Dispoing the mild copd&chf exacerbations, and the ambulatory sat

[ahgykson]

Hey all, EM resident here.

How often do you experienced people use the ambulatory sat to dispo your patients?

For example, in the dyspneic patients (with no c/f ACS, PE, effusion/tamponade etc etc, via testing, clinical scores, pocus), perhaps an old person with extensive comorbids comes with a mild copd or CHF exacerbation but who were satting low 80s by EMS, treated/worked up and now are sitting up, satting well with no new o2 requirement, and talking to you in full sentences. What's your practice in dispoing these patients? Do you ambulatory sat and use that to decide whether they needed to be admitted for IV/monitor vs discharge?

Also in general, what's your practice using ambulatory sat to dispo your patients? Any other situations you use it to help you dispo?

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[WorkNoteEmergency]

I probably use an ambulatory Sat most often when I want to admit a patient and need a good number for the hospitalist. I don’t worry too much about a lowish Sat (in a COPD pt) if they otherwise look good and breathing is comfortable. I’d be hard pressed to admit a patient like you describe above unless there’s some other issue like can’t walk or some such.

I use the road test, I.e walking, quite a bit to help with my dispo decisions but the sat rarely comes into play. Hope that helps.

 

[JacobMcCandles]

If they continue to desat or get incredibly tachycardic/tachypnea on ambulation then they can't go home.

 

[RustedFox]

Yeah; there's nothing really higher-order about the decision-making process here - though it really seems like there should be.

"SmokyBoomer1953 is still huffing and puffing and requires more supplemental oxygen?" = Admit.
"SmokyBoomer1953 can complain about the food and won't stay in his bed?" = Discharge.

 

[thegenius]

Hey all, EM resident here.

How often do you experienced people use the ambulatory sat to dispo your patients?

For example, in the dyspneic patients (with no c/f ACS, PE, effusion/tamponade etc etc, via testing, clinical scores, pocus), perhaps an old person with extensive comorbids comes with a mild copd or CHF exacerbation but who were satting low 80s by EMS, treated/worked up and now are sitting up, satting well with no new o2 requirement, and talking to you in full sentences. What's your practice in dispoing these patients? Do you ambulatory sat and use that to decide whether they needed to be admitted for IV/monitor vs discharge?

Also in general, what's your practice using ambulatory sat to dispo your patients? Any other situations you use it to help you dispo?

Sometimes I do yes...remember most patients have dyspnea on exertion when they come to the ED with a chief complaint of SOB. They may not say "dyspnea on exertion". But that's what they mean. Few have dyspnea at rest.

So yes I treat them and then I have the nurse walk them and tell me how they do. Both their breathing effort and their SpO2. I don't want them to come back to the ER. So I test them.

In your case above where they were satting in the low 80's when EMS arrived....fo sho I walk them prior to discharging them. Again, remember I don't want them to come back. They either get admitted or they get discharged. So if they were low 80's when EMS arrived that's probably good enough reason to just admit them outright when they get to the ED. But if you want to send them home then walk them.

 

[nVictus]

Looks good? DC. Looks like they need my help still? Admit.

Only used ambulation tests/sats to appease my attendings back in residency. I suppose it does build a little bit of gestalt.

 

[LChristmas]

If you're going to send someone home, they need to be able to walk from their bed to the bathroom and to the kitchen. For me, making them do a lap around the ER is the best way to test that, and it seals my dispo one way or the other for the people in the gray area you describe.

I also think it's a great way to decrease some of your cognitive load on shift too to narrow your dispo down to a single test when none of your other tests are definitive. Can walk = home. Can't walk = admit.

It can make the conversation easier with the hospitalist too since the person may not look like they need admission when they're sitting in bed. If they desat or start breathing 40x/min after walking 20' you've proven that they can't go home and that leaves only one place left to go, upstairs.

 

[DocEspana]

Hey all, EM resident here.

How often do you experienced people use the ambulatory sat to dispo your patients?

For example, in the dyspneic patients (with no c/f ACS, PE, effusion/tamponade etc etc, via testing, clinical scores, pocus), perhaps an old person with extensive comorbids comes with a mild copd or CHF exacerbation but who were satting low 80s by EMS, treated/worked up and now are sitting up, satting well with no new o2 requirement, and talking to you in full sentences. What's your practice in dispoing these patients? Do you ambulatory sat and use that to decide whether they needed to be admitted for IV/monitor vs discharge?

Also in general, what's your practice using ambulatory sat to dispo your patients? Any other situations you use it to help you dispo?

If they fail it, it helps me to admit someone who I want to keep for reasons that don't show up on the results tab of cerner. The person who just wont succeed for more than a day or two on their own because of things (medical or social). It gives me a bad number to put in the chart to make the admitting team shut up.

Never really used it on a person who I wanted to send home - my gestalt doesn't really require that. Theyll tell me if they think they cant walk (and often the ones I send home walk on their own in the ED at some point regardless)

 

[RustedFox]

The phrase "returned to baseline" is a very useful charting tool, especially if followed by "family members at bedside are in agreement".

 

[Cinclus]

I road test this complaint and lots of other complaints pretty much every shift. The number of patients I admit for not being able to walk for one reason or another is pretty high.

 

[JacobMcCandles]

I find that patients aren’t very good judge of their own abilities whether they overestimate or underestimate. If you don’t road test these people you’re going to find that A LOT will bounce back. They’ve got to be able to get to their bed, kitchen, bathroom, etc. Takes 30 seconds and you can use one of the finger probes you’ve got left over from COVID that’s collecting dust in your ED.

 

[CoolDoc1729]

If they fail it, it helps me to admit someone who I want to keep for reasons that don't show up on the results tab of cerner. The person who just wont succeed for more than a day or two on their own because of things (medical or social). It gives me a bad number to put in the chart to make the admitting team shut up.

Never really used it on a person who I wanted to send home - my gestalt doesn't really require that. Theyll tell me if they think they cant walk (and often the ones I send home walk on their own in the ED at some point regardless)

I’m in an urban core with a huge rural swath 5 miles out .. a significant amount of the ones who want to go home live 30 miles away. I think I use the road test equally to persuade the city dwellers that they are ok to go 1 block down the road to their senior living building, and to persuade the folks that live 45 minutes away that they probably shouldn’t go home. Fwiw