Homunculus

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Knowing that EM practicies vary, and that I am at a place staffed with PA's and a few non-EM trained providers (but some EM residency trained people now), is there some non-written (or written) mantra with "bounce backs" being automatic admissions? i've had multiple consults over the past week of the sole admission criteria being the patient had been there twice now for the same complaint.

i know clinics are different, but especially with peds we get "bounce backs" all the time-- ranging from neurotic parents to prolonged clearing of whatever viral crud they have to true worsening of illness. but this does not an admission make, in my opinion.

does this come from some well meaning practice guideline or are our people here in the ED just not comfortable counselling people regarding illnessess not going away after a day or two?

--your friendly neighborhood bouncing back bounce backs caveman
 

tkim

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It's condition/patient-dependant. The PNA you gave a zpak for who comes back 1-2 days later and looks worse = admit. The viral URI that comes back, not so much. But something more gray, like N/V/D that persists after reglan/zofran scripts, or the cellulititis that isn't getting any worse, but not any better with bactrim aftera couple days - judgement call. I think people who come back with the expectation of admission, if you can admit, they get admitted, because in their minds, they 'deserve' it.
 

Mighty Mouse

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interesting to read your thread as I have 2 patients in my small ED right now....both bounce backs. I am currently working up a 26 yo female with abdominal pain....5th visit in a week. Already neg CT, HIDA, GB U/S, has no uterus, and has GI follow up. In the room next to her I have an elderly lady, known GI vascular malformations causing bleeds, and hx of transfusions for anemia. today she's here with gross blood per rectum, emesis, and hypotension. she was in seen in our ED last friday, and has had the appropriate battery of tests in the last week or two.

Some people see bouncebacks as a pain. Sometimes it hard to sift through real illness vs. seeker vs. crazy. In the end, I look at the bounceback as someone where I have to make sure there were no holes in the previous workup...and if there are, go fill those holes. Treat them as a blank slate, but at the same time have in your back pocket the info from before.

I intend to conservatively rule out bad pathology with the girl, and then I have every intention of sending her home. the older lady was an admit the minute she walked through the door.

there's no cookbook to our practice. there's no substitue for a clear mind, a good H&P, and sound clinical judgement. admitting for admitting sake is a waste of resources. admitting for real pathology is always warranted. sometimes it takes a visit or two to declare itself.
 
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med2UCC

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there's no cookbook to our practice. there's no substitue for a clear mind, a good H&P, and sound clinical judgement. admitting for admitting sake is a waste of resources. admitting for real pathology is always warranted. sometimes it takes a visit or two to declare itself.
We don't admit for bouncebacks unless there is clearly something going on, but we work them up from scratch usually, unless we have something known that just isn't getting better.
This sometimes leads to a miss. Early on, I was working with one of our very experienced ERP's who had me send home a woman who was having odd back pain. He was convinced it was shingles, I was less so, but there were no findings and it could have been pain without vesicles, which you do (unfortunately) get. She came back the next day - pain meds we gave her not doing much. Reassured, sent home with "shingles". She came back the next day - neither of us were there so she got a fresh look. On the CT she had hydronephrosis and a big old kidney stone that we had totally and conclusively missed.
The exception to the bounce back admission criteria would be children. If Mum or Dad brings them in 3 times we admit them regardless of the pathology present or absent. Either the Mum sense (similar to the Spidey sense) is tipping them off to something we're missing or not seeing because it only happens for 5 minutes at 3 am, or there is something else going on and a nice stay in hospital may give us a chance to figure out what that is (Mum is crazy, Dad is on drugs, Grandmother is driving them nuts, there's family stress, whatever). Sometimes this screen is negative, but a surprising number of times we find something either medical or social that needs dealing with. Cheers,
M
 

Homunculus

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If Mum or Dad brings them in 3 times we admit them regardless of the pathology present or absent. Either the Mum sense (similar to the Spidey sense) is tipping them off to something we're missing or not seeing because it only happens for 5 minutes at 3 am, or there is something else going on and a nice stay in hospital may give us a chance to figure out what that is (Mum is crazy, Dad is on drugs, Grandmother is driving them nuts, there's family stress, whatever). Sometimes this screen is negative, but a surprising number of times we find something either medical or social that needs dealing with. Cheers,
M
this is precisely the issue i'm butting heads with our people with. admitting and waiting for "something to declare itself" is a hard thing to justify resources on. there is no ICD-9 for "at wits end". if the story makes some sense for *something* even remotely bad i try to do what i can to help them out to justify bringing them in, but a totally stable virally 6 month old who is satting well, feeding fine, and has normal sats on room air i'm not going to admit because "well, mom is crazy and overbearing and says she won't leave until he is admitted". i admit and the kid gets some med screwup or something and my @ss will be in the grinder, lol. worse yet, what is my discharge criteria when, for all intents and purposes, the kid meets dicharge criteria on admission? :confused:

we see repeat kids in the clinic all the time and don't admit them without a good reason, so i don't see why the simple fact "they're back . . AGAIN" warrants such aggressive management.

i can appreciate having to restart the process over again to take a fresh look, and "patching up the holes" of previous workups. it's what y'all do so well (most of you, lol) that makes me not dread ED pages.

i don't begrudge the ED at all-- i'm just trying to figure out how i can talk "EM-speak" to the peeps here so they don't page me to admit colds "just in case. . ."

--your friendly neighborhood RVU churning caveman
 

USCDiver

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I have heard, and most likely mangling the recollection, that with the EMP staffing group if you have a patient who bounces back for a 3rd visit in some short time period, you have to call a central dispatcher and justify your discharge.
Three visits for the same non-chronic complaint within a week. It's a risk management thing.
 

Jeff698

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if the story makes some sense for *something* even remotely bad i try to do what i can to help them out to justify bringing them in, but a totally stable virally 6 month old who is satting well, feeding fine, and has normal sats on room air i'm not going to admit because "well, mom is crazy and overbearing and says she won't leave until he is admitted".
You don't have to admit them, just evaluate them.

Let's look at this from another perspective. Say that 1 in a million event occurs. In the retrospectoscope (which we all understand is unfair yet we also know it is the instrument of choice used to bludgeon us to death in a court by lawyers and our peers), it'll play like this:

"Dr. X... how could you be so uncaring that you refused, despite the mother's frantic pleas with you for help, to ask for a pediatrics consult? You did this not once, not twice, but THREE TIMES! If only you weren't a heartless bastard who kicks dogs, pushes old ladies and hates children, my client wouldn't have ..."

A very common risk management strategy is, as Greg Henry says, three strikes and their in. If the patient has come back to you for a third time, whatever you're doing isn't working. Call for help.

Help, in this case, may be requesting a pediatric consult, whether we think they need admission or not. We're not necessarily saying they need a bed, but that WE need help. In every case I've been involved in like this, I'm perfectly happy if the pediatrician comes down, evaluates the patient and, after doing so (in person), decides to send them home AND the parent is OK with this.

There is no way on God's green earth that I'm taking the hit for a missed diagnosis and pissed off family just to keep my consultant in bed. I'll do an awful lot for them and do everything I can to shield them, but some things are a bit much. The insistent parent after three visits qualifies for me. The bottom line is that I'm not a pediatrician. The skill set that I (and my colleagues) have hasn't been sufficient for that patient. I get help.

Take care,
Jeff
 

lucky_deadman

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is there some non-written (or written) mantra with "bounce backs" being automatic admissions?
Not automatic admissions but I think that the patient does deserve to have an escalation in work-up and care with each "bounce back".

Sometimes this means they wind up admitted, others it just means you need further testing to prove (to yourself and the patient/family) that the 400 pound gorilla in the corner is just a stuffed animal and not real.
 

Homunculus

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You don't have to admit them, just evaluate them.

Let's look at this from another perspective. Say that 1 in a million event occurs. In the retrospectoscope (which we all understand is unfair yet we also know it is the instrument of choice used to bludgeon us to death in a court by lawyers and our peers), it'll play like this:

"Dr. X... how could you be so uncaring that you refused, despite the mother's frantic pleas with you for help, to ask for a pediatrics consult? You did this not once, not twice, but THREE TIMES! If only you weren't a heartless bastard who kicks dogs, pushes old ladies and hates children, my client wouldn't have ..."

A very common risk management strategy is, as Greg Henry says, three strikes and their in. If the patient has come back to you for a third time, whatever you're doing isn't working. Call for help.

Help, in this case, may be requesting a pediatric consult, whether we think they need admission or not. We're not necessarily saying they need a bed, but that WE need help. In every case I've been involved in like this, I'm perfectly happy if the pediatrician comes down, evaluates the patient and, after doing so (in person), decides to send them home AND the parent is OK with this.

There is no way on God's green earth that I'm taking the hit for a missed diagnosis and pissed off family just to keep my consultant in bed. I'll do an awful lot for them and do everything I can to shield them, but some things are a bit much. The insistent parent after three visits qualifies for me. The bottom line is that I'm not a pediatrician. The skill set that I (and my colleagues) have hasn't been sufficient for that patient. I get help.

Take care,
Jeff
i have absolutely no issue with consulting or coming in-- in fact, i probably go to the ED more than most because i don't mind the place at all and have a healthy appreciation for the work done there. i know for every kid i see there are many i don't, and with most consults (unlike my clinic appointments) i can spend all the time i want with the parents and patient to complete my assessment-- and have found that when a dispo is hanging in the balance the ED can sometimes move mountains, :laugh:

my issue is the "this kid needs to be admitted" opening line because they are in for their 2nd visit in 3 days or other such (in my opinion) nonsense. they are put off and pissy when i tell them i will come evaluate them and see what i can do, but won't promise an admision-- it seems like they want is a "sure, we'll bring them in" over the phone so they can get their dispo rolling. trust me, i understand the need to get people moving, but it has gotten to the point where it's an instant consult for admission-- as in, their diagnosis is "bounce-back needs to be admitted". no additional workup, just an "auto admit". i'm sure it varies place to place, and i was just curious if there was an underlying "rule" they have somehow misinterpreted. i normally say "this kid can go home and follow up with me tomorrow" and i get flak like "are you sure?" or "wow, that surprises me."

i always respect that 1 in a million because there's an even chance it will come through the ED than my clinic, and i don't want to be the one on who could have assisted with the proper management of a patient simply because people were hesitant to consult the "*****hole dr. homunculus". in trying to keep the peace, i'm trying to understand where they are coming from so i can (politely) change their practice habits to be more in tune with what i think is best for the patient. ie, auto-consult instead auto admission, or "if i expand my workup today and it is still negative, maybe we'll give them one more chance" type stuff.

thanks for everyone's input.

--your friendly neighborhood wishing he had t-sheets for clinic visits caveman
 

docB

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I don't have a blanket 3 strikes rule because I see too many drug seekers but we are more conservative with kids. Many of are just not as comfortable with kids as we could be and when a kid comes back who is sicker despite outpatient therapy we get nervous. Obviously the mom who brings the kid back three times in one day because the fever comes back when the Tylenol wears off is a different story.

From the legal standpoint kids are a high risk situation. One of the determinants of a patient, or family, filing suit is if they were angry. If they're demanding admit and we put our foot down and say no it garantees a suit if a bad outcome occurs. That's not just for us, that's for you guys with your clinic patients too.

So when I call the peds guys on these I usually end with the "and this is their 3rd visit" nugget. I start with "I've got a kid who looks sick and has not been responding to outpatient therapy."
 

Stitch

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Just curious: how many of you have an in house accepting pediatrician or someone capable of taking care of/working up a sick kid? Or are you sending them over to a children's hospital? Our peds hospitalist will sometimes come down and see what he considers a 'soft' admission and discharge them right after admission from the ED. He takes responsibility then and we're off the hook (supposedly).

We get a fair amount of these 'kid needs to be admitted' calls, but I often say 'please don't promise them anything.' I don't ever refuse the transfer, but often there's nothing that will happen in patient. Of course it all depends on the age and situation. Remember also that admitting younger kids to the hospital isn't without risks, mainly exposure to significantly sick people.

It's mainly a matter of comfort level I guess.
 

Zanegray

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This thread is pretty interesting in that it seems like the OP has something to complain about about "our guys" and is looking for support here. I think generally we (all of us physicians - ED AND consultants) don't spend enough time thinking about what its like in the other guy's shoes.

I am an EM intern and I already see this pattern in my friends. One of my best friends is a Urology intern on the General Surgery service this year and its - "you won't believe what they did in the ED" or "what they called me for in the ED."

Similarly, us ED residents say, "I can't believe this or that" about a consultant - they were rude... tried to block and admission... etc.

I frequently hear this about "incomplete workups" - non-ED people want more background info when sometimes the ED people are saying -hey, here's the critical info, we are slammed, but we know we need you (and you are going to do a lengthy workup anyway) so help us out.

I really hate this blame game (although I am guilty too). I also see it in - for example - chest pain rule out. Wide practice variation - but with zero tolerance for missed ACS among the general public, right age, risk factors... patient is coming in. Even if they had a negative stress recently - apparently studies have shown that means didly in terms of ruling a patient out... but hospitalists/consultants frequently give you a hard time about admitting.

Any thoughts about this? What do you guys see?
 

Arcan57

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I think cooperation and collegiality are important between the ED and our consultants/admitting physicians. That being said, understanding what it's like in the other doc's shoes is not your primary concern. We have a hospitalist group that has one member that routinely melts down around 8PM when he's on call. He'll pitch a fit about how big his census is and that its getting unsafe because of the volume. I'm sure it sucks immensely for him, but if I send a patient home that I think needed to be admitted because he's overwhelmed... I'm not doing the best thing for the patient. And that always has to be our primary concern.
 

med2UCC

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I think cooperation and collegiality are important between the ED and our consultants/admitting physicians. That being said, understanding what it's like in the other doc's shoes is not your primary concern. We have a hospitalist group that has one member that routinely melts down around 8PM when he's on call. He'll pitch a fit about how big his census is and that its getting unsafe because of the volume. I'm sure it sucks immensely for him, but if I send a patient home that I think needed to be admitted because he's overwhelmed... I'm not doing the best thing for the patient. And that always has to be our primary concern.
Absolutely. Ultimately we have to do what is best for the patient. We'll take a little flak along the way for consulting but in the long run we have to take care of the guy on the stretcher.
We have a radiologist who likewise pitches a fit if he is even called after 8pm (to the point that the ward clerk will say to me "I hate to tell you but it's Doc *** on call for rads tonight" and I will reflexively cringe when I pick up the phone to take his call) and won't do scans for residents 9/10. One of my treasured memories of this year is hearing a senior surgeon a) obviously getting this same treatment over the phone and b) quietly but succinctly ripping him a new one :love:. We got our scan. He's charming during the day, by the way, and very helpful.
Cheers,
M
 

kungfufishing

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I think one point that has been glossed over a bit is the significance of the venue. If mom has (hopefully) perceived junior's problem as an emergency three times now and he looks sick at all I'm probably going to admit him or at least give his pediatrician the option.

If mom has brought the kid back three times out of convenience or he is dismantling the room, etc. I don't think many of us would knee jerk admit.

If mom is bringing her kid back over and over as part of a pattern of utilizing the ED as a clinic, our "three strikes and you are in" dogma, which exists for good reason, is misapplied. Perhaps the OP scenario has something to do with this type of utilization?
 

Jeff698

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i normally say "this kid can go home and follow up with me tomorrow" and i get flak like "are you sure?" or "wow, that surprises me."
That reaction (your ED's) would surprise me, too. All I can ask is that we get another set of eyes on the kid to be sure I'm not missing something. If you come down and offer to see the kid the next day, that's what I'd consider a dispo with a pretty little bow on it.

Take care,
Jeff
 

Aloha Kid

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It comes down to risk and how much you are willing to accept. If you have a restless night and are worrying about the patient you sent home, then you are probably accepting too much risk or just need anxiety meds.

Bounce backs and patients that return after being discharged are high risk. I know the group I work with has a 3 visit ED rule. If you come back for the third time to the ER with the same complaint, you get admitted - within reason of course. There is a fail safe line (an older doc on the phone) you have to call in order to send someone with chest pain home for the third time for example.

As best possible, ER docs like no brainers. We like automaticity and succinct pathways to follow. Not having to exert a lot of brain power for easy complaints is really nice. BUT knowing when something isn't right "danger sense" is crucial.
 

MountainEM

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all I know is that the bounce back case on EM RAP this month was crazy good. Made me think a lot about the subject.
d