Behold the Referral! "Just go to the ER"

[thegenius]

Just had a shift full of referrals. Saw about 16 patients (slow day), and 10 of them were referrals of one sort or another. And ridiculous ones too:

1. 24 yo woman with a dental abscess in her mandibular cheek. She saw her dentist earlier today who prescribed clindamycin and sent her to the ED to have the abscess drained. I asked her "your dentist is sending you to a doctor who knows nothing about teeth to drain an abscess? I've done this about 20 times in my life. He's presumably done this 20 times a month. This doesn't make sense, does it?" She nodded in agreement.

So I drained it. Then about an hour later she started getting septic. I was worried I may have made her bacteremic. After labs, IVF and IV clinda she turned around and I dc'ed her.

2. 60 yo woman lost her hearing in one ear last night. Slowly started coming back. She called her PMD today who put in an emergent referral to ENT, then sent her to the ED saying "you might need prednisone, so go to the ED." I told the patient that you don't need special powers to prescribe presdnisone, your doctor could have done this too. I talked to the on-call ENT who said send her to my office for an audiogram, and did so. All three of these doctors are in the same system. They all know each other. The PMD could have just have easily done the same thing I did. Pt's insurance will now pay me a few hundred bucks to make a phone call.

3. PMD sent in a guy to rule out sepsis. His vital signs were normal. Sepsis ruled out.

4. PMD sent in a guy who was transiently hypotensive for like 5 minutes in his office. When he arrived here he was normotensive. Feeling normal now and for the past few weeks.

5. Guy had a thalamic stroke like 2 months ago and now has thalamic pain syndrome. He has been to the ER three times in 1 month with various non-emergent symptoms as the result of this new pain syndrome. Same symptoms each time. We discharge him each time. He called his PCP to see him today for help and they said "go to the ER, they can help." Umm...no I cannot.

6. Young guy lifted something at work and pulled a muscle in his back. Employer sent him to me to get checked out. he can bend over and touch his toes faster than I can do it.

7. Young woman has a sore throat for a few days. Walked into her doctors office. Can't get appt until 3:00 PM that day (it was 9:00 AM). The receptionist or nurse (NOT the doctor) looked in her throat and said "you have white stuff on your throat, you should get checked out now. Go to the ER." She was in her doctor's office!!!

8. Young woman had dysuria and low back pain for a few days. Called her doctor, who I guess was concerned for pyelonephritis. Go to the ER. She has normal vitals, no temp, normal everything. Had a routine bladder infection.

9. Middle aged woman has "burning lung pain" for like 1 year after the fires out here in CA. She has had XR, CT, nebs, everything. Tried to make appt with her PMD today and was told sorry...just go to the ER.

10. Middle aged guy had an injury to his left foot, then days later swelled up with pus. Has some cellulitis and an abscess on the top of this foot. Sent to ED for further eval. Out of all of these...this was probably the only legitimate one I had.



I guess this stuff pays the bills. I'm not surprised at all that payors are increasingly rejecting paying ER bills.

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[gamerEMdoc]

Yep. Its absurd. We are the dumping ground for EVERYONE. If it stopped, many of us would be out of a job of course, but you can definitely see why insurance agencies want to raise co-pays higher and higher to discourage this. But punishing the patients with high co-pays from terrible advice they get from their doctors office isn't exactly fair either.

The best is when a patient is sent by their doc for something super easy because the wait was too long in the PCPs office and their doc sent them to get seen RIGHT NOW for their sore throat, back pain, UTI, etc, then they get stuck waiting longer in the ED to be seen than they would in their PCPs office. After a 6 hour wait in the waiting room, I love having that conversation.

 

[thegenius]

I'll tell ya....my perception is these PCP's are seeing, or want to see, fewer and fewer sick patients. They want well visits, health maintenance, and mild chronic non rheum/ortho complaints. I'm jaded as I only see the ones that come to the ER....maybe they are seeing 90% of the visits for urgent complaints. Sure doesn't seem that way. What the hell is wrong with our system? (a largely rhetorical question).

 

[southerndoc]

Would rather see all of those than the asymptomatic 180/100 BP. One PCP sent me a message in our EMR asking why I didn't rapidly lower it. I had written a prescription for losartan. I gave him a link to the ACEP guidelines.

 

[gamerEMdoc]

Good point. I'd at least rather see the variety rather than 15 "my BP is high and my PCP told me to immediately come here". That ranks up there with one of my least favorite things to deal with in medicine because no matter what you tell the patient, they think you are absolutely crazy.

 

[TheComebacKid]

This is what I tell all of our consultants who say that our admission from the ED is a "dump".

You mean, the time you sent your cardiology patient FROM YOUR CLINIC to the ED for "elevated blood pressure?" without any evidence of end organ damage?

Or the time you told your patient in your clinic in some middle of nowhere town who has been having abdominal pain for 3 years, "Just go to the ER 6 hours away by car, tell them you've been having abdominal pain for 3 years and 5 negative CT scans, negative abdominal MRI, and 2 negative upper and lower endoscopies with negative biopsies, all negative labs. Also, don't worry, they won't want to see any of the images so you don't need any disks. Don't tell them that you already flew to the Mayo Clinic and were evaluated there and was told that nothing is wrong. They'll have a gastroenterologist see you in the ED immediately."

 

[BoardingDoc]

I think you meant "behold" and not "beholden."

That said, my favorite referral to the ED was something I posted about a little while ago and have copied here:

PCP calls ED saying pt is coming in for "elevated BNP, DOE, failing outpatient treatment."
Patient is sitting comfortably in bed.
No SOB at rest.
No SOB while walking around the ED.
No LE edema.
No rales on exam.
CXR squeaky clean.
Pt reports feeling baseline.
BNP found to be ~ 1400 at PCP office today. Was 1700 2 weeks ago and over 2k last month.
Pt reports lasix hasn't been adjusted by PCP for >1 month.
I D/C patient as I don't really know why they're actually there.
PCP calls and explains how I should have admitted the patient and had cards come see them because they're just going to "bounce back in florid failure now."
I stare blankly at the handset for a few seconds wondering if I can catch stupid through the phone lines before hanging up.

 

[thegenius]

I think you meant "behold" and not "beholden."

Huh? what?

 

[deleted859689]

The Doc (ortho surg) I scribed for stressed upon me never sending a patient to the ED unless necessary. We see soo many patients that have had extensive visits to the ER for literally "headache" "lower back pain" "shoulder hurts." I mean this is one causes of high healthcare costs right? My doc always told these patients not to go to the ED and talk to their PCP --- but if PCP's are referring them to the ED that kinda grinds my gears. Then again, patients with medicaid have free visits, even to the ED I believe. If I ever become a PCP I'll actually treat patients.

 

[DO3]

Lately, a large percentage of the patients I’ve seen could have avoided an ED visit by simply talking to an EM doc on the phone or had their PCP talk to an EM doc on the phone.

 

[GonnaBeADoc2222]

Jenny McJennerson, NP here. I'm sending a patient to the ED with BP 180/100.

Do they have symptoms?

No.

Then why are you sending them?

Because their blood pressure is high. They might have a stroke.

Sigh. I'm not going to do anything in the ED.

But they might have a stroke.

[Quotes ACEP guidelines] Send them if you want but please tell the patient ahead of time that I'm likely going to immediately discharge them.

Sends patient. Did she tell patient what I said to tell them? Nope. Discharged patient. Called their attending.

 

[thegenius]

Lately, a large percentage of the patients I’ve seen could have avoided an ED visit by simply talking to an EM doc on the phone or had their PCP talk to an EM doc on the phone.

That's it! Totally true. Kaiser has a better (although not great) triage system. All the nurses who answer the phone lines have MD's for backup and for help.

Although I do suspect it's probably harder than we think triaging these patients over the phone.

 

[thegenius]

The Doc (ortho surg) I scribed for stressed upon me never sending a patient to the ED unless necessary. We see soo many patients that have had extensive visits to the ER for literally "headache" "lower back pain" "shoulder hurts." I mean this is one causes of high healthcare costs right? My doc always told these patients not to go to the ED and talk to their PCP --- but if PCP's are referring them to the ED that kinda grinds my gears. Then again, patients with medicaid have free visits, even to the ED I believe. If I ever become a PCP I'll actually treat patients.

There are a few main drivers of this behavior
- patients want immediate care. They get a sore throat for 12 hours they want to see somebody in the health care field right now. I suspect most with a sore throat would be happy to see their primary doctor that day as they think a sore throat is an appropriate complaint for a primary care doctor to handle. But the key is they want to be seen right away, they are not willing to wait, so the phone conversation probably goes like

Patient: Hi can I see Dr. McPrimaryInternist today? I have a sore throat.
Receptionist: Hi Patient! I'm sorry Dr. McPrimaryInternist is all booked today. He can see you 2 days though, is that OK?
Patient: Well my throat really really hurts and I want to be seen today.
Receptionist: Well...I wish I could get you in sooner, but I can't.
Patient: What am I supposed to do? It hurts. How can I be seen today?
Receptionist: Well...you can always go to the ER.

Hence the Chief Complaint in the ER: "MD Referral, Sore Throat"

ER utilization would go down significantly (my estimate after doing extensive modeling, looking at decades of historical data, doing heuristics and regression analysis of ER claims, and just make believing all of this and guessing) by at least 10-20% if people just paid $50-100 to go to the ER.

- I honestly think that receptionists, nurses, and even some doctors think they are doing the right thing telling patients to go to the ER. They think they are giving them an option, they are not ignoring them. People think they are doing the right thing to...
"just go to the hospital and get checked out"
"just go! It can't hurt!"
"go to the hospital"
"don't think about it...just go to the hospital"
over and over. The reason why I don't like most of these visits is that at the end of the day people leave not happy because we can't figure out what is going on, they don't want to hear "you don't have an emergency, please see your doctor". It's not the legal aspect...it's the customer care aspect.

 

[namethatsmell]

I don’t mind the patients sent in with asymptotic HTN. While I wish they were never sent in these visits are easy and usually take 5 mins of time before d/c. They often have vitals in the EMR from previous visits. When I print them out and show patients that their current BP is actually lower than the last time they were vitalized, they get it. Shortest way to illustrate to patients that there is no emergency.

 

[deleted836128]

Our urgent cares are notorious for sending ridiculous stuff to the ER. Last week I got one for “blood pressure 152/60.” Another was a abscess related to an infected sebaceous cyst on the neck and they were sent to rule out a deep space neck infection. We get urgent care patients for fractures ALL THE TIME. Not talking about urgent or emergent surgical stuff. Or something that needs reduction. I am talking about a nondisplaced distal radius fracture. Arrives in a great splint. The patient looks at me when I am crazy when I look at the x-rays, check out the splint and discharge them (the worst is when they don’t come with x-rays and it’s a pain in the rear to get them so I just have to repeat them).

I had an urgent care doctor come up to me a few months ago and said that she had a huge problem with one of two of PAs in the ER not taking her referrals seriously. She said “they just blow off what I sent them for.” I asked for examples and then looked up the cases. One was sent to “rule out a bowel obstruction” in a patient that hadn’t pooped for three days. No vomiting, no pain (!), passing flatus, eating normally, benign abdomen, no prior history of belly surgeries or past obstructions. She was upset that the PA didn’t order a CT. She was also pissed that the same PA “blew her off” when she sent in a patient with blood pressure of 182/something and then didn’t do much of anything. I asked if they were symptomatic and she said “Yes, they were lightheaded.” Apparently the doc is on the lookout and checks in on the work ups the PAs and the docs do... everytime I get one of the patients referred I have to be careful about what I document and what I order because she’s one of the hospital directors... sigh.

 

[VA Hopeful Dr]

As a PCP, I'd like to think that most of these are the result of non-doctors doing triage - call centers, receptionists, MAs stuff like that, but I know better as many of my colleagues are either idiots or lazy.

 

[Rekt]

As a PCP, I'd like to think that most of these are the result of non-doctors doing triage - call centers, receptionists, MAs stuff like that, but I know better as many of my colleagues are either idiots or lazy.

This.

Everytime this happens I make it a point to ask. Probably 95% of the time they only spoke to someone who probably doesn't even have a high school diploma.

 

[southerndoc]

We get patients all the time from urgent cares with non-reducible fractures for them to "see the orthopedic surgeon." The patient isn't happy when I tell them that they see the orthopedic surgeon in the office, not in the ER. Orthopods are playing sports on Saturday, not hanging around the ER.

The absolute best patient I've ever seen from a PCP office was a lady told to come to the ER immediately (by ambulance!) for asymptomatic bradycardia. Sinus brady at 48 bpm on the EKG from the PCP. She brings with her a prescription that reads "please evaluate for unexplained bradycardia." The patient did NOT want to be in the ER and was ticked at the PCP. She kept asking why he sent her there. I kept telling her I had no idea. It was great writing on the same prescription paper: "Patient evaluated. Rec stopping or decreasing her atenolol." He had her on atenolol 50 mg daily and seriously could not figure out her bradycardia? I actually told the patient she should consider finding a new PCP.

 

[Groove]

If I'm not mistaken (per one of my old colleagues who owns/runs an Urgent care) they can bill for a higher level of care if they disposition the pt to the ER.

I used to get all in a huff and puff about these patients and try to call up the PCP to make fun of them but then realized that wasn't really helping anything. I don't mind anymore. Hell, you guys do realize this is the same thing that hospitalists do to our patients once they leave the ER in a completely different clinical state and are assessed for the first time upstairs. Our "Asthmatic in respiratory distress" after aggressive resus suddenly becomes "Pt with hx of asthma, breathing fine with minor expiratory wheezing and no O2 sat requirements" and then they sit around chuckling about how horrible we are at making patients assessments. I try to give some of these guys the benefit of a doubt, since I wasn't there in the office when they decide to send the pt over.

That being said, I do get some silly ones like the rest of you but I've quit caring. They are usually really easy to dispo and it's great job security. PCP having decision paralysis about how to dispo a pt? NO PROBLEM, send them over to the ER and I'll be happy to do it.

 

[VA Hopeful Dr]

If I'm not mistaken (per one of my old colleagues who owns/runs an Urgent care) they can bill for a higher level of care if they disposition the pt to the ER.

I used to get all in a huff and puff about these patients and try to call up the PCP to make fun of them but then realized that wasn't really helping anything. I don't mind anymore. Hell, you guys do realize this is the same thing that hospitalists do to our patients once they leave the ER in a completely different clinical state and are assessed for the first time upstairs. Our "Asthmatic in respiratory distress" after aggressive resus suddenly becomes "Pt with hx of asthma, breathing fine with minor expiratory wheezing and no O2 sat requirements" and then they sit around chuckling about how horrible we are at making patients assessments. I try to give some of these guys the benefit of a doubt, since I wasn't there in the office when they decide to send the pt over.

That being said, I do get some silly ones like the rest of you but I've quit caring. They are usually really easy to dispo and it's great job security. PCP having decision paralysis about how to dispo a pt? NO PROBLEM, send them over to the ER and I'll be happy to do it.

Yep. If I send someone to the ED from the office I can bill that at the highest possible level for outpatient care.

 

[GonnaBeADoc2222]

If I'm not mistaken (per one of my old colleagues who owns/runs an Urgent care) they can bill for a higher level of care if they disposition the pt to the ER.

I used to get all in a huff and puff about these patients and try to call up the PCP to make fun of them but then realized that wasn't really helping anything. I don't mind anymore. Hell, you guys do realize this is the same thing that hospitalists do to our patients once they leave the ER in a completely different clinical state and are assessed for the first time upstairs. Our "Asthmatic in respiratory distress" after aggressive resus suddenly becomes "Pt with hx of asthma, breathing fine with minor expiratory wheezing and no O2 sat requirements" and then they sit around chuckling about how horrible we are at making patients assessments. I try to give some of these guys the benefit of a doubt, since I wasn't there in the office when they decide to send the pt over.

That being said, I do get some silly ones like the rest of you but I've quit caring. They are usually really easy to dispo and it's great job security. PCP having decision paralysis about how to dispo a pt? NO PROBLEM, send them over to the ER and I'll be happy to do it.

The difference between our admission and the urgent care's "referral" is that we have stabilized the patient and now they need some period of observation / continued non emergent maintenance care that we are not going to do in the ED.

The urgent care / pcp sends the patient either without seeing them or without attempting any intervention. A duoneb and steroids can be given in the office, an extra dose of metoprolol can be given in the office, a simple laceration can be repaired in the office...these things aren't difficult. My old school pediatrician repaired lacerations in his office.

These patients may be easy dispos, but they become a nightmare when you are busy running 2 resuscitations and managing 10 other patients.

A great whistle blower case can probably be had against these ridiculous urgent "care" centers that work up patients and then still send them to the ED. If you refer to the ED you should lose your reimbursement for that encounter .

 

[VA Hopeful Dr]

A great whistle blower case can probably be had against these ridiculous urgent "care" centers that work up patients and then still send them to the ED. If you refer to the ED you should lose your reimbursement for that encounter .

That is a terrible idea. If I don't get paid if despite my efforts the patient still ends up in the ED, why would I ever risk seeing a patient who MIGHT need to go to the ED?

 

[BoardingDoc]

If you refer to the ED you should lose your reimbursement for that encounter .

Agree with @VA Hopeful Dr above. This is a terrible idea. Your argument is that the patient got a workup and the sending doc shouldn't get paid because they still needed to hand the patient off to someone else? That's like saying any patient we admit to the ICU we shouldn't get paid for because we had to hand them to the intensivist. I understand that some of these urgent cares are staffed by idiots and they arguably shouldn't get paid because of how terrible they are, but saying that all visits which get kicked up to the next level of care shouldn't get paid is hardly the solution.

 

[GonnaBeADoc2222]

Agree with @VA Hopeful Dr above. This is a terrible idea. Your argument is that the patient got a workup and the sending doc shouldn't get paid because they still needed to hand the patient off to someone else? That's like saying any patient we admit to the ICU we shouldn't get paid for because we had to hand them to the intensivist. I understand that some of these urgent cares are staffed by idiots and they arguably shouldn't get paid because of how terrible they are, but saying that all visits which get kicked up to the next level of care shouldn't get paid is hardly the solution.

No no that's not what I'm saying.

There are some urgent cares that have clinical policies that mandate them to send a given patient to the ED. So like a 20 year old with chest pain. They do the workup, knowing that they are going to send to the ED, and then send them to the ED and bill for all the labs they got.

 

[BoardingDoc]

No no that's not what I'm saying.

There are some urgent cares that have clinical policies that mandate them to send a given patient to the ED. So like a 20 year old with chest pain. They do the workup, knowing that they are going to send to the ED, and then send them to the ED and bill for all the labs they got.

Hrm, I find that approach interesting. Obviously your 20M with CP who has to go to the ED because of "policy" is nonsense and that patient should probably have neither labs drawn nor be sent to the ED. That said, I feel a more common example is the 50M with a hx of CAD who presents to UC or a PCP's office. That, unsurprisingly should go to the ED. If they draw a troponin there with a plan to send the result to the ED and expedite the workup or they do an EKG to ensure it isn't a STEMI, that seems entirely reasonable to me. Moreover, I argue that the sending doc should 100% be paid for the encounter.

 

[deleted109597]

ER utilization would go down significantly (my estimate after doing extensive modeling, looking at decades of historical data, doing heuristics and regression analysis of ER claims, and just make believing all of this and guessing) by at least 10-20% if people just paid $50-100 to go to the ER.

It would. Hospitals would also close.
I know people who don't work in them love to hate on freestandings. They see them as glorified urgent cares (notwithstanding that every other specialty sees us as glorified triage. It's not medicine if you aren't putting someone down)
We see people that aren't having emergencies all the time. They get their free MSE as required by law. Then, the front desk goes over their copay, their deductible, and potential costs of workup based on what the doctor thinks. Approximately 99% of the time, they either leave quietly, or storm out saying they're going to call the news because we are overcharging them for xyz.
The worst is lacerations. Nobody dies of skin lacerations. There are some that are of course emergencies (tendons, deeper stuff), but the rest is cosmetic. Heaven forbid you imply to someone that you aren't going to treat their snowflake for free. They will flat out tell you that you're required to do it.
People pay >$1000 a month on premiums to have a $6000 deductible, so an emergency in December will cost them ~$18000. "But I have insurance" they'll say. And then the insurance companies won't pay because nobody makes them. Rural hospitals are having the same problems.

 

[alpinism]

Good point. I'd at least rather see the variety rather than 15 "my BP is high and my PCP told me to immediately come here". That ranks up there with one of my least favorite things to deal with in medicine because no matter what you tell the patient, they think you are absolutely crazy.

I hate these patients with a burning passion. Probably because I’m sick and tired of reciting the same speech over and over again but also because they often come with ridiculous expectations from their PCPs.

It’s a enormous PITA because no matter how much time I spend explaining the current guidelines they still demand everything including getting laboratory testing and IV antihypertensives.

 

[GeneralVeers]

I hate these patients with a burning passion. Probably because I’m sick and tired of reciting the same speech over and over again but also because they often come with ridiculous expectations from their PCPs.

It’s a enormous PITA because no matter how much time I spend explaining the current guidelines they still demand everything including getting laboratory testing and IV antihypertensives.

I hate them too. Most of the complaint letters against me are high blood pressure patients. They complain either because their PCP told them they needed it lowered IMMEDIATELY, or because "last time" the ER doctor pumped them full of anti-hypertensives.

 

[GeneralVeers]

My biggest complaint these days are the bull**** ER-ER transfers. I work in two systems who really don't allow direct admits from outside emergency departments.

There's one ED in particular that drives me crazy. It's full service, and technically staffed with board certified EM docs, but a couple of them are complete idiots. The small hospital can admit simple things, but doesn't have specialists like cards, GI, etc.

A few of their genius transfers:

1. 47 yo female with chest pain. Negative EKG, normal troponin and HEART score 1. Transferred for "cardiology consultation". I discharged her immediately and apologized for the stupidity of the doctor.

2. 56 yo male sent in for "New Onset A-fib". The patient had a small tremor. Their EKG read "A-fib" but it was clearly normal sinus, in the 70's with p-waves.

3. Anyone with slight elevation in LFT gets sent in for "GI consultation".

4. 8 week pregnant vag bleeder, with IUP on US and normal vitals. Sent in for "We need OB consultation to find out where the blood is coming from!" This one was actually from the freestanding down the road staffed by docs in my group.

 

[GonnaBeADoc2222]

My biggest complaint these days are the bull**** ER-ER transfers. I work in two systems who really don't allow direct admits from outside emergency departments.

There's one ED in particular that drives me crazy. It's full service, and technically staffed with board certified EM docs, but a couple of them are complete idiots. The small hospital can admit simple things, but doesn't have specialists like cards, GI, etc.

A few of their genius transfers:

1. 47 yo female with chest pain. Negative EKG, normal troponin and HEART score 1. Transferred for "cardiology consultation". I discharged her immediately and apologized for the stupidity of the doctor.

2. 56 yo male sent in for "New Onset A-fib". The patient had a small tremor. Their EKG read "A-fib" but it was clearly normal sinus, in the 70's with p-waves.

3. Anyone with slight elevation in LFT gets sent in for "GI consultation".

4. 8 week pregnant vag bleeder, with IUP on US and normal vitals. Sent in for "We need OB consultation to find out where the blood is coming from!" This one was actually from the freestanding down the road staffed by docs in my group.

Wtf?! Are you in bizarro land?

 

[gamerEMdoc]

8 week pregnant vag bleeder, with IUP on US and normal vitals. Sent in for "We need OB consultation to find out where the blood is coming from!"

My educated guess is the blood was probably coming from the vagina but I'm not an OB.

 

[thegenius]

Yep. If I send someone to the ED from the office I can bill that at the highest possible level for outpatient care.

Our system is really screwed up.

I find most of these encounters quite frustrating because patient expectations is either lots of tests done, resolution of their chronic symptoms, seeing specialty services when not indicated. “then why was I sent over?” Patients generally don’t leave happy

 

[TooMuchResearch]

But don't you need a female reproductive system specialist to do a physical exam and order an ultrasound? J. K.

My educated guess is the blood was probably coming from the vagina but I'm not an OB.

 

[gamerEMdoc]

But don't you need a female reproductive system specialist to do a physical exam and order an ultrasound? J. K.

Oh the transfer was even worse, they already had an US showing an IUP if you read the original post.

 

[RustedFox]

My biggest complaint these days are the bull**** ER-ER transfers. I work in two systems who really don't allow direct admits from outside emergency departments.

There's one ED in particular that drives me crazy. It's full service, and technically staffed with board certified EM docs, but a couple of them are complete idiots. The small hospital can admit simple things, but doesn't have specialists like cards, GI, etc.

A few of their genius transfers:

1. 47 yo female with chest pain. Negative EKG, normal troponin and HEART score 1. Transferred for "cardiology consultation". I discharged her immediately and apologized for the stupidity of the doctor.

2. 56 yo male sent in for "New Onset A-fib". The patient had a small tremor. Their EKG read "A-fib" but it was clearly normal sinus, in the 70's with p-waves.

3. Anyone with slight elevation in LFT gets sent in for "GI consultation".

4. 8 week pregnant vag bleeder, with IUP on US and normal vitals. Sent in for "We need OB consultation to find out where the blood is coming from!" This one was actually from the freestanding down the road staffed by docs in my group.

Wow.

And I thought my local referring systems were bad.

To dovetail on this post: I have now wondered for years why the local ER is the place to send everyone to when their "widget" is broken.

The PEG tube fell out.
The cath won't flush.
The XXXX won't YYYY.

Okay. Sure. This needs to be taken care of, but not emergently. I don't know how there isn't a better avenue for these visits.

 

[GeneralVeers]

Wow.

And I thought my local referring systems were bad.

To dovetail on this post: I have now wondered for years why the local ER is the place to send everyone to when their "widget" is broken.

The PEG tube fell out.
The cath won't flush.
The XXXX won't YYYY.

Okay. Sure. This needs to be taken care of, but not emergently. I don't know how there isn't a better avenue for these visits.

The nursing homes could all do take care of these non-emergently, but it's easier and less work for their nurses to get rid of a patient for a few hours by sending them to the hospital.

Not sure why "picc line replacement", "nephrostomy tube plugged" and "needs paracentesis" all need to be sent to the ER. Most of them come in on weekends or after 5 PM when I have no IR to fix the problems anyway.

 

[GeneralVeers]

Oh the transfer was even worse, they already had an US showing an IUP if you read the original post.

I think he may have been a new grad. We hired a bunch of inexperienced new grads of dubious qualifications to be single coverage at our freestanding. I told this guy "I'd probably just send that home. Can you just call my OB on-call and see if they want the patient to come?" Needless to say they never ended up at my ER.

The worst part is we can't refuse any transfer or the hospital system will fire us. Any transfer no matter how stupid or trivial has to be accepted. We technically aren't even allowed to tell the other physicians to inform the patient that we will send them home, as that could be interpreted as an EMTALA violation.

 

[RustedFox]

The nursing homes could all do take care of these non-emergently, but it's easier and less work for their nurses to get rid of a patient for a few hours by sending them to the hospital.

Not sure why "picc line replacement", "nephrostomy tube plugged" and "needs paracentesis" all need to be sent to the ER. Most of them come in on weekends or after 5 PM when I have no IR to fix the problems anyway.

This is why we ER staff need to "break the system". The admins don't care because that's one more number for them to make sure that was greeted within :10 minutes and was dispo'd within :90 minutes because it was a level-4.... nevermind the fact that nobody could find the right sized widget, and a crashing septic patient showed up via EMS about :18 minutes later, requiring a single-coverage doc to place a central line, pressors, and sort out all that mess.

We need a true "emergency department" and a second "Community referral bull**** department".

Staff 'em both.

That's what American Healthcare has come down to: a bunch of useless @ssholes who just throw their patients to the ER.

RUSTEDFOX RANTS:

I'm trying to get my wife thru a basic rheumatologic workup in my health system.
She has said (and I respect it): Look, I want autonomy and objectivism with my healthcare. Don't grease the wheels.
Okay. I get it. I love you.

She got a primary care appointment in three months.
She went to that primary care appointment.
Jenny McJennyson was there to greet her, and welcome her to the practice!
Nothing actually got done besides ordering a "whole panel of things"!

[She brought home the order sheet to me: none of these things were autoimmune in nature.]

She now has an appointment in two months to discuss... things.

Hey, Primary Care.... YOOR DOIN IT ROONG!

 

[deleted109597]

We need a true "emergency department" and a second "Community referral bull**** department".

There are not many places with 24 hour UC, which would fit the bill of the second. And why not? Because insurance doesn't pay well enough. You get about $150 a pop for in network UC patients. You get about $12 for Medicaid. Everything you do comes out of that number. Want to run a lab? $150-lab costs. It's a single payment, not piecemeal like the ER.
There's a reason hospitals don't have UCs in house.

 

[AMEHigh]

As a PCP, I'd like to think that most of these are the result of non-doctors doing triage - call centers, receptionists, MAs stuff like that, but I know better as many of my colleagues are either idiots or lazy.

Yeah this.

Also, are you getting a report/sign out directly from the physician? Or are you relying on what the patient is telling you? Cause yeah patients forget 99% of what we say and hear what they want to hear.

Whenever a patient tells me the ED told me XYZ and it sounds ridiculous, I just nod my head nicely, but don’t believe a word they just said.

 

[RustedFox]

There are not many places with 24 hour UC, which would fit the bill of the second. And why not? Because insurance doesn't pay well enough. You get about $150 a pop for in network UC patients. You get about $12 for Medicaid. Everything you do comes out of that number. Want to run a lab? $150-lab costs. It's a single payment, not piecemeal like the ER.
There's a reason hospitals don't have UCs in house.

Okay. Fine. Then under the auspices of the "Emergency Department"; triage the "my widget is broken" or "my doctor sent me for transfusion" to a separate department for appropriate care that doesn't require me to meet/greet them within :10 minutes and be discharged within :90 minutes.

Oh, HAI ! I run a level-1 community bull$hit referral department!

Don't let that STEMI alert get in your way.

 

[deleted109597]

You left out "by ambulance". Which is patient-speak for "they can't put me in the lobby" when we all know it doesn't matter.
I agree with you. Honestly, the NH, LTAC, SNF facilities could manage 90%+ of this if their physician on call had to take care of it instead of "send it to the ER".
I once had a patient transferred for an IV. Apparently not a single one of the LVNs at that facility could start one. I asked EMS why they couldn't just start one, and they replied that they had done so, but they were still required to transport it.

 

[alpinism]

Heh I once had a 90 year old demented NH patient sent for chief complaint less confused than normal.

That's right they sent him for a complete AMS workup because he was sitting up in bed talking with family.

 

[Groove]

I'm surprised nobody is complaining about the end of line hospice patients who start to decompensate and the hospice nurse calls 911 to bring them to the ER. Those piss me off way more than the PCP referrals (which I truly don't mind). What's more...inevitably, we have this one hospice company that has no contract with the hospital for in patient hospice (they have a contract with the hospital down the street) and they will always bring them to us. It's a colossal pain in the ass dispositioning these people. The ones that qualify for in patient hospice are easier but ugh.... It always takes me awhile to figure out what to do with them. If we admit them to medicine, it terminates their hospice many times which is completely not what the pt or family wants. I then have to make several calls and re-explain advanced directives to the families who act like this is the first time anyone had discussed DNR with them at all.

 

[TooMuchResearch]

Oh, in that case you need a GI specialist to rule out rectal bleeding. It's so obvious.

Oh the transfer was even worse, they already had an US showing an IUP if you read the original post.

 

[VA Hopeful Dr]

I'm surprised nobody is complaining about the end of line hospice patients who start to decompensate and the hospice nurse calls 911 to bring them to the ER. Those piss me off way more than the PCP referrals (which I truly don't mind). What's more...inevitably, we have this one hospice company that has no contract with the hospital for in patient hospice (they have a contract with the hospital down the street) and they will always bring them to us. It's a colossal pain in the ass dispositioning these people. The ones that qualify for in patient hospice are easier but ugh.... It always takes me awhile to figure out what to do with them. If we admit them to medicine, it terminates their hospice many times which is completely not what the pt or family wants. I then have to make several calls and re-explain advanced directives to the families who act like this is the first time anyone had discussed DNR with them at all.

That's either a sign of a bad hospice nurse or, more likely, family who don't understand what hospice really is.

 

[AlmostAnMD]

My very first code moonlighting during residency was in a small community ER and it was next to a hospice place. An end-stage COPD'er choked on a peanut and coded.

So when he arrives from hospice with his DNR-CC and, well, I find out he's from inpatient hospice and CPR is in progress I had to explain to the wife DNR-CC covers both peanuts and COPD

 

[Groove]

That's either a sign of a bad hospice nurse or, more likely, family who don't understand what hospice really is.

It's obscene sometimes. I had one hospice pt arrive peri-arrest and with no DNR form. The paramedic goes "Yeah, he's a DNR" but yet...there's no POST form anywhere. Nobody will answer from hospice, no family present and no contact numbers provided. Guy codes and gets tubed, ACLS, admitted to the ICU. 24 hours later they are able to finally get family to the hospital and discuss DNR, make out a POST form (I'm not sure if the original got lost or was just never filled out?) and then they pulled everything. I must work with the absolute worst hospice companies on the planet. I feel like I get one of these every 2-3 months.

The absolute worst was the one hospice company who doesn't have a contract with the hospital. They brought their pt. The hospice nurse...actually no it wasn't the hospice nurse, she was useless. It was the director for the hospice company that called me and states she is communicating with the MD that handles admissions for inpatient hospice in the hospital and requested to admit to him. Well, I admit and as he goes upstairs I get a call from bed control saying that his privileges are suspended because he didn't sign charts or something. I can't get in touch with him. I call our two other docs who handle inpt hospice for our other two local hospice companies and neither want to admit/manage because it's with another hospice company. I end up having to bring the pt back down to the ER and finally figure out they have no contract with the hospital. I get more family there and they finally decide to take the pt back home for continued home hospice and feel that the hospice nurse overreacted. All of this took hours during an overnight shift. I'm pretty sure I got a stomach ulcer that night.

 

[VA Hopeful Dr]

It's obscene sometimes. I had one hospice pt arrive peri-arrest and with no DNR form. The paramedic guy goes "Yeah, he's a DNR" but yet...there's no POST form anywhere. Nobody will answer from hospice, no family present and no contact numbers provided. Guy codes and gets tubed, ACLS, admitted to the ICU. 24 hours later they are able to finally get family to the hospital and discuss DNR, make out a POST form (I'm not sure if the original got lost or was just never filled out?) and then they pulled everything. I must work with the absolute worst hospice companies on the planet. I feel like I get one of these every 2-3 months.

The absolute worst was the one hospice company who doesn't have a contract with the hospital. They brought their pt. The hospice nurse...actually no it wasn't the hospice nurse, she was useless. It was the director for the hospice company that called me and states she is communicating with the MD that handles admissions for inpatient hospice in the hospital and requested to admit to him. Well, I admit and as he goes upstairs I get a call from bed control saying that his privileges are suspended because he didn't sign charts or something. I can't get in touch with him. I call our two other docs who handle inpt hospice for our other two local hospice companies and neither want to admit/manage because it's with another hospice company. I end up having to bring the pt back down to the ER and finally figure out they have no contract with the hospital. I get more family there and they finally decide to take the pt back home for continued home hospice and feel that the hospice nurse overreacted. All of this took hours during an overnight shift. I'm pretty sure I got a stomach ulcer that night.

Give it time. Pretty soon Medicare is going to realize that they're paying too much for hospice care (why else are home hospice companies springing up on every corner). Once half of those companies go under, things should improve.

 

[Hercules]

There are not many places with 24 hour UC, which would fit the bill of the second. And why not? Because insurance doesn't pay well enough. You get about $150 a pop for in network UC patients. You get about $12 for Medicaid. Everything you do comes out of that number. Want to run a lab? $150-lab costs. It's a single payment, not piecemeal like the ER.
There's a reason hospitals don't have UCs in house.

This is only true with payors that capitate UC visits. In some regions that includes most payors, but in other regions very few. Less than 5% of the visits at our UC are capitated. Based on some of the over testing though it might be a good thing for several UC chains.