Don't discharge old people any more

[The White Coat Investor]

This great study from BMJ just came out:

http://www.bmj.com/content/356/bmj.j239

Objective To measure incidence of early death after discharge from emergency departments, and explore potential sources of variation in risk by measurable aspects of hospitals and patients.

Design Retrospective cohort study.

Setting Claims data from the US Medicare program, covering visits to an emergency department, 2007-12.

Participants Nationally representative 20% sample of Medicare fee for service beneficiaries. As the focus was on generally healthy people living in the community, patients in nursing facilities, aged ≥90, receiving palliative or hospice care, or with a diagnosis of a life limiting illnesses, either during emergency department visits (for example, myocardial infarction) or in the year before (for example, malignancy) were excluded.

Main outcome measure Death within seven days after discharge from the emergency department, excluding patients transferred or admitted as inpatients.

Results Among discharged patients, 0.12% (12 375/10 093 678, in the 20% sample over 2007-12) died within seven days, or 10 093 per year nationally. Mean age at death was 69. Leading causes of death on death certificates were atherosclerotic heart disease (13.6%), myocardial infarction (10.3%), and chronic obstructive pulmonary disease (9.6%). Some 2.3% died of narcotic overdose, largely after visits for musculoskeletal problems. Hospitals in the lowest fifth of rates of inpatient admission from the emergency department had the highest rates of early death (0.27%)—3.4 times higher than hospitals in the highest fifth (0.08%)—despite the fact that hospitals with low admission rates served healthier populations, as measured by overall seven day mortality among all comers to the emergency department. Small increases in admission rate were linked to large decreases in risk. In multivariate analysis, emergency departments that saw higher volumes of patients (odds ratio 0.84, 95% confidence interval 0.81 to 0.86) and those with higher charges for visits (0.75, 0.74 to 0.77) had significantly fewer deaths. Certain diagnoses were more common among early deaths compared with other emergency department visits: altered mental status (risk ratio 4.4, 95% confidence interval 3.8 to 5.1), dyspnea (3.1, 2.9 to 3.4), and malaise/fatigue (3.0, 2.9 to 3.7).

Conclusions Every year, a substantial number of Medicare beneficiaries die soon after discharge from emergency departments, despite no diagnosis of a life limiting illnesses recorded in their claims. Further research is needed to explore whether these deaths were preventable.

They controlled for what you would expect is causing this.

My conclusion? Admit all Medicare patients no matter what they came in with. Then they'll die within 7 days of hospital discharge instead of ED discharge. I wish they had more of a discussion about what an acceptable 7 day death rate was, because 0% isn't happening.

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[deleted480308]

This great study from BMJ just came out:

http://www.bmj.com/content/356/bmj.j239

Objective To measure incidence of early death after discharge from emergency departments, and explore potential sources of variation in risk by measurable aspects of hospitals and patients.

Design Retrospective cohort study.

Setting Claims data from the US Medicare program, covering visits to an emergency department, 2007-12.

Participants Nationally representative 20% sample of Medicare fee for service beneficiaries. As the focus was on generally healthy people living in the community, patients in nursing facilities, aged ≥90, receiving palliative or hospice care, or with a diagnosis of a life limiting illnesses, either during emergency department visits (for example, myocardial infarction) or in the year before (for example, malignancy) were excluded.

Main outcome measure Death within seven days after discharge from the emergency department, excluding patients transferred or admitted as inpatients.

Results Among discharged patients, 0.12% (12 375/10 093 678, in the 20% sample over 2007-12) died within seven days, or 10 093 per year nationally. Mean age at death was 69. Leading causes of death on death certificates were atherosclerotic heart disease (13.6%), myocardial infarction (10.3%), and chronic obstructive pulmonary disease (9.6%). Some 2.3% died of narcotic overdose, largely after visits for musculoskeletal problems. Hospitals in the lowest fifth of rates of inpatient admission from the emergency department had the highest rates of early death (0.27%)—3.4 times higher than hospitals in the highest fifth (0.08%)—despite the fact that hospitals with low admission rates served healthier populations, as measured by overall seven day mortality among all comers to the emergency department. Small increases in admission rate were linked to large decreases in risk. In multivariate analysis, emergency departments that saw higher volumes of patients (odds ratio 0.84, 95% confidence interval 0.81 to 0.86) and those with higher charges for visits (0.75, 0.74 to 0.77) had significantly fewer deaths. Certain diagnoses were more common among early deaths compared with other emergency department visits: altered mental status (risk ratio 4.4, 95% confidence interval 3.8 to 5.1), dyspnea (3.1, 2.9 to 3.4), and malaise/fatigue (3.0, 2.9 to 3.7).

Conclusions Every year, a substantial number of Medicare beneficiaries die soon after discharge from emergency departments, despite no diagnosis of a life limiting illnesses recorded in their claims. Further research is needed to explore whether these deaths were preventable.

They controlled for what you would expect is causing this.

My conclusion? Admit all Medicare patients no matter what they came in with. Then they'll die within 7 days of hospital discharge instead of ED discharge. I wish they had more of a discussion about what an acceptable 7 day death rate was, because 0% isn't happening.

if you could guarantee life for a week after an ED visit, I would go every week

 

[Apollyon]

Is it a bit more than ironic that the BMJ published a study about Americans and Medicare (although I will grant that the authors are American)?

 

[gman33]

I wonder if you would come up the the same 0.12 7 day mortality from other events.

7 days from going to church.
7 days from going to McDonalds.
7 days from going to a bull fight.

Old people die.

Studies like this are a waste of resources and just reinforce false expectations.

Things get missed, but that is not usually the reason for a death in this population.

 

[Spectre of Ockham]

So free echos , spirometry and blood works for everybody ? I'd love that but we'd have techs and radiologist jumping out the window after several days.

As for admitting what if it's flu season and IM is low on beds ? A lot of 60 and 70 year old come in the ER because they have a problem that can be easily taken care off by their PCP.

 

[WilcoWorld]

Is it a bit more than ironic that the BMJ published a study about Americans and Medicare (although I will grant that the authors are American)?

Makes you wonder if it got rejected from JAMA and NEJM first.

 

[WilcoWorld]

For me, the most notable part of the abstract was this: 2.3% died of narcotic overdose, largely after visits for musculoskeletal problems.

Those deaths may have been the most preventable of those seen in the study.

 

[RustedFox]

This is practice changing news for me.

...


All jokes aside. Last night, I discharge 82 year old male with non-Hodgkins lymphoma, awaiting PET scanning and staging after workup for "weakness and fatigue" and "looks great, asks to go home".

This morning, same 82 year old returns 1 hour prior to my shift ending with saddle PE. Dead 3 hours later.

Old people die. Its what they do.

 

[WilcoWorld]

This is practice changing news for me.

...


All jokes aside. Last night, I discharge 82 year old male with non-Hodgkins lymphoma, awaiting PET scanning and staging after workup for "weakness and fatigue" and "looks great, asks to go home".

This morning, same 82 year old returns 1 hour prior to my shift ending with saddle PE. Dead 3 hours later.

Old people die. Its what they do.

If I discharge someone over 80 with any complaint more serious than ankle sprain, the chart usually reads "Admission was offered, after a discussion of risks and benefits the patient preferred discharge."

 

[Mad Jack]

Clearly, all Medicare beneficiaries should just live in the hospital so that zero percent would die after discharge.

 

[RustedFox]

Clearly, all Medicare beneficiaries should just live in the hospital so that zero percent would die after discharge.

Future CEO, right here. Calling it now.

 

[Apollyon]

Makes you wonder if it got rejected from JAMA and NEJM first.

Yeah, that's what I was thinking, too. But the NEJM is right there with those Harvard dudes - they have to know people in common. I think that says even more.

 

[Psai]

We should just stop old people from going to the ED so that none of them will be killed by ED docs.

 

[deleted109597]

Meh, it's only bad once you get above pneumonia on the chart above. Although syncope is probably a tougher sell to send home. Apparently discharging with cellulitis and chest pain is protective though.

 

[Zebra Hunter]

If I discharge someone over 80 with any complaint more serious than ankle sprain, the chart usually reads "Admission was offered, after a discussion of risks and benefits the patient preferred discharge."

Rather than say "offer" I say "strongly advised" as offered sounds like you don't feel strongly that they need to be admitted. Usually I don't feel strongly, but I feel safer medicolegally demonstrating significant concern in my chart and then having the patient refuse admission despite my concern.

 

[coachB]

Clearly, all Medicare beneficiaries should just live in the hospital so that zero percent would die after discharge.

Someone should pull up the data regarding inpatient mortality for those same patients who are admitted. Probably even higher. The problem is that those same old patients who are at risk of dying when discharged are also at much greater risk for all sorts of complications of admission (nosocomial infection, delirium, etc).

 

[doctalaughs]

Rather than say "offer" I say "strongly advised" as offered sounds like you don't feel strongly that they need to be admitted. Usually I don't feel strongly, but I feel safer medicolegally demonstrating significant concern in my chart and then having the patient refuse admission despite my concern.

But do you actually strongly advise every elderly patient with more than an ankle sprain admission? Or do you just offer it as an option and document that way.


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[RustedFox]

Rather than say "offer" I say "strongly advised" as offered sounds like you don't feel strongly that they need to be admitted. Usually I don't feel strongly, but I feel safer medicolegally demonstrating significant concern in my chart and then having the patient refuse admission despite my concern.

In my case, I couldn't even advise observation with a clear conscience. A 82 year old with NHL is going to feel "tired and weak". He can go home and enjoy his days in the comforts of his abode, rather than stay in the hospital during the peak of flu season.

I can say, with good conscience and faith - that there was no way I would have expected gramps to pop from a saddle embolus that night. Not with normal vitals and labs, a happy family, and a plan for follow-up with onc in 2 days.

 

[erdoc00]

0.12%? Is this an article from the onion?

This is brought to us by the same people that made pain the 5th vital sign but now complain about the opioid epidemic.

Also the same people that brought us the patient satisfaction metric but complain about over prescription of antibiotics.

it's almost as if these people are *****s...

 

[deleted77919]

…

 

[Raryn]

I do this when possible, but how often do you do workups on old patient, feels weak and tired and don't find anything? There is no way I could get my hospitalists to admit a patient for "feels weak."

I don't think it helps me to write I recommended admission and after consulting the hospitalist refused.

I've just always assumed whenever you guys don't find anything you sprinkle some dirt into the urine sample and admit them for a UTI

 

[WilcoWorld]

I do this when possible, but how often do you do workups on old patient, feels weak and tired and don't find anything? There is no way I could get my hospitalists to admit a patient for "feels weak."

I don't think it helps me to write I recommended admission and after consulting the hospitalist refused.

Very rarely do the patients who have had a fully negative workup decide that they want admission. My discussion will go something like "I've checked you for X, Y, Z, P, D and Q and everything looks good so far. We can't be sure something won't develop, however. I can admit you to the hospital to be watched, or you can go rest at home. Of course, if you feel worse, or something comes up we're here 24/7 and you can always come back. Also, if I admit you there are risks of blood clots, hospital-associated infections and other conditions." Almost everyone wants to go home once they know that they were tested for the main thing they were worried about (a piece of information I try to gather during my initial H&P) and after learning that whatever test their second cousin, the retired EMT, told them they needed was negative.

When someone over 80 wants to be admitted, I can pretty much always find something to admit them for. But I must admit (pun not intended) that this is the case at my current shop. At the place I used to work (which I left, largely for this reason) the admitting services would push back on all sorts of ridiculous things.

 

[BAM!]

I do this when possible, but how often do you do workups on old patient, feels weak and tired and don't find anything? There is no way I could get my hospitalists to admit a patient for "feels weak."

I don't think it helps me to write I recommended admission and after consulting the hospitalist refused.

Seems like it might help you medico-legally, especially if you can get the hospitalist to discharge the patient. However, it's definitely not going to help with interdepartmental relations.

 

[BAM!]

I'm telling all patients I discharge over 65 yo, You have a 1/1000 chance of dying in the next week. :/

 

[alpinism]

I don't even understand how garbage like this gets published. I seriously don't. These authors should have their credentials stripped.

Let's think about this for a minute. This study states than 1 in 833 (0.12%) of patients over the age of 65 discharged from the ED die within a week. 1 in 833.

I wonder how that would compare to the general population? 1 in 833 people over the age of 65 in the general population dying per week would mean 1 in 16 per year. Now consider that the life expectancy in the United States is somewhere in the late 70's. Wouldn't it then seem reasonable to assume that 1 in 16 people over the age of 65 would be expected to die each year?

My guess is that 1 in 833 people over the age of 65 who went to the grocery store today will die within a week.

Sheesh.

The best part is that they describe the >65 medicare patients as "generally healthy" then go on to state that the leading causes of death were CAD and COPD.

 

[gutonc]

I don't even understand how garbage like this gets published. I seriously don't. These authors should have their credentials stripped.

Let's think about this for a minute. This study states than 1 in 833 (0.12%) of patients over the age of 65 discharged from the ED die within a week. 1 in 833.

I wonder how that would compare to the general population? 1 in 833 people over the age of 65 in the general population dying per week would mean 1 in 16 per year. Now consider that the life expectancy in the United States is somewhere in the late 70's. Wouldn't it then seem reasonable to assume that 1 in 16 people over the age of 65 would be expected to die each year?

My guess is that 1 in 833 people over the age of 65 who went to the grocery store today will die within a week.

Sheesh.

So...based on this data from the CDC (warning, PDF)...the annualized death rate for people 65-69 in 2014 (most recent data I could find) is 1454/100000 so, ~1.45%/y =~0.028%/wk. For the 85+ crowd it's 13407.9/100000 or 13.4%/y or 0.25%/wk. For the middle group (75-80), it's 3560.5/100000 = 3.56%/y = .068%/wk.

I'm not smart enough to do the rest of the math myself, but I'd say, roughly, the going weekly death rate for the Medicare population is probably on the order of 0.1-0.15%.

It would have been nice if they'd broken it down by age strata so we could make a better comparison though.

 

[gutonc]

The best part is that they describe the >65 medicare patients as "generally healthy" then go on to state that the leading causes of death were CAD and COPD.

When I was a resident and fellow at a place with a huge VA where we did ~50% of our training, someone with stable CAD, COPD, HLD and DM2 with an A1c of <9 was routinely described as "VA Healthy".

 

[Psai]

When I was a resident and fellow at a place with a huge VA where we did ~50% of our training, someone with stable CAD, COPD, HLD and DM2 with an A1c of <9 was routinely described as "VA Healthy".

Some of the attendings here question you if you say that someone in their 60s is old. Sorry but if you're sporting some greys and pulling in social security from my paycheck, you're not middle aged anymore.

 

[Doc_Mcstuffins]

Its good to see that many of the ER docs on here seem to understand the value of this study (or lack thereof) and also seem to practice evidence based medicine. As a hospitalist, I'm constantly amazed at how most of the ED physicians I've worked with in numerous hospitals remove clinical judgement or evidence based medicine from their practice and instead practice defensive medicine.

As an example, last shift, I was called for a 56 yo Patient with community acquired pneumonia but curb-65 score of 0 and psi score is low risk, ED doc felt strongly to admit to hospitalist. Tried talking to ED doc but they said their dispo was to admit and I can do freely what I want with patient but they will document decision to admit.

I think there has been too much emphasis on LOS in ED and no incentive to getting the right disposition. So I admit the patient to observation, she has no insurance so she gets a large bill after she is discharged the next day in 12 hours and she never really should have been admitted in the first place. The ED physician looks good on their metrics because the patient's ED LOS was only 3 hours. I would like to see more focus placed not only on ED LOS but unnecessary admissions, not evidence based. There will always be a few unique situations where a patient is admitted but is discharged the next day but this is a common problem that I've seen in most of hospitals I work at where easily 33-50% of my admissions every night are patients who don't need to be admitted to the hospital.

 

[Raryn]

Its good to see that many of the ER docs on here seem to understand the value of this study (or lack thereof) and also seem to practice evidence based medicine. As a hospitalist, I'm constantly amazed at how most of the ED physicians I've worked with in numerous hospitals remove clinical judgement or evidence based medicine from their practice and instead practice defensive medicine.

As an example, last shift, I was called for a 56 yo Patient with community acquired pneumonia but curb-65 score of 0 and psi score is low risk, ED doc felt strongly to admit to hospitalist. Tried talking to ED doc but they said their dispo was to admit and I can do freely what I want with patient but they will document decision to admit.

I think there has been too much emphasis on LOS in ED and no incentive to getting the right disposition. So I admit the patient to observation, she has no insurance so she gets a large bill after she is discharged the next day in 12 hours and she never really should have been admitted in the first place. The ED physician looks good on their metrics because the patient's ED LOS was only 3 hours. I would like to see more focus placed not only on ED LOS but unnecessary admissions, not evidence based. There will always be a few unique situations where a patient is admitted but is discharged the next day but this is a common problem that I've seen in most of hospitals I work at where easily 33-50% of my admissions every night are patients who don't need to be admitted to the hospital.

The ED sounds like they were wrong in this case, but you realize you have the power to not admit, right?

That is, if you feel so strongly, you can typically put the discharge orders in yourself without admitting the patient. You still have to write a note explaining your reasoning and discussions with the patient, and may not be able to bill for that note, but if it's the right thing to do...

 

[sum dude]

Its good to see that many of the ER docs on here seem to understand the value of this study (or lack thereof) and also seem to practice evidence based medicine. As a hospitalist, I'm constantly amazed at how most of the ED physicians I've worked with in numerous hospitals remove clinical judgement or evidence based medicine from their practice and instead practice defensive medicine.

As an example, last shift, I was called for a 56 yo Patient with community acquired pneumonia but curb-65 score of 0 and psi score is low risk, ED doc felt strongly to admit to hospitalist. Tried talking to ED doc but they said their dispo was to admit and I can do freely what I want with patient but they will document decision to admit.

I think there has been too much emphasis on LOS in ED and no incentive to getting the right disposition. So I admit the patient to observation, she has no insurance so she gets a large bill after she is discharged the next day in 12 hours and she never really should have been admitted in the first place. The ED physician looks good on their metrics because the patient's ED LOS was only 3 hours. I would like to see more focus placed not only on ED LOS but unnecessary admissions, not evidence based. There will always be a few unique situations where a patient is admitted but is discharged the next day but this is a common problem that I've seen in most of hospitals I work at where easily 33-50% of my admissions every night are patients who don't need to be admitted to the hospital.

Why even admit, then? D/c from ED.. just like when we send home a pta pmd or urgent care thinks "needs admission"

 

[sum dude]

But was the 100-AGE protocol used?? New study! Apparently BMJ will pubish anything

 

[TooMuchResearch]

I've just always assumed whenever you guys don't find anything you sprinkle some dirt into the urine sample and admit them for a UTI

"If you can't walk, you probably can't get back home tonight. We'll have someone come in to help see if grandma can walk. Wink wink, nudge nudge."

Just kidding. Not really. Sort of.

I do actually tell the hospitalist if it's a sh*tty admission, but I know them well enough for that to be okay.

 

[WilcoWorld]

It's worth noting that you could have severe sepsis and a CURB-65 score of zero at the same time.

Don't get me wrong, I use the CURB-65 score to support discharges. But I only use it in patients with a WALLS score of 0.

 

[gro2001]

Its good to see that many of the ER docs on here seem to understand the value of this study (or lack thereof) and also seem to practice evidence based medicine. As a hospitalist, I'm constantly amazed at how most of the ED physicians I've worked with in numerous hospitals remove clinical judgement or evidence based medicine from their practice and instead practice defensive medicine.

As an example, last shift, I was called for a 56 yo Patient with community acquired pneumonia but curb-65 score of 0 and psi score is low risk, ED doc felt strongly to admit to hospitalist. Tried talking to ED doc but they said their dispo was to admit and I can do freely what I want with patient but they will document decision to admit.

I think there has been too much emphasis on LOS in ED and no incentive to getting the right disposition. So I admit the patient to observation, she has no insurance so she gets a large bill after she is discharged the next day in 12 hours and she never really should have been admitted in the first place. The ED physician looks good on their metrics because the patient's ED LOS was only 3 hours. I would like to see more focus placed not only on ED LOS but unnecessary admissions, not evidence based. There will always be a few unique situations where a patient is admitted but is discharged the next day but this is a common problem that I've seen in most of hospitals I work at where easily 33-50% of my admissions every night are patients who don't need to be admitted to the hospital.

If you really think that the average ED doc practices more defensively than the average IM doc, then you need to reassess your biases. I understand why that would seem to be the case from your perspective, but you should try to account for why you may be mislead. For example:

-You don't get to see when the ED docs DON'T practice defensively. I wish I could tell you how many IM docs send their patients to the ED for all sorts of BS, particularly asymptomatic hypertension in the 180/90 range that for some reason needs to be treated and imaged emergently. We discharge all those folks, but you don't see any of it.

-You probably don't see defensive medicine done by IM folks as such, but think of it as "being thorough". For example, an IM hospitalist that would routinely lecture me on all the unnecessary admissions for low risk chest pain would happily go on to consult orthopedics for an old clavicular fracture discovered incidentally on Chest Xray on the same weak admission and not even see the irony of that. If we start polling all the sub specialists, neurologists, and surgeons on what percentage of the consults coming from the general IM folks are "not EBM driven" then I think you will find your specialty may not be as enlightened as you initially thought.

Also, think back to all those weak, non EBM driven admissions. What percentage of them got labs the next day? If its more than zero... why? They wouldn't have gotten labs at home, which is where you wanted the ED doc to send them, right?

 

[sum dude]

If you really think that the average ED doc practices more defensively than the average IM doc, then you need to reassess your biases. I understand why that would seem to be the case from your perspective, but you should try to account for why you may be mislead. For example:

-You don't get to see when the ED docs DON'T practice defensively. I wish I could tell you how many IM docs send their patients to the ED for all sorts of BS, particularly asymptomatic hypertension in the 180/90 range that for some reason needs to be treated and imaged emergently. We discharge all those folks, but you don't see any of it.

-You probably don't see defensive medicine done by IM folks as such, but think of it as "being thorough". For example, an IM hospitalist that would routinely lecture me on all the unnecessary admissions for low risk chest pain would happily go on to consult orthopedics for an old clavicular fracture discovered incidentally on Chest Xray on the same weak admission and not even see the irony of that. If we start polling all the sub specialists, neurologists, and surgeons on what percentage of the consults coming from the general IM folks are "not EBM driven" then I think you will find your specialty may not be as enlightened as you initially thought.

Also, think back to all those weak, non EBM driven admissions. What percentage of them got labs the next day? If its more than zero... why? They wouldn't have gotten labs at home, which is where you wanted the ED doc to send them, right?

I love when Hospitalist/CM/Admin complains about weak admissions, then keep patient for 5 days. If its so weak, then sack up and d/c pt w/in 23 hrs...We had CM complain about a patient who got admitted and they could not kick out for 6 days...HELLO if you can't dispo them in 6 days, how am I supposed to dispo them in 120 minutes?

 

[DrDrummer]

Don't get me wrong, I use the CURB-65 score to support discharges. But I only use it in patients with a WALLS score of 0.

That is pretty excellent. I really like the score posted by John Hinds in the top comment, too.

 

[da8s0859q]

That is pretty excellent. I really like the score posted by John Hinds in the top comment, too.

Amen. Left us too young.

 

[WilcoWorld]

That is pretty excellent. I really like the score posted by John Hinds in the top comment, too.

The ROPE score is great. But, like Ranson's criteria, if you're applying it in the ED, you're working in the wrong ED.

 

[ERMudPhud]

So...based on this data from the CDC (warning, PDF)...the annualized death rate for people 65-69 in 2014 (most recent data I could find) is 1454/100000 so, ~1.45%/y =~0.028%/wk. For the 85+ crowd it's 13407.9/100000 or 13.4%/y or 0.25%/wk. For the middle group (75-80), it's 3560.5/100000 = 3.56%/y = .068%/wk.

I'm not smart enough to do the rest of the math myself, but I'd say, roughly, the going weekly death rate for the Medicare population is probably on the order of 0.1-0.15%.

It would have been nice if they'd broken it down by age strata so we could make a better comparison though.

So based on this US Census data the annualized death rate for those over 65 is just over 5% which puts the weekly death rate at around 0.1% so there is an absolute increase in death rate of about 0.02% . But when you realize that they excluded over half the patients because they were either over 90, had known life threatening comorbidities, or got admitted it starts to look like there might be a bigger difference. Also, if it was just a reflection of the baseline death rate you would expect the death rate at week 4 or 8 or 32 to be similar to week 1 but that was definitely not seen particularly in those hospitals with the lowest admit rate. They actually address all this in the next to last paragraph of their paper. Truth is being sick enough to go the ED almost certainly increases your risk for all sorts of bad things. See references 14,15,16 from their paper as well.

Being sick enough to bounce back to and ED is almost certainly worse!

 

[MSmentor018]

I love when Hospitalist/CM/Admin complains about weak admissions, then keep patient for 5 days. If its so weak, then sack up and d/c pt w/in 23 hrs...We had CM complain about a patient who got admitted and they could not kick out for 6 days...HELLO if you can't dispo them in 6 days, how am I supposed to dispo them in 120 minutes?

now that's a damn good question!

 

[engineeredout]

It's worth noting that you could have severe sepsis and a CURB-65 score of zero at the same time.

Thank you. Was getting pushback yesterday on the 45 YO 350lbs HTN/DM with BG 420 PNA I was trying to admit. Hospitalist asks why she needs to be admitted with a CURB65 of 0. I have to make it clear that with her HR of 130 after 3L IVF, spo2 of 91%, and the fact that at baseline she carries the weight of another human on her chest, I'm not sending her home on PO levaquin.

 

[MSmentor018]

Thank you. Was getting pushback yesterday on the 45 YO 350lbs HTN/DM with BG 420 PNA I was trying to admit. Hospitalist asks why she needs to be admitted with a CURB65 of 0. I have to make it clear that with her HR of 130 after 3L IVF, spo2 of 91%, and the fact that at baseline she carries the weight of another human on her chest, I'm not sending her home on PO levaquin.

tell him severe sepsis motherf@#$er !
I am 100% his dept chief doesn't want to answer to the cmo on why this person wasn't admitted
at my shop when these numbers pop up, even on an error a nurse magically appears and starts the damn clock on abx, lactic...etc. of course this is only 9a-5p. the hospitals all bought into this b/c it pays. 1/3 of the cmo salary are from bonuses like this so there's no way in hell they'll allow this person to go home. that's usually all i have to say when I get the "just give abx and go home" statements

 

[e30ftw]

Thank you. Was getting pushback yesterday on the 45 YO 350lbs HTN/DM with BG 420 PNA I was trying to admit. Hospitalist asks why she needs to be admitted with a CURB65 of 0. I have to make it clear that with her HR of 130 after 3L IVF, spo2 of 91%, and the fact that at baseline she carries the weight of another human on her chest, I'm not sending her home on PO levaquin.

Don't worry too much about this kind of stuff. It will continue post residency but hopefully less often. Your patient had multiple admission criteria and for the hospitalist this should be an easy admission. You could walk your patient, drop her sat to 88%, diagnose her with severe sepsis due to multi-organ dysfunction (hypoxia and tachycardia post resus), bill critical care time, and admit her for hypoxic respiratory failure.

Blood glucose > 350 also meets criteria for OBS status at least.

The most recent patient I got push back on was an 80 year old with multi-vessel CAD/CHF who syncopized. Patient wasn't comfortable going home and hospitalist didn't want to admit because his abnormal EKG was chronic and lytes/trop were non-acute. Had to explain risk factors for short term morbidity in patients with syncope in detail on the phone before she would admit the patient. It's like, 'dude for real, you are a hospitalist, this is what you do; you admit people to the hospital. This patient is old and obviously needs to come in, why are you even wasting energy arguing about this patient? Would you rather admit an NSTEMI in cardiogenic shock who is probably going to code in the middle of the night and take up 4 hours of your time trying to keep them alive? geeze just let me off the phone so I can go see the fifteen people who just signed in..'

It's not you, it's them.

 

[TrumpetDoc]

Don't worry too much about this kind of stuff. It will continue post residency but hopefully less often. Your patient had multiple admission criteria and for the hospitalist this should be an easy admission. You could walk your patient, drop her sat to 88%, diagnose her with severe sepsis due to multi-organ dysfunction (hypoxia and tachycardia post resus), bill critical care time, and admit her for hypoxic respiratory failure.

Blood glucose > 350 also meets criteria for OBS status at least.

The most recent patient I got push back on was an 80 year old with multi-vessel CAD/CHF who syncopized. Patient wasn't comfortable going home and hospitalist didn't want to admit because his abnormal EKG was chronic and lytes/trop were non-acute. Had to explain risk factors for short term morbidity in patients with syncope in detail on the phone before she would admit the patient. It's like, 'dude for real, you are a hospitalist, this is what you do; you admit people to the hospital. This patient is old and obviously needs to come in, why are you even wasting energy arguing about this patient? Would you rather admit an NSTEMI in cardiogenic shock who is probably going to code in the middle of the night and take up 4 hours of your time trying to keep them alive? geeze just let me off the phone so I can go see the fifteen people who just signed in..'

It's not you, it's them.

This stuff was a huge source of early burn out for me. I eventually landed in a place much different

I don't understand hospitals. There seems to be this desire to not admit people, when admits are what bring in $$. And then you hear the b!@&$ and moaning from the hospital how there short on $$???
CMS is a game plain and simple. Hospitals cannot be responsible for "saving the system" money and be expected to remain in the green!

 

[shoal007]

Don't worry too much about this kind of stuff. It will continue post residency but hopefully less often. Your patient had multiple admission criteria and for the hospitalist this should be an easy admission. You could walk your patient, drop her sat to 88%, diagnose her with severe sepsis due to multi-organ dysfunction (hypoxia and tachycardia post resus), bill critical care time, and admit her for hypoxic respiratory failure.

Blood glucose > 350 also meets criteria for OBS status at least.

The most recent patient I got push back on was an 80 year old with multi-vessel CAD/CHF who syncopized. Patient wasn't comfortable going home and hospitalist didn't want to admit because his abnormal EKG was chronic and lytes/trop were non-acute. Had to explain risk factors for short term morbidity in patients with syncope in detail on the phone before she would admit the patient. It's like, 'dude for real, you are a hospitalist, this is what you do; you admit people to the hospital. This patient is old and obviously needs to come in, why are you even wasting energy arguing about this patient? Would you rather admit an NSTEMI in cardiogenic shock who is probably going to code in the middle of the night and take up 4 hours of your time trying to keep them alive? geeze just let me off the phone so I can go see the fifteen people who just signed in..'

It's not you, it's them.

Same exact thing for me. Chf Ef 35% 90 yo M syncopized. Why r u admitting ? says the hospitalist. High risk of death according to San Fran rule, no AICD and patient and family wants to stay. The doc throws a big stink and finally agree to come and see the patient. He Argues with the family for 45 minutes then family still wants them admitted. He would have been done 30 minutes ago by doing the right thing and not piss me off, take up space and time in my ED and have higher patient satisfaction scores... why ohhh why


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[MSmentor018]

Same exact thing for me. Chf Ef 35% 90 yo M syncopized. Why r u admitting ? says the hospitalist. High risk of death according to San Fran rule, no AICD and patient and family wants to stay. The doc throws a big stink and finally agree to come and see the patient. He Argues with the family for 45 minutes then family still wants them admitted. He would have been done 30 minutes ago by doing the right thing and not piss me off, take up space and time in my ED and have higher patient satisfaction scores... why ohhh why


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there's an insurance program at my place in which the hospitalist get a bonus for the amt of pts he can keep out of the hospital. no arguements, he comes to the ER 24/7, sometimes order extra labs/meds. tunes them up then d/c home. downside, it sucks up the bed for a few hours. upside, it's not on my metric. sh#$$y thing to say but that's how I am using the metrics against them