything that's going to need longer than 2-3 hours of observation is going to get admitted in order to free up a precious bed for a new patient. BTW the wait last night to be seen was 5 hours + at one point due to nursing issues.

 

[emergentmd]

This is our standard of care. I know my system is different from most. I am in a community ER that is NOT fee for service, nor county/academic. Our ambulatory care is completely connected to our inpatient. We DO board patients in the ER for social work/discharge planners to place patient's in SNFs directly from the ER for complaints that do not need inpatient treatment. We do NOT board patient's in the ER that are waiting for hospital admission. One of our core 'metrics' is consult rate... for better or worse.

Please do not take this the wrong way but an ED with a standard of care where 6 hr trop is common is doomed. I would never sign up for this unless its a moonlighting gig but never a permanent home.

I already get litigious checkouts of, "Pt Doe has been here for 18 hrs waiting for a psych bed". I surely would not want to get regular check outs of, "please check the 6 hr trop and discharge the pt if neg" which is highly litigious.

Sorry, but count me out with this 6 hr trop mini rule outs. I can see myself dragged into a lawsuit now b/c I was the last man holding the discharge instructions.

 

[Danbo1957]

It's a unique situation whereby we have beds available upstairs, but are extremely limited in ED throughput due to staffing. Anything that's going to need longer than 2-3 hours of observation is going to get admitted in order to free up a precious bed for a new patient. BTW the wait last night to be seen was 5 hours + at one point due to nursing issues.

You make this sound as if staffing is a consistent issue... I'd be upstairs politely screaming at people wearing Ann Taylor and heels.

 

[gman33]

Please do not take this the wrong way but an ED with a standard of care where 6 hr trop is common is doomed. I would never sign up for this unless its a moonlighting gig but never a permanent home.

I already get litigious checkouts of, "Pt Doe has been here for 18 hrs waiting for a psych bed". I surely would not want to get regular check outs of, "please check the 6 hr trop and discharge the pt if neg" which is highly litigious.

Sorry, but count me out with this 6 hr trop mini rule outs. I can see myself dragged into a lawsuit now b/c I was the last man holding the discharge instructions.

Signing out 2 set CP r/o seems crazy to me.
I'm sure it occurs in many places, but I'd hate to be a part of it.

I am fortunate to work at a place with decent coverage and overlapping shifts, so signout is minimal.
I don't know that I've ever signed out an ED CP r/o.
I think I've gotten signout on a few.
I just admit those or document that the patient refused admission.

These are high risk. I feel like I have to go back and really start over from scratch with those patients.
In many cases it takes more work than seeing the patient initially because I may have to convince the patient that I think they should stay in the hospital.

 

[Arcan57]

Signing out 2 set CP r/o seems crazy to me.
I'm sure it occurs in many places, but I'd hate to be a part of it.

I am fortunate to work at a place with decent coverage and overlapping shifts, so signout is minimal.
I don't know that I've ever signed out an ED CP r/o.
I think I've gotten signout on a few.
I just admit those or document that the patient refused admission.

These are high risk. I feel like I have to go back and really start over from scratch with those patients.
In many cases it takes more work than seeing the patient initially because I may have to convince the patient that I think they should stay in the hospital.

Some CP patients that are signed out are going to be high risk. Most are not. Unlike belly pain, we have well validated risk stratification tools that require minimal physician judgment. I'd rather take sign out on a CP r/o then a belly pain.

 

[Janders]

Across our network we've been signing out CP for many years-- some in true obs units, even getting stresses, many just getting two sets.
I feel MUCH better getting a CP signout which has been properly risk stratified with a patient who's engaged in shared decision making, versus an old person with belly pain who "might" be able to go home.

 

[Old Grunt]

Furthermore, I used to be the stalwart of the academic argument... until I sent a man younger than myself (31 at age 33) to the cath lab for his widowmaker LAD lesion.

I can say this with honesty. I called up my attending-buddies from residency and told them about the case. I said this: "Dude; I felt your hand slap me across the face when I considered not calling the cath lab with this patient. I actually, physically moved after you spiritually hit me. Thanks for that."

Yeah, had a 30 year old female with an MI the other day. The problem with high risk complaints is that the outcome of a miss is lethal to a patient. When that happens, it kind of like Bill Buckner. It doesn't matter how many catches you made. The big miss stands out.

 

[gman33]

Across our network we've been signing out CP for many years-- some in true obs units, even getting stresses, many just getting two sets.
I feel MUCH better getting a CP signout which has been properly risk stratified with a patient who's engaged in shared decision making, versus an old person with belly pain who "might" be able to go home.

Elderly belly pain has one of the highest mortalities of the big chief complaints.
The work up is also more variable compared to CP.

I agree with that point.

Overall signout sucks because we all have different risk tolerances and different ways of working up each patient.

I will usually go along with a plan to admit anything, many times I end up admitting stuff that the original doc wanted to go home.

 

[Angry Birds]

With the elderly with abdominal pain, is it still that high risk if the CT scan is negativo?

 

[goodoldalky]

With the elderly with abdominal pain, is it still that high risk if the CT scan is negativo?

It depends. I remember a couple of years ago I had an old lady in atrial fib with acute abdominal pain, and a benign belly, but a really honest and legit lady. Super uncomfortable. I thought for sure she had mesenteric ischemia, labs normal, immediately ran her for a CT angio abdomen... that came back normal.

Went back to check on her, still hurting. Abdomen still totally soft. I was sort of at a loss and admitted her to medicine, disappointed that my bedside diagnosis of slam dunk mesenteric ischemia was incorrect. Then about 3 hours later she perfed an ulcer.

Although you are generally right that these sign outs of CT negative then home are generally low risk, you have the last name on the chart and you are taking on medico legal liability which exists on every patient (and can unexpectedly be pretty severe). So it is my general opinion that all patients undergoing sign out in the emergency department should be rounded on by the off going and ongoing provider at the bedside with a repeat exam prior to discharge (ducking for rotten tomatoes). Believe it or not we actually do this at my site, which sees >100K a year (it's been hell for a while but is becoming part of the routine, and although I was initially hell-bent against it, I am a convert, as are most of our docs). And to that point if you are RVU or productivity based I think the last name on the chart should take the chart and receive all RVUs for that work.

Signouts are super high risk, such a pain in the @$$ as a provider, are really hard to defend in court unless you have done and documented the above, and should be minimized as much as possible, with things like shift overlap, RVU pay for last name on chart only, overall throughput efficiency, obs units, shift staggering, bedside rounds... my .02.

 

[WilcoWorld]

And to that point if you are RVU or productivity based I think the last name on the chart should take the chart and receive all RVUs for that work.

Wholeheartedly agree.

 

[emergentmd]

Across our network we've been signing out CP for many years-- some in true obs units, even getting stresses, many just getting two sets.
I feel MUCH better getting a CP signout which has been properly risk stratified with a patient who's engaged in shared decision making, versus an old person with belly pain who "might" be able to go home.

I completely disagree. Most if not all abd pain pass offs are, "Discharge if CT negative. You don't even have to talk to the pt. Pt already knows they will go home if neg". I have very little to do with this. But i feel very comfortable if labs are neg, CT neg, and pt willing to go home. What am I missing? What other tests are there to do? I think very little.

When it comes to chest pain it is a WHOLE lot of GRAY. Some docs are very conservative while others more cavalier. Neither style is wrong. Whichever helps you sleep better at night is the kind of doc you will become. If you are a conservative doc and taking CP check outs from a cavalier doc, then you will not be able to sleep at night.

Sorry, CP check outs are the worse. We NEVER do it in my ER. But if you can sleep well at night taking CP pass offs, then you are a better person than I. I have seen many great ED docs and some i would not want to care for my family. You are playing with a loaded gun IMO

 

[emergentmd]

It depends. I remember a couple of years ago I had an old lady in atrial fib with acute abdominal pain, and a benign belly, but a really honest and legit lady. Super uncomfortable. I thought for sure she had mesenteric ischemia, labs normal, immediately ran her for a CT angio abdomen... that came back normal.

Went back to check on her, still hurting. Abdomen still totally soft. I was sort of at a loss and admitted her to medicine, disappointed that my bedside diagnosis of slam dunk mesenteric ischemia was incorrect. Then about 3 hours later she perfed an ulcer.

Although you are generally right that these sign outs of CT negative then home are generally low risk, you have the last name on the chart and you are taking on medico legal liability which exists on every patient (and can unexpectedly be pretty severe). So it is my general opinion that all patients undergoing sign out in the emergency department should be rounded on by the off going and ongoing provider at the bedside with a repeat exam prior to discharge (ducking for rotten tomatoes). Believe it or not we actually do this at my site, which sees >100K a year (it's been hell for a while but is becoming part of the routine, and although I was initially hell-bent against it, I am a convert, as are most of our docs). And to that point if you are RVU or productivity based I think the last name on the chart should take the chart and receive all RVUs for that work.

Signouts are super high risk, such a pain in the @$$ as a provider, are really hard to defend in court unless you have done and documented the above, and should be minimized as much as possible, with things like shift overlap, RVU pay for last name on chart only, overall throughput efficiency, obs units, shift staggering, bedside rounds... my .02.

There are always bad outcome in medicine. And everyone has anecdotal cases that should not change a person's practice.

Abd Pain with Neg labs, Neg CT, and pt has a benign abd then they go home. NO one will fault you if she comes back with a bad outcome. Your case is different b/c she still had significant pain. I admit intractable belly pain with neg CT/Labs all the time.

But You can not defend a CP with 2 neg Trop even with a benign story on check out. If you are doing 2 set of Trop, you are worried enough about the pt. If they come back with an MI, their benign story will begin to have many Cardiac equivalents in court. Also, Who here ever reads all of the nurses notes? I don't. The plaintiff lawyers will kill you in court with a bad outcome b/c the nurses notes many time will crucify you.

I would take 10 abd check out to 1 CP check out any day.

 

[Arcan57]

There are always bad outcome in medicine. And everyone has anecdotal cases that should not change a person's practice.

Abd Pain with Neg labs, Neg CT, and pt has a benign abd then they go home. NO one will fault you if she comes back with a bad outcome. Your case is different b/c she still had significant pain. I admit intractable belly pain with neg CT/Labs all the time.

But You can not defend a CP with 2 neg Trop even with a benign story on check out. If you are doing 2 set of Trop, you are worried enough about the pt. If they come back with an MI, their benign story will begin to have many Cardiac equivalents in court. Also, Who here ever reads all of the nurses notes? I don't. The plaintiff lawyers will kill you in court with a bad outcome b/c the nurses notes many time will crucify you.

I would take 10 abd check out to 1 CP check out any day.

CT does not catch all serious pathology. Blindly taking a "CT neg, go home" at face value is risky to the point of stupidity. MI's masquerading as belly pain, gastric bypass complications, mesenteric ischemia, early appy all may have initially negative CTs. I suppose the chest pain piece is going to vary by region but on the population that MOST EPS are doing the two troponin and home route on the 30 day adverse event rates are measured in the 1:1000 range. If you're doing two trops and home with high TIMI or HEART scores I can see being anxious. If you're refusing sign-out on low risk CP patients (most of which are what Jerry Hoffman would call no-risk), you're being an obstructionist a$%. If you're colleagues are signing out high-risk patients because they don't want to have to fight with the hospitalist or the patient about coming in, that's a separate discussion.

Also, completely agree with sentiment that physician that dispo's pt gets RVUs.

 

[Janders]

If you believe all CP needs stress testing prior then discharge, then of course you are going dislike them getting signed out to you.

We don't believe that. We try to have a standard hospital protocol for LOW RISK chest pain, evidence based, to go home after the patient has had, basically, written informed consent. I feel much better about this than the 80yo with nausea pending a U/A or the 75 yo with belly pain pending CT final read. Belly pain I ALWAYS document another, serial, belly exam in the chart before they leave.

Part of this involves trusting your partners, if you have a diverse set of docs with vastly different risk barometers, then it causes more trouble.

Additionally, you can create mechanisms to have the second troponin return and the discharge be performed under the name of the initial doc, so you never have your name on the chart.

And of course, if you disagree with the initial doc's moves, go see the patient, assume care, write a new chart, take the billing, and make your own disposition. Totally fair. I think we've all gotten the sign out from the typically excellent partner, often after a rough overnight, where they give you that weak "um, I think they can go home after the labs are normal"... and five minutes after they leave you go look at the patient and they look like twice-warmed pig manure.

I just can't imagine a setting where I have the physical capacity to place the great majority of chest pain presentations upstairs!

 

[RustedFox]

Bumping this because I referenced it in another recent thread.

Janders: "I just can't imagine a setting where I have the physical capacity to place the great majority of chest pain presentations upstairs!"

Imagine it. Now imagine this... a setting where you aren't crucified for missing the "low-risk" MI. Which is more realistic? Admitting EVERYONE with the words "chest" and "pain" in the chart... or asking for a reasonable medicolegal system that limits damages and truly judges you by a jury of your "peers".

Yeah, before you all say it: the argument is old, and it hasn't changed, and whatever.

But seriously... in light of threads entitled "Is the practice of medicine sane?!" this deserves additional reflection.

 

[Arcan57]

Bumping this because I referenced it in another recent thread.

Janders: "I just can't imagine a setting where I have the physical capacity to place the great majority of chest pain presentations upstairs!"

Imagine it. Now imagine this... a setting where you aren't crucified for missing the "low-risk" MI. Which is more realistic? Admitting EVERYONE with the words "chest" and "pain" in the chart... or asking for a reasonable medicolegal system that limits damages and truly judges you by a jury of your "peers".

Yeah, before you all say it: the argument is old, and it hasn't changed, and whatever.

But seriously... in light of threads entitled "Is the practice of medicine sane?!" this deserves additional reflection.

I think we get so inured to the pain that we forget there's (potentially) a better way because it causes despair to consider what we could have. I will say the jury of "peers" would have to be carefully considered. I have yet to meet a cardiologist who tolerates anything less than 100% sensitivity and many of our own specialty have Stockholm syndrome from the beatings they've had to endure.

 

[deleted109597]

Bumping this because I referenced it in another recent thread.

Janders: "I just can't imagine a setting where I have the physical capacity to place the great majority of chest pain presentations upstairs!"

Imagine it. Now imagine this... a setting where you aren't crucified for missing the "low-risk" MI. Which is more realistic? Admitting EVERYONE with the words "chest" and "pain" in the chart... or asking for a reasonable medicolegal system that limits damages and truly judges you by a jury of your "peers".

Yeah, before you all say it: the argument is old, and it hasn't changed, and whatever.

But seriously... in light of threads entitled "Is the practice of medicine sane?!" this deserves additional reflection.

Well, no jury of doctors, but here in Texas we are afforded the ability to practice sane medicine each day, every day. Sure, some still don't, but when the standard goes from "anything that could ever happen to the patient that could be traced back to that hospital visit" to "willful and wanton", it's a game changer.

 

[WilcoWorld]

I think we get so inured to the pain that we forget there's (potentially) a better way because it causes despair to consider what we could have. I will say the jury of "peers" would have to be carefully considered. I have yet to meet a cardiologist who tolerates anything less than 100% sensitivity and many of our own specialty have Stockholm syndrome from the beatings they've had to endure.

If the threads on this forum are any indication of how a jury of doctors would act than I certainly wouldn't want them judging my care. It seems like we fall all over ourselves here to find ways to disagree with and criticize each other.

 

[Arcan57]

I just got done reading a note where the cardiologist consultant chastised the prior EP for sending home a non toxic ct proven kidney stone. The admitting diagnosis for the repeat visit was acute cholecystitis.