Appropriate to admit this patient?

[Creflo]

I run a house call practice, have a Medicare patient that is blind, on dialysis, no vehicle, diabetic, PAD, neuropathy, smokes 1ppd, uses cocaine, history of multiple toe amps. I see him and he has swollen, malodorous, toe with ulcer with positive probe to bone. I call hospitalist who is glad to admit him. I order vascular consult, MRI, infectious disease consult, then on the second full day in hospital the hospitalist says the hospital administration is going to call me to complain that toe amputation could have been handled as outpatient. Thoughts on this? When dealing with such a patient is it appropriate to admit? I worry that without hospital admission the patient would have been unable to coordinate the outpatient consults.

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[CutsWithFury]

I run a house call practice, have a Medicare patient that is blind, on dialysis, no vehicle, diabetic, PAD, neuropathy, smokes 1ppd, uses cocaine, history of multiple toe amps. I see him and he has swollen, malodorous, toe with ulcer with positive probe to bone. I call hospitalist who is glad to admit him. I order vascular consult, MRI, infectious disease consult, then on the second full day in hospital the hospitalist says the hospital administration is going to call me to complain that toe amputation could have been handled as outpatient. Thoughts on this? When dealing with such a patient is it appropriate to admit? I worry that without hospital admission the patient would have been unable to coordinate the outpatient consults.

Was the patient septic?

Did patient have elevated WBC in the ER? Elevated ESR/CRP? Abnormal vital signs?

Any objective data that documents the patient was sick from this ulcer or was developing a limb threatening infection?

If no then yes this is not appropriate for hospital admission. Nobody cares about the comorbidities. Is the patient sick from ulcer or not? That is all that matters.

Just get a medical clearance from patient PCP and amp as an outpatient surgery. You could have consulted vascular surgery as an outpatient as well. I do it all the time with my wound care patients. I order my NIVS studies outpatient and send them to vascular if poor. Get them revascularized and then schedule for outpatient toe amps. I actually just scheduled an elective outpatient toe amp today for a chronic non healing ulcer with probe to bone.

There has to be medical necessity for admission to prove to insurance otherwise the hospital doesn't get paid. This is a real thing that hospitals take seriously.

If there were objective signs of infection and the patient was sick from the ulcer then they really have no bearing prevent you from admitting the patient in my opinion.

 

[air bud]

Was the patient septic?

Did patient have elevated WBC in the ER? Elevated ESR/CRP? Abnormal vital signs?

Any objective data that documents the patient was sick from this ulcer or was developing a limb threatening infection?

If no then yes this is not appropriate for hospital admission. Nobody cares about the comorbidities. Is the patient sick from ulcer or not? That is all that matters.

Just get a medical clearance from patient PCP and amp as an outpatient surgery. You could have consulted vascular surgery as an outpatient as well. I do it all the time with my wound care patients. I order my NIVS studies outpatient and send them to vascular if poor. Get them revascularized and then schedule for outpatient toe amps. I actually just scheduled an elective outpatient toe amp today for a chronic non healing ulcer with probe to bone.

There has to be medical necessity for admission to prove to insurance otherwise the hospital doesn't get paid. This is a real thing that hospitals take seriously.

If there were objective signs of infection and the patient was sick from the ulcer then they really have no bearing prevent you from admitting the patient in my opinion.

Agree completely.

 

[Scrantonicity]

If they were otherwise stable (vascularity appears intact, etc), no signs/symptoms of sepsis, I probably would have elected to amputate the toe outpatient. You did get a vascular consult, so obviously there was some question as to whether or not the foot would heal an amputation. In that case, I'd say it was a justified admission. As you said, the patient is blind with lots of other comorbidities (along with possible transportation issues)--so I would think you could argue that if you get the phone call. Maybe could have worked with the dialysis center and got him admitted to a swing bed or something instead of a full admission if he wasn't really sick.

It happens...I can think of at least one time where I admitted someone, then later came to realize that it was probably unnecessary. I would still argue that it was better to err on that side rather than the other way (sending someone home from your clinic that should have been admitted). The other way makes you look a lot dumber .

 

[heybrother]

A new patient came to my office - his wife had begged to have him come in that day. His wound smelled so badly that other patients were complaining - I could smell it down the hallway. Smelled like death. He has a large deep draining sinus wound plantarmedial. Drainage has soaked bandaging in his post-op shoe. His foot is red, swollen, hot to the level of the ankle and redness extends proximally posteriorly. 6 months without treatment. For the last 2 weeks he is having fever, chills, nausea, vomiting, loss of appetite, malaise. He relates the foot is horribly painful. 60ish. X-ray shows complete fracture/fragmentation/dissolving of the 1st ray. Bone breakdown appears to extend through the TMTJs laterally. Arguable small air focus/ vs bubbles around the wound. Vitals not substantially impressive though I would argue them if I had to fight it out with a hospital in an ED. Full discussion about risk of life and limb, need to proceed directly to ED. States allergies to a bunch of antibiotics - penicillin, levaquin. Leave room - nurse to put on dressing. Told to pop head in next door if more questions. See another patient. Emerge. Patient told front desk on way out they won't go to ED and left.

Call patient. Ask him to go to ED. Has driven home but now says can't drive. Call ambulance if you can't drive. Ask for phone number for his wife. Leave message and text. She calls me back. Long phonecall about seriousness of infection, need for care. Says she'll take him to hospital when she gets home.

Today she texts me asking if I know where a piece of his post-op shoe is...

 

[CutsWithFury]

A new patient came to my office - his wife had begged to have him come in that day. His wound smelled so badly that other patients were complaining - I could smell it down the hallway. Smelled like death. He has a large deep draining sinus wound plantarmedial. Drainage has soaked bandaging in his post-op shoe. His foot is red, swollen, hot to the level of the ankle and redness extends proximally posteriorly. 6 months without treatment. For the last 2 weeks he is having fever, chills, nausea, vomiting, loss of appetite, malaise. He relates the foot is horribly painful. 60ish. X-ray shows complete fracture/fragmentation/dissolving of the 1st ray. Bone breakdown appears to extend through the TMTJs laterally. Arguable small air focus/ vs bubbles around the wound. Vitals not substantially impressive though I would argue them if I had to fight it out with a hospital in an ED. Full discussion about risk of life and limb, need to proceed directly to ED. States allergies to a bunch of antibiotics - penicillin, levaquin. Leave room - nurse to put on dressing. Told to pop head in next door if more questions. See another patient. Emerge. Patient told front desk on way out they won't go to ED and left.

Call patient. Ask him to go to ED. Has driven home but now says can't drive. Call ambulance if you can't drive. Ask for phone number for his wife. Leave message and text. She calls me back. Long phonecall about seriousness of infection, need for care. Says she'll take him to hospital when she gets home.

Today she texts me asking if I know where a piece of his post-op shoe is...

Can’t fix stupid. Darwinism. Let nature take him out


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[Scrantonicity]

A new patient came to my office - his wife had begged to have him come in that day. His wound smelled so badly that other patients were complaining - I could smell it down the hallway. Smelled like death. He has a large deep draining sinus wound plantarmedial. Drainage has soaked bandaging in his post-op shoe. His foot is red, swollen, hot to the level of the ankle and redness extends proximally posteriorly. 6 months without treatment. For the last 2 weeks he is having fever, chills, nausea, vomiting, loss of appetite, malaise. He relates the foot is horribly painful. 60ish. X-ray shows complete fracture/fragmentation/dissolving of the 1st ray. Bone breakdown appears to extend through the TMTJs laterally. Arguable small air focus/ vs bubbles around the wound. Vitals not substantially impressive though I would argue them if I had to fight it out with a hospital in an ED. Full discussion about risk of life and limb, need to proceed directly to ED. States allergies to a bunch of antibiotics - penicillin, levaquin. Leave room - nurse to put on dressing. Told to pop head in next door if more questions. See another patient. Emerge. Patient told front desk on way out they won't go to ED and left.

Call patient. Ask him to go to ED. Has driven home but now says can't drive. Call ambulance if you can't drive. Ask for phone number for his wife. Leave message and text. She calls me back. Long phonecall about seriousness of infection, need for care. Says she'll take him to hospital when she gets home.

Today she texts me asking if I know where a piece of his post-op shoe is...

Ugh, that's painful to read...also, familiar sadly. Just make sure you document like hell. Do you not have co-admitting privileges at the hospital? I would have called the hospitalist and had him direct-admitted with me as a consult. I guess there's still no guarantee that he would have shown up for admission either though, huh. Anyways, if that's not an option, I guess you did what you could. Sounds like he's headed for BKA if not death anyways

 

[heybrother]

Still getting things in place at one hospital. Sent him to an academic center that ran off its podiatrists 20+ years ago.

I thought he needed a BKA that day, but I wonder if someone will find a way to drag him along with IV antibiotics and HBO at a WHC while he drains pus and dissolves. I feel like I'm seeing a lot of patients who were prescribed one of those new long acting infusion antibiotics. Wouldn't surprise me if that sort of thing was in his future

 

[diabeticfootdr]

I run a house call practice, have a Medicare patient that is blind, on dialysis, no vehicle, diabetic, PAD, neuropathy, smokes 1ppd, uses cocaine, history of multiple toe amps. I see him and he has swollen, malodorous, toe with ulcer with positive probe to bone. I call hospitalist who is glad to admit him. I order vascular consult, MRI, infectious disease consult, then on the second full day in hospital the hospitalist says the hospital administration is going to call me to complain that toe amputation could have been handled as outpatient. Thoughts on this? When dealing with such a patient is it appropriate to admit? I worry that without hospital admission the patient would have been unable to coordinate the outpatient consults.

That’s certainly an appropriate admission.