Consultants Being Less Conservative

[docB]

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I've noticed lately that consultants seem to have gotten much more cavalier about sending people home. I'm not talking here about the lazy dude trying to send home the obviously inappropriate patient. I'm talking about a consultant who says "We don't admit that." and he's telling the truth.

For example I recently had a 50 yo with 50K WBCs on his knee tap who I wanted to admit for septic joint. When I trained those got admitted for IV abx and a wash out in the OR. The ortho told me that they don't take people to the OR for less than 85K any more and they treat these in the office with POs. If worse in a week then they go in or, more commonly, tap again.

I had a peds patient with N/V and a bicarb of 16. Peds was adamant that patient go home. I also had a 45 day old with a fever of 103. I lined, labed, cultured, lpd and started abx and called to transfer. The recieving was really reluctant to take the kid. Wanted me to wait on the results and then send the kid home. I transferred the kid anyway because he looked sick and his bicarb was low but he got d/cd by the receiving doc.

As we know in the ED sometimes you have to fight to get the consultants to do the right thing. But you also have to pick your battles. Maybe this is just something that happens when you've been for a while. Is this a matter of stale knowledge?

 

[Interpolfanclub]

I've noticed lately that consultants seem to have gotten much more cavalier about sending people home. I'm not talking here about the lazy dude trying to send home the obviously inappropriate patient. I'm talking about a consultant who says "We don't admit that." and he's telling the truth.

For example I recently had a 50 yo with 50K WBCs on his knee tap who I wanted to admit for septic joint. When I trained those got admitted for IV abx and a wash out in the OR. The ortho told me that they don't take people to the OR for less than 85K any more and they treat these in the office with POs. If worse in a week then they go in or, more commonly, tap again.

I had a peds patient with N/V and a bicarb of 16. Peds was adamant that patient go home. I also had a 45 day old with a fever of 103. I lined, labed, cultured, lpd and started abx and called to transfer. The recieving was really reluctant to take the kid. Wanted me to wait on the results and then send the kid home. I transferred the kid anyway because he looked sick and his bicarb was low but he got d/cd by the receiving doc.

As we know in the ED sometimes you have to fight to get the consultants to do the right thing. But you also have to pick your battles. Maybe this is just something that happens when you've been for a while. Is this a matter of stale knowledge?

I would have without a doubt admitted both of those patients which I do not think is unreasonable. I haven't heard anything about patients with septic knees and 45 d/o febrile kids being acceptable for outpatient care. I think American health care in general admits too many people and works up too many but the current acceptable miss rate in the public's mind is 0.0% so people get admitted and worked up.

What do we talk about in my ED's quality meetings? Why didn't you admit that guy you sent home, why didn't you get labs and an xray? So we admit, get labs and xrays even if the other 300 people I see that month do fine because it isn't acceptable to miss anything. We have to decide whether we want a health care system that sends people home and doesn't work everyone up for everything or whether we do everything for everyone all the time. It's pretty clear which one we have...end rant.

 

[gro2001]

I've noticed lately that consultants seem to have gotten much more cavalier about sending people home. I'm not talking here about the lazy dude trying to send home the obviously inappropriate patient. I'm talking about a consultant who says "We don't admit that." and he's telling the truth.

For example I recently had a 50 yo with 50K WBCs on his knee tap who I wanted to admit for septic joint. When I trained those got admitted for IV abx and a wash out in the OR. The ortho told me that they don't take people to the OR for less than 85K any more and they treat these in the office with POs. If worse in a week then they go in or, more commonly, tap again.

I had a peds patient with N/V and a bicarb of 16. Peds was adamant that patient go home. I also had a 45 day old with a fever of 103. I lined, labed, cultured, lpd and started abx and called to transfer. The recieving was really reluctant to take the kid. Wanted me to wait on the results and then send the kid home. I transferred the kid anyway because he looked sick and his bicarb was low but he got d/cd by the receiving doc.

As we know in the ED sometimes you have to fight to get the consultants to do the right thing. But you also have to pick your battles. Maybe this is just something that happens when you've been for a while. Is this a matter of stale knowledge?

Not sure about the first two patients, but at my place a well appearing 45 day old with fever to 103 and otherwise normal vital signs (also not premature or anything else funky on history), with reliable follow up available the next day at his pediatrician would get the full septic workup (including lp) but only get admitted if something showed up on labs. Otherwise, fluids/tylenol/nap and sent home with antibiotics. However, this is apparently institution dependent. There are places that admit the kid you described regardless of labs. Our cut off to do that is 28 days though.

 

[WilcoWorld]

Agree that a well-appearing 45 day old can go home (with the plan to return the next day for a recheck) if the work-up is negative. But if the kid does not look good, as docB said was the case with this one, then it's ABX and admit.

I find consultants are getting increasingly hard to impress with pathology. Sometimes this is based on novel good evidence (like the trend in fevers under 3 months of age), but all too often it isn't.

I also feel that in the US we have an unsustainable expectation that nothing ever gets missed, and that this not only leads to higher costs, but is harmful to patients (unnecessary radiation, antibiotics, caths etc). However, I do not think that the ED (or even physicians as a group) should be trying to change this on our own. This needs to be a cultural change involving the media and the politicians/lawyers.

 

[deleted65604]

They are plagued by our conservativism. They hate us, because we make them work. They will try to send anyone home, at anytime for any reason. If they can send the occasional soft admit home, they hope to teach us a lesson, that we are wusses.

We are.

The fact is, that ER doctors see far more patients than a hospitalist. If I miss 1/1000 patients with serious medical problems, I will be committing malpractice 3 times a year, and will quickly be out of a job and a career. They are rolling the dice on 12 patients a year that they decide to send home. We are playing russian roulette 3,000 times a year, they are doing it 12 times.

Simple mathematics.

I believe that hospitals are desparate to cut costs and are increasingly paranoid of government intervention in healthcare (appropriately). The economy has really affected most hospitals, and none are optimistic about the future of the economy. My ER has a couple of "social workers" that hang out in the ER like Doberman Pinschers. I believe they are really just hospital goons hired to make sure that all admits are going to get reimbursed by medicare maximally. They will come up to you and start pimping you on why you are admitting and telling you that such and such a diagnosis isn't reimbursed by medicare, etc.

Bureaucracy is killing our society and medicine.

I have been asked to send a 23 year old kid home with a CK of 50,000. I have been told that a 16 year old kid with myocarditis, diffuse ST segment elevation and a troponin of 9 needs to go home. Their reasoning is nonsensical. Their motives are logical... be antagonistic in the hopes that the ER admits fewer patients while you are on call.

 

[deleted109597]

Once our hospitalist argued against admitting a guy who syncopized at the gym, they put an AED on, and it shocked him. He woke up after he regained his pulse.
EKG, labs, CXR negative. Cards wouldn't take him. Hospitalist stated "there is no acute problem, I cannot admit."

This guy had just died at the gym, and everyone wanted to send him home. It is ridiculous sometimes.

 

[WilcoWorld]

Once our hospitalist argued against admitting a guy who syncopized at the gym, they put an AED on, and it shocked him. He woke up after he regained his pulse.
EKG, labs, CXR negative. Cards wouldn't take him. Hospitalist stated "there is no acute problem, I cannot admit."

This guy had just died at the gym, and everyone wanted to send him home. It is ridiculous sometimes.

You don't have discharge planners who can set up a home AED yet?

🙄

 

[Arcan57]

Once our hospitalist argued against admitting a guy who syncopized at the gym, they put an AED on, and it shocked him. He woke up after he regained his pulse.
EKG, labs, CXR negative. Cards wouldn't take him. Hospitalist stated "there is no acute problem, I cannot admit."

This guy had just died at the gym, and everyone wanted to send him home. It is ridiculous sometimes.

In many countries death is still an outpatient work-up.

 

[KidDr]

Wow, as a peds person I feel bad that you're having to fight so hard to get these kids admitted. Have I sent home febrile 6 week olds? Yes, absolutely--but only if all labs (blood, urine, and usually also CSF) are stone cold normal, the baby looks great and 100% non-toxic, the parents are reliable, and f/u within the next 24 hours is arranged (or the parents are reliable enough to arrange it on their own). I also don't give empiric antibiotics to febrile babies that I'm sending home.

The tricky thing about a 103 fever in a 6 week old is that I find most of them don't look great. Fever of 100.4 or 101? Absolutely--most of those babies look pretty good. But a fever of 103? Most of those babies don't look wonderful. And we know the risk of sepsis is higher with a higher fever, so I'm less likely to discharge them home. And our pediatric admitting docs would never push back against me if I felt that a 6 week old needed to be admitted for IV antibiotics and r/o sepsis--even a 6 week old baby with a 103 fever who looked wonderful and had completely normal labs, if I had a good reason (and that reason might be the height of the fever itself, and nothing else). That's unfortunate that your admitting docs would give you a hard time.

As for the kid with gastro with the bicarb of 16, again, I've sent those kids home, but only if they've gotten a big bolus of NS in the ED, are looking better, can drink without vomiting, have reliable parents, and aren't having diarrhea every 15 minutes. I've found that the kids with really frequent diarrhea can and will drop their bicarbs faster (and lower) than kids who are just vomiting, and they will oftentimes bounce back if they are discharged home from the ED.

I guess that overall I'm surprised by the pushback, and find it unfortunate. Either of the pediatric cases you cited could go either way, and I would hope that the admitting docs who are sitting at home (and have not seen the patient themselves) would give us the benefit of the doubt if we feel like someone needs to be admitted. I feel very lucky to work where I do...but I do worry that as the percentage of unreimbursed care we provide rises, I'll start to get more pushback too. I'm not looking forward to it.