Cardiology CP clearance

[ZigZag]

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I am practicing in a setting where cardiology is fairly available for routine chest pain consults from ED.
The downside to that that some of them tend to "clear" a lot of atypical chest pain cases after 1 troponin and EKG.
It is not uncommon at all for them to "clear" 56yo smoker with HTN who came in with 30 minutes of atypical pain and troponin of 0.12.
My coworkers seem to think that if cardiology signs off the case, you as an emergency physician are protected against any litigation when **** hits the fan. To me this doesn't sound right.
Does anybody have any experience or opinion about this?

 

[southerndoc]

That's pretty gutsy clearing chest pain patients with indeterminate troponins unless they have clean caths done a week prior.

You aren't protected from liability just because a cardiologist signs off. A jury would wonder why you didn't care enough about the person to get a second troponin. Not all troponins are MI's, but as I said before, indeterminate troponins can really hang you if you ignore them.

 

[elwademd]

i'd say that regardless of what happens with any patient for any diagnosis (chest pain or not), you are never truly protected against any litigation. in other words, you can do everything right, and still be sued.

with that being said, i think the way in which you present a patient for consultation can skew the way the consulting physician responds...

"hey, i got this guy... i don't know... he's squirrely... came in with some vague complaints... kinda said he had some discomfort... ekg's normal, troponin .12... you think we need to do anything?"

"hey, gotta 56 year old smoker with hypertension who comes in with some atypical chest pain. ekg's a little abnormal with some t wave inversions in the lateral leads, 1st troponin's 0.12. i think he oughta come in and be ruled out for acs/nstemi. can you see him?"

just threw in the the ekg bit, as you didn't mention the finding... but i hope i got my point across. i think if you're truly worried, you ought to let the consultant know. and if you're not so worried...

said another way, garbage in equals garbage out. so if you want your consultant to be diligent, you should be diligent about the way in which you present it to the consultant.

just my 2 cents.

 

[jbar]

I'd argue that your department should have some sort of protocol, like "patients with chest pain and risk factors need 2 sets of troponins to be cleared." Also one of my attending put it well when he said "if one troponin isn't going to allow you to clear the patient, don't send it unless you are going to send a second set. Don't do tests that aren't going to change your management."

With that thinking you could argue that cardiology shouldn't be called until you have a second set unless you are asking cardio to admit the patient. Why call if you wouldn't feel comfortable discharging the patient? If they don't have ECG changes its not like they are getting rushed back for a cath, so what's the rush? Would cardio be angry at the delay? Or is it an issue of moving people through the department? I'd argue that if you guys have enough patient's with chest pain who are waiting for enzymes, it might be worth thinking about getting a chest pain center where they can be monitored while they wait without a whole lot of resources being expended.

 

[EctopicFetus]

Bottom line is that if you dc the patient and he drops dead both you and the cardiologist are on the hook. If you do 1 trop 1 ekg and dc you are probably in deep trouble esp if the CP started within 4-6 hours of your 1 trop/ekg/xray.

My take is admit, 2-3 sets, stress/cath.

 

[Peds2ER]

If the consultant has recommended management that you feel is inapprorpriate, you are in no way relieved from managing the patient appropriately. Your ethical and legal obligation to the patient is in no way alleviated. It's your patient, your responsibility. Consultants can recommend, but ultimately you are "the decider."

 

[docB]

If the consultant has recommended management that you feel is inapprorpriate, you are in no way relieved from managing the patient appropriately. Your ethical and legal obligation to the patient is in no way alleviated. It's your patient, your responsibility. Consultants can recommend, but ultimately you are "the decider."

I don't know that that's true. In my setting if there is a disagreement about disposition between the EP and the admitting doc the admitting doc has 30 min to see and dispo the patient (we call this the nuclear option). Once you've made that call we write holding orders, ie. we admit the patient to that doc's service. We don't actually have admitting privileges. 99% of the time the admitting docs are happy for us to do this as it gives them some time leeway in seeing the patient. In this instance it transfers care of the patient to the admitting doc. If the doc comes in and immediately discharges the patient we have no power to stop it. The fact that there's very little we can do to intervene should shield us to some degree but, as everyone notes, you can get sued for anything.

 

[Peds2ER]

I don't know that that's true. In my setting if there is a disagreement about disposition between the EP and the admitting doc the admitting doc has 30 min to see and dispo the patient (we call this the nuclear option). Once you've made that call we write holding orders, ie. we admit the patient to that doc's service. We don't actually have admitting privileges. 99% of the time the admitting docs are happy for us to do this as it gives them some time leeway in seeing the patient. In this instance it transfers care of the patient to the admitting doc. If the doc comes in and immediately discharges the patient we have no power to stop it. The fact that there's very little we can do to intervene should shield us to some degree but, as everyone notes, you can get sued for anything.

In the context of an ER-consultant interction, I don't think a consultant's recommendation insulates you from legal liability especially if it deviates from typical practice or standard of care.

With respect to admissions, we have a similar system where I work. The ED writes admission orders for stable patients. Our ED director is very sensitive to minimizing the ED's legal exposure however and has mandated that the orders explicity state that they are only temporary and are to expire two hours after being written. I think what's he's worried about is the "limbo" that exists after the ED has written the orders prior to the admission team laying eyes and hands on the patient. I think that until the admissions team physically takes custody of the patient, the ED physicians are still at least partially on the hook. Could be wrong...

 

[Stitch]

With respect to admissions, we have a similar system where I work. The ED writes admission orders for stable patients. Our ED director is very sensitive to minimizing the ED's legal exposure however and has mandated that the orders explicity state that they are only temporary and are to expire two hours after being written.

We had problems with this setup because insurance companies were canceling the admission and refusing to pay for it since the 'admission orders' expire after 2 hours. Don't know the details of why they could do that, but basically they weren't paying for the admission. So now our ED 'hold orders' have become 'admission orders' which get 'revised' by the admit team within 2 hours.

 

[southerndoc]

Our admission orders expire in 4 hours (or at 8 am if they are written after 11pm so a doc isn't awakened in the middle of the night to extend the orders).

You can send a single troponin and discharge a patient, especially if they've had pain for more than 6 hours. If you send a single troponin and the patient dies after discharging them, then you are no more liable than if you hadn't sent one and the patient died. Either way you're going to face the wrath of a jury. In one instance they will say "you didn't seem concerned enough to send a second troponin" while the other they will say "is your diagnostic abilities that bad that you didn't recognize this as cardiac? you didn't even send a troponin."

Keep in mind that troponins are elevated in other disorders. So sending a troponin doesn't automatically make it a cardiac rule out. You could be looking for myocarditis, pericarditis (with subsequent myocardial irritation), prognostic abilities in PE, etc.

 

[dmitrinyr]

Our admission orders expire in 4 hours (or at 8 am if they are written after 11pm so a doc isn't awakened in the middle of the night to extend the orders).

You can send a single troponin and discharge a patient, especially if they've had pain for more than 6 hours. If you send a single troponin and the patient dies after discharging them, then you are no more liable than if you hadn't sent one and the patient died. Either way you're going to face the wrath of a jury. In one instance they will say "you didn't seem concerned enough to send a second troponin" while the other they will say "is your diagnostic abilities that bad that you didn't recognize this as cardiac? you didn't even send a troponin."

Keep in mind that troponins are elevated in other disorders. So sending a troponin doesn't automatically make it a cardiac rule out. You could be looking for myocarditis, pericarditis (with subsequent myocardial irritation), prognostic abilities in PE, etc.

If you are concerned about NSTEMI while the ECG shows no changes (even if over 6 hrs after CP), why not just send a 2nd set of troponins? If they are not elevated or are borderline, then you can document that given this there is a low chance of the pt's presentation being ACS related. I understand that this will keep these pts in the ED for another 4-6 hrs, but at least you show that you are investigating the issue more fully and based on the labs, the chances of pt having ACS event are low. Yes the person might drop dead once they leave the ED, but at least it looks better than having only one ECG and Trop on record. I've seen many times where the story is borderline, the 1st ECG and trop is normal, Cardio wanted to d/c pt and see pt as outpt and then the 2nd trop is elevated and/or 2nd ECG has significant changes.

Yes regardless of what you do, you can be sued. As others have mentioned, consultants are just there to make their expert recommendation and you are not obligated to do what they want and if they clear a pt, it doesn't mean that you're off the hook. So, if you are not convinced, then do what you think is right. I would agree and don't call cards unless I have more than 1 trop and ECG.

 

[Hercules]

If you are concerned about NSTEMI while the ECG shows no changes (even if over 6 hrs after CP), why not just send a 2nd set of troponins? If they are not elevated or are borderline, then you can document that given this there is a low chance of the pt's presentation being ACS related. I understand that this will keep these pts in the ED for another 4-6 hrs, but at least you show that you are investigating the issue more fully and based on the labs, the chances of pt having ACS event are low. Yes the person might drop dead once they leave the ED, but at least it looks better than having only one ECG and Trop on record. I've seen many times where the story is borderline, the 1st ECG and trop is normal, Cardio wanted to d/c pt and see pt as outpt and then the 2nd trop is elevated and/or 2nd ECG has significant changes.

Yes regardless of what you do, you can be sued. As others have mentioned, consultants are just there to make their expert recommendation and you are not obligated to do what they want and if they clear a pt, it doesn't mean that you're off the hook. So, if you are not convinced, then do what you think is right. I would agree and don't call cards unless I have more than 1 trop and ECG.

In community practice, tying up a bed for another 4-6 hrs is an expensive choice to make (assuming you don't have an obs unit you can ship them to). I may due it from time to time, but it's definitely not standard practice for me or my group. That said, when I was a resident I did exactly what you're suggesting it. It's just not acceptable now for me to have patients with 6-8 hour length of stays.

 

[docB]

In the context of an ER-consultant interction, I don't think a consultant's recommendation insulates you from legal liability especially if it deviates from typical practice or standard of care.

With respect to admissions, we have a similar system where I work. The ED writes admission orders for stable patients. Our ED director is very sensitive to minimizing the ED's legal exposure however and has mandated that the orders explicity state that they are only temporary and are to expire two hours after being written. I think what's he's worried about is the "limbo" that exists after the ED has written the orders prior to the admission team laying eyes and hands on the patient. I think that until the admissions team physically takes custody of the patient, the ED physicians are still at least partially on the hook. Could be wrong...

Well, we're always on the hook. But are we really expected to know what the standard of care for every condition is? Isn't that what the consultants are for? I understand your point about the obvious ones like "Just send the appy home and I'll see it in the office tomorrow." but there are a lot of cases in the gray area. I don't think that the consultant's advice absolves me but a well documented discussion where I explained the case and the consultant, who now has a doctor-patient relationship with the patient says this is what I want done does help.

We have to pick our battles. We can't just admit everyone and demand that every patient who needs a consultant follow up be seen in the ED. That's just not realistic.

As for the sundown on the orders. That is becoming more common. We don't have it right now but we look into it about once a year. We have just had the issue of insurers not paying for admits because the ED docs don't have admit privileges. As is the fix for most things, we got a new form to fill out.

 

[Jeff698]

You can send a single troponin and discharge a patient, especially if they've had pain for more than 6 hours.

I'd be careful with a single marker rule out at 6 hours. The ACEP guideline on this recommends at least 8-10 hours of continuous symptoms before a single marker rule out.

I'd been doing a 1 hour delta troponin/ECG rule out for awhile. I reviewed those guidelines which recommend a 2 hour delta CKMB/troponin/ECG. I decided to switch to that and picked up a NSTEMI in an otherwise unlikely patient on the first iteration. Scarred me into reviewing that document a little more carefully.

Take care,
Jeff

 

[Jeff698]

...but at least you show that you are investigating the issue more fully and based on the labs, the chances of pt having ACS event are low.

Danger Will Robinson. While I'm assuming this is just a syntax issue in your post, I think it's worth discussing a bit more.

Please remember what we're looking for with "rapid rule out" systems using only markers and ECGs...NSTEMI only. Any pathway that doesn't include provocative testing/cath can not rule out Acute Coronary Syndrome, which includes angina, unstable angina, NSTEMI and STEMI.

It's OK to discharge a patient at low risk for imminent MI (by whatever tea leaves we decide to use) after confirming they don't have a STEMI or NSTEMI. That's what the accelerated R/O pathways are for. We should all be very careful, however, in our discharge discussions with patients in explaining that we can't comment on the presence or absence of ACS, just NSTEMI.

I typically tell patients that, while I've done everything possible to determine that they aren't having a 'heart attack', I can't tell them this "isn't their heart". For that, they need further testing. I tell them that the testing should be done in the next 72 hours but can be safely done as an outpatient. If they don't feel comfortable assuming that risk, I bring them in. Otherwise, I refer them to cards for a follow up visit. Our cards guys are great about getting them in within that 72 hour timeframe.

Remember, markers can't evaluate for all types of ACS, just MI.

In fact, that's the only Level A recommendation from the ACEP guidelines. Let me quote:

"Do not utilize cardiac serum marker tests to exclude non-AMI acute coronary syndromes (ie, unstable angina)".

Here's the link to the PDF file: http://www.acep.org/WorkArea/DownloadAsset.aspx?id=8776

Take care,
Jeff

 

[BatmanMD]

Do any of you guys use the biosite machine and its infamous" 90 minute rule out". A small paper justified its use, but still seems risky and the hospitalist/cardio guys don't believe in it either. A couple places I've been at has these,so whats your take.

 

[Hamhock]

rule out Acute Coronary Syndrome, which includes angina, unstable angina, NSTEMI and STEMI.

I have understood ACS to be a syndrome that does not include angina.

It may be just semantics, but since money paying for admissions is on the line (not admitting for "rule-out MI" - which is not a disease - but admitting for ACS) and we are already getting picky, I think it is important to point out that cardiac chest pain does not equal ACS. We don't admit stable angina. We admit ACS: unstable angina, NSTEMI, and STEMI...or at least we try to do so. 🙂

HH

 

[dmitrinyr]

I have understood ACS to be a syndrome that does not include angina.

It may be just semantics, but since money paying for admissions is on the line (not admitting for "rule-out MI" - which is not a disease - but admitting for ACS) and we are already getting picky, I think it is important to point out that cardiac chest pain does not equal ACS. We don't admit stable angina. We admit ACS: unstable angina, NSTEMI, and STEMI...or at least we try to do so. 🙂

HH

I was taught this as well. Also, according to Washington Manual, ACS includes UA, NSTEMI and STEMI and does not include stable/chronic angina.