High Risk Dispos?

[The Knife & Gun Club]

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For the more seasoned heads on here (or less seasoned and just better at this than me) - how do you all deal with patients who seem high risk but end up with a stone cold or minimal/nonspecific work up?

Just last night I had 2 cases where the patients were I felt decently high risk for badness but a thorough work up didn’t reveal anything worth acting on. Just felt like I was missing something the whole time but couldn’t figure out what, and finally ended up sending them home.

How did y’all go about figuring out which of these high-ish risk/negative work up people home? Any tricks you’ve picked up or resources you’ve come across?

Cases, for discussion…
Case 1: 84 year old male, ALL and prostate CA both in remission, s/p CABG, with generalized nonspecific weakness. Labs, ekg, trop, cxr, CTAP all normal. Nothing. Like the labs of a 30 year old. No pain. Can eat but says he “doesn’t feel like it.” Minimal improvement with fluids, zofran, Tylenol. Ended up sending him home after confirming he could get into see his PCP this week.

Case 2: 29 year old female with SOB and Chest pain on exertion, 16 weeks pregnant, normal vitals but tachys up to 130 without desatting when I walk her. Labs + EKG + Pocus of the heart, lungs, baby, Lower Ext WNL. Is that high risk for PE? Who’s to say, not a ton of evidence on 1st trimester PE that I could find quickly. Technically she Percs out. I dimered her but the attending stepped in and canceled it, sent her home after a L of fluids calling it dehydration.

 

[PianoMedic]

I’m in my first year out so others can chime in and likely give better thoughts than I can, but I’ll give my two cents fwiw:
Patients are often very ill at baseline. We are in the midst of a massive covid surge where I am, so I’ve had to literally change my standard practice on the fly. You just can’t admit these borderline people who “might” have something. I lean on several things: road test (watch them get up and walk, with pulse ox for resp complaints), po challenge, and a conversation about return precautions. For example: two neg trops, pain free with prior chest pain with decent story but nasty heart history of multi vessel cabg. I may touch base with the cardiologist, let them know I’m planning on discharge and can they try to work them in. Sometimes, they know the patient and know they wanted to cath them soon and that will change dispo, but more often they agree. And I document that I am recommending discharge and then document what they say. Learned tonight that 6 shocks from aicd for a fib Rvr in the 180s is 4 too many shocks. Looked great, patient felt a bit sore from the 6 shocks but otherwise felt great. EP recs admit on amio drip to try to keep in sinus as when pt went into a fib, it was always RVR. Totally changed my plan to discharge with increase in metoprolol dosing, had about 20 bpm to work with on HR. But that’s what I will call on these when I’m on the fence, they help me not f up and miss something critical or life threatening.

Recent case: middle age guy with epigastric/subxiphoid sharp chest pain that went into his belly intermittently. Prior laryngectomy, known metastatic lung cancer. Not better with his home tramadol. Going on for 4 hours. No diaphoresis, dyspnea, or nausea. I was in my solo coverage portion of the night, and we can get up to 10 patients to see in 2 hours pretty my easily. Rather than f around with a dimer, I just dissection scanned him, didn’t feel like missing that in this ticking time bomb. “Possible developing lieus or enteritis”. Had lots of distended bowel and lots of gas in the bowel lumen. Ask him about farting, couldn’t since pain started. Pain didn’t get better with morphine, gave 1 mg dilaudid. Pain down to a 1 from a 7. Po challenged him. Hadn’t been puking at all with this. Kept everything down, started farting. Sent him home with good return precautions. Might bounce back. But I can’t just watch him. Stress test unlikely to be fruitful with his story that is essentially noncardiac. I can’t get a stress in the next month outpatient here so if I think they need it, they have to be admitted.

Don’t know as I’ll ever be comfortable with these dispos but I get the patients input too, although I won’t follow it a decent amount of the time. Some people just want admitted no matter what and I have to tell them it isn’t a good idea. Being overrun with covid and scaring them with that has been helping lately. Shared decision making seems to help and gets the patient to buy into the plan. I try to do what is right for the patient, and I believe that people feel better sleeping and healing at home if they can do so safely.

 

[Zebra Hunter]

Welcome to EM, this will happen your entire career regardless of how seasoned you are. Just do the work up you can live with and helps you sleep at night and try to forget about it afterwards. Consider doing callbacks to those you are most nervous about.

 

[Dr Mantis Toboggan]

For the more seasoned heads on here (or less seasoned and just better at this than me) - how do you all deal with patients who seem high risk but end up with a stone cold or minimal/nonspecific work up?

Just last night I had 2 cases where the patients were I felt decently high risk for badness but a thorough work up didn’t reveal anything worth acting on. Just felt like I was missing something the whole time but couldn’t figure out what, and finally ended up sending them home.

How did y’all go about figuring out which of these high-ish risk/negative work up people home? Any tricks you’ve picked up or resources you’ve come across?

Cases, for discussion…
Case 1: 84 year old male, ALL and prostate CA both in remission, s/p CABG, with generalized nonspecific weakness. Labs, ekg, trop, cxr, CTAP all normal. Nothing. Like the labs of a 30 year old. No pain. Can eat but says he “doesn’t feel like it.” Minimal improvement with fluids, zofran, Tylenol. Ended up sending him home after confirming he could get into see his PCP this week.

Case 2: 29 year old female with SOB and Chest pain on exertion, 16 weeks pregnant, normal vitals but tachys up to 130 without desatting when I walk her. Labs + EKG + Pocus of the heart, lungs, baby, Lower Ext WNL. Is that high risk for PE? Who’s to say, not a ton of evidence on 1st trimester PE that I could find quickly. Technically she Percs out. I dimered her but the attending stepped in and canceled it, sent her home after a L of fluids calling it dehydration.

She doesn’t “PERC out” with a HR of 130…

 

[e30ftw]

You have to define "risk". If you mean "risk of 30-day mortality" vs "risk of malpractice judgement".

Case 1 is higher risk for 30d mortality but low risk medico-legally. This is bread and butter EM and typically these patients should go home unless they "can't walk" or "don't feel safe at home" etc. If the 82 year old goes home and dies the next day no one is going to sue you and tbh even if you hospitalized the patient it wouldn't have changed the outcome so you shouldn't even feel bad about it. If I'm moderately concerned about a bounce-back I just offer the patient observation if they "don't feel safe to go home" with the expectation that they're just going to sit in the hospital, the patient almost always declines admission and I document that I offered admission and pt feels safe at home and prefers discharge. Low risk discharge.

Case 2 is trickier. Every pregnant PE rule out should be approached individually. If patient 2 went home and died and the autopsy showed a PE it would likely result in a settlement >$1million so over typical policy limits. BTW 16 wks is second trimester just clarifying. The problem with that case is that the patient is having chest pain, you were concerned enough to order BLE ultrasounds, yet when the ultrasound did not show a potential cause of the chest pain, you stopped investigating. YEARS would say order ddimer but I generally consider ddimer useless in pregnancy. If you're going down the pathway of ruling out a PE that patient probably needs a CTA. Now here's the other side: it's probably very unlikely she had a PE. You could also discuss this with the pt, advise risks/benefits, discuss with her OB, document that everyone is on board to defer CTA, and discharge the patient. That's very "reasonable". The chart honestly would look better if you just hadn't ordered ultrasounds and documented that not having any clinical symptoms of DVT and presentation is not cw PE.

What probably happened with case 2 is your attending talked to the patient and was just like, "naw she doesn't have a PE" and just discharged her. Happens all the time and that's dependent on personal risk tolerance. Also just FYI PERC is not validated in pregnancy asfaik. The evidence for PE rule out in pregnancy is pretty weak all round imo so you just have to approach every case individually and document your decision making. Also sometimes the best option is to just say "no it's not a PE" and just order ekg/trop/cxr etc..

 

[Groove]

For high risk cases, it pays to document well. Take your time...maybe document that case last when you're wrapping up for the night or at home. Make sure your MDM is solid and the entire chart is as bullet proof as possible. If a lawyer ever gets a hold of it, they are going to dissect it with surgical precision. Every time in my career where I thought a case was high risk and took my time to document well, it always paid off. I've had cases result in complaints, suit, QA, PEER review, bounce back, death, you name it and I was always grateful for the solid documentation and it got me out of any trouble the vast majority of the time. My very first suit was early in my career and had terrible documentation which made the whole case much more difficult than it should have been.

Don't be afraid to work up PEs in pregnancy. I've found that most people tend to take the "see no evil, hear no evil, speak no evil" approach and become suddenly overconfident on their clinical gestalt to "rule out PE" in pregnancy. Most just don't want to CTA them or can find a million reasons not to obtain a dimer or do any imaging. If it's high on your differential, you need to rule it out or at least document why they didn't require any additional testing. You'll find that after discussing risks/benefits of radiation exposure to the pregnancy, a great deal of women will simply refuse the CTA/VQ or any further work up altogether. In which case documentation becomes very simple and you can honestly say you discussed risks/benefits including but not limited to death/perm disability/fetal harm/death and they refused.

I'm assuming you're doing COVID tests on some of these pt's? Your first guy sounds exactly like one of my pt's from last night, in which case he ended up being COVID + which explained the majority of his sx and simplified disposition.

Learn to listen to your gut. If you have serious reservations about sending someone home but are in a hurry and tempted to prematurely hit discharge. Stop, take a breather, re-assess or run the case by another doc.

That being said, early in your career, all cases seem high risk. Later on after you've accumulated more pattern recognition and developed a more well rounded clinical gestalt, your spidey sense will go off when you need to pay attention to a case/chart/note and spend extra time on documentation and/or management.

 

[carbonizedeyesockets]

I will use YEARS in pregnant patients (it now has external validation). Yes, dimer is often elevated at baseline, but the cutoff is 1000 unless signs of DVT is present. And as mentioned, careful documentation, shared decision making, etc is very important. I think bedside US can be very helpful as it can show normal RV function (measure a TAPSE if you know how - its actually not that hard), which will bolster your decision making. There is evidence that physician gestalt is as good as decision rules for PE, thus at times I will document that my suspicion for PE is "exceedingly low" as to not require further pursuit of the diagnosis.

 

[AlmostAnMD]

If it makes you feel any better, incidence of thrombotic disease in pregnancy is rare in the population, but especially so prior to third trimester/immediate post partum. This is the same reason you're likely to get laughed at when talking about pre-eclampsia prior to 20 weeks. I'm too lazy to look at data but from what I recall from OB you're looking for unicorns in second trimester unless they have comorbid conditions (factor V, etc).

 

[greatnt249]

I think bedside US can be very helpful as it can show normal RV function (measure a TAPSE if you know how - its actually not that hard), which will bolster your decision making.

Just as a word of caution, absence of RV dysfunction does not mean a PE has been ruled out.

 

[Kryptocoin]

I would send the pt in case 1 home. No question. That's bread and butter EM aka....elderly pts with weakness.

Case 2 is tricky and I hate those cases. Even our OB hate those cases. Logic goes out the window when a pregnant woman dies. I tend to pad the chart in those cases. Document I spoke with OB, document I recommended CTA to pt but pt refused, .........then I make them sign a refusal form. Documentation is not enough. They have to sign a refusal. A lawyer can shred your chart in a deposition but will be hard pressed to do so in a signed document by their client.

 

[The Knife & Gun Club]

That being said, early in your career, all cases seem high risk. Later on after you've accumulated more pattern recognition and developed a more well rounded clinical gestalt, your spidey sense will go off when you need to pay attention to a case/chart/note and spend extra time on documentation and/or management.

Yea I think this last part is where I really tend to get stuck. I see high risk where some of my attendings don’t.

I don’t mind having the attending see the person after me and change my plan, but it leaves me wondering how much of this is “it will come with time” and how much is “you’re bad at EM and need to read more/study more/suck less at life”

 

[Groove]

Yea I think this last part is where I really tend to get stuck. I see high risk where some of my attendings don’t.

I don’t mind having the attending see the person after me and change my plan, but it leaves me wondering how much of this is “it will come with time” and how much is “you’re bad at EM and need to read more/study more/suck less at life”

Well, at least your not on the wrong side of the Dunning Kruger curve. I'd much rather have a resident who's overly cautious than one who's overly confident.

Also, keep in mind that part of residency is observing all the different styles between your attendings and developing your own style. Some are minimalists, others are maximalists. I used to overwork patients earlier in my career but as time has progressed and I've seen thousands and thousands of patients, I am much more of a minimalist these days. Your management style will likely undergo it's own evolution throughout your career. There's nothing wrong with being cautious early on. I've got a super star PGY 3 resident who tends to overwork things a bit, but I usually just keep my mouth shut and let him do his thing placing greater value on him practicing autonomy in his last year versus me nit picking over his order set.

The dirty secret of EM residency is that for certain cases, you can line up 10 attendings and get 10 different management plans. Don't get bummed out if your management plan isn't identical to your attending. Residency is not about guessing what your attending wants to do, it's about developing logical emergency differentials and expediting a work up to determine whether any of those differentials exist and if not, implementing a responsible discharge plan.

 

[RustedFox]

Case 1 is higher risk for 30d mortality but low risk medico-legally. This is bread and butter EM and typically these patients should go home unless they "can't walk" or "don't feel safe at home" etc. If the 82 year old goes home and dies the next day no one is going to sue you and tbh even if you hospitalized the patient it wouldn't have changed the outcome so you shouldn't even feel bad about it.

Medical director buddy of mine was sued for an 84 year old who "died the next day" after being sent home with a stone cold negative workup.

I'm in a case right now about an 80 year old that I admitted and did everything right on.

It's really not so cut-and-dry.

 

[Mount Asclepius]

Medical director buddy of mine was sued for an 84 year old who "died the next day" after being sent home with a stone cold negative workup.

I'm in a case right now about an 80 year old that I admitted and did everything right on.

It's really not so cut-and-dry.

Moral of the story - 80 year olds like to die regardless if they are at home or in the hospital. Apparently no one gets out alive. It’s a game of hot potato. Don’t toss it, just cover it with chili, bacon and cheese joining the rest of America. You can practice as conservatively as you want, but if you can learn to sleep at night accepting some risk it will take you further.

 

[RustedFox]

Moral of the story - 80 year olds like to die regardless if they are at home or in the hospital. Apparently no one gets out alive. It’s a game of hot potato. Don’t toss it, just cover it with chili, bacon and cheese joining the rest of America. You can practice as conservatively as you want, but if you can learn to sleep at night accepting some risk it will take you further.

Oh, I agree.
In both cases; nothing... NOTHING was done incorrectly. But the lawsuits still came, and depositions were still taken, and settlements still happened (or will happen).

The expert witness in one of my cases was the Greek God of [Subspecialty], decreeing that no negligence occured.

Didn't matter.

 

[Zebra Hunter]

Medical director buddy of mine was sued for an 84 year old who "died the next day" after being sent home with a stone cold negative workup.

I'm in a case right now about an 80 year old that I admitted and did everything right on.

It's really not so cut-and-dry.

Real moral of the story…don’t work in f***ing Florida.

 

[RustedFox]

Real moral of the story…don’t work in f***ing Florida.

This.

 

[Janders]

For the first case… I like to just talk to the patient (and their likely present family). Explain that generally they are a priori high risk, but all our tests are really reassuring. Show that I care, have put effort in, and am not omniscient. Involve them. The great majority want to go home, and I’m agreeable. Shared decision making. Make sure they have a low threshold to come back.

You’ll get a feel for those that aren’t comfortable leaving, that have some type of social, psychological or physical secondary reason to be at the hospital.

One of those things that sitting and talking for 3-4 minutes can lift the fog and shine a light upon the right move.

 

[thegenius]

For the first case… I like to just talk to the patient (and their likely present family). Explain that generally they are a priori high risk, but all our tests are really reassuring. Show that I care, have put effort in, and am not omniscient. Involve them. The great majority want to go home, and I’m agreeable. Shared decision making. Make sure they have a low threshold to come back.

You’ll get a feel for those that aren’t comfortable leaving, that have some type of social, psychological or physical secondary reason to be at the hospital.

One of those things that sitting and talking for 3-4 minutes can lift the fog and shine a light upon the right move.

Well said and I totally agree.

 

[emergentmd]

For the more seasoned heads on here (or less seasoned and just better at this than me) - how do you all deal with patients who seem high risk but end up with a stone cold or minimal/nonspecific work up?

Just last night I had 2 cases where the patients were I felt decently high risk for badness but a thorough work up didn’t reveal anything worth acting on. Just felt like I was missing something the whole time but couldn’t figure out what, and finally ended up sending them home.

How did y’all go about figuring out which of these high-ish risk/negative work up people home? Any tricks you’ve picked up or resources you’ve come across?

Cases, for discussion…
Case 1: 84 year old male, ALL and prostate CA both in remission, s/p CABG, with generalized nonspecific weakness. Labs, ekg, trop, cxr, CTAP all normal. Nothing. Like the labs of a 30 year old. No pain. Can eat but says he “doesn’t feel like it.” Minimal improvement with fluids, zofran, Tylenol. Ended up sending him home after confirming he could get into see his PCP this week.

Case 2: 29 year old female with SOB and Chest pain on exertion, 16 weeks pregnant, normal vitals but tachys up to 130 without desatting when I walk her. Labs + EKG + Pocus of the heart, lungs, baby, Lower Ext WNL. Is that high risk for PE? Who’s to say, not a ton of evidence on 1st trimester PE that I could find quickly. Technically she Percs out. I dimered her but the attending stepped in and canceled it, sent her home after a L of fluids calling it dehydration.

I haven't read others responses so here it goes. My rule of thumb is to never leave a shift worrying about a pt that I discharged. That is the bottom line. I can confidently say that I may have a pt like this once a year.

This is my algorithm. Dispo time and still concerned about discharge. Will any other test make me feel better? Yes, then do it. No, then I let the pt decide. If pts wants to go home, then I chart that the pt understands the risks, offered admission but decided to go home TO FOLLOW UP WITH PCP TOMORROW. If they want to be admitted, then I call them in. If the hospitalist balks then I tell them they are consulted so they can make that decision. They never come in and just admit the pts typically as hospitalist just want less work. So coming in to consult vs calling in the admission then they will call it in.

#2 alitte tricky but call her OB doc and let them decide assuming pt is ok with going home. If pt has no OB doc, then talk to the on call OB doc. If on call OB wants to dc her, and pt ok with it, then I document this. If pt feels tooooo bad to go home, then I just call it severe dehydration, tachycardia, and admit. Who knows what this pt has but I am NOT sending a pt home who wants to be admitted and unexplained tachycardia with SOB/CP on exertion. Could be dehydration. Could be pericarditis, who knows.

Regardless, any pts that I am worried about decompensating gets admitted if they are not comfortable going home.

I have refined this in my 20 yrs of EM to the point that I almost never leave a shift worrying about a pt. Had 1 lawsuit in 20 yrs and was an ICU multiple comorbidity inpatient on multiple pressors that I was called for a code blue and happened to be the last doc to touch the pt. Never had an ER pt I discharge sue me.

From OJ, if I cant Commit, I must admit!!!!! Nothin wrong with admitting a concerning case.

 

[Tenk]

Always look at a chart’s chief complaint and vitals. Take a step back. If x seems completely plausible based on what you’re looking at, rule out x. Keep it simple. I’ve lost count how many times I thought I was stupid looking for x and it’s not only x, it’s x, y, z and the rest of the damn alphabet as well.

Medicine is dumb.

 

[Aesculapius]

Document, document, document your MDM. Ally with the patient and their families to make sure everyone is on the same page and in agreement. If you can get a PCP or a consultant involved to corroborate you, that helps too.

 

[Jabbed]

I’m curious what people’s approach to recurrent chest pain patients with HEART scores of 4-6 is. Are you discharging patients with negative stress tests in the past year if negative hs-troponin and normal EKG?

Major adverse cardiac events after emergency department evaluation of chest pain patients with advanced testing: Systematic review and meta-analysis - PubMed

 

[thegenius]

I’m curious what people’s approach to recurrent chest pain patients with HEART scores of 4-6 is. Are you discharging patients with negative stress tests in the past year if negative hs-troponin and normal EKG?

Major adverse cardiac events after emergency department evaluation of chest pain patients with advanced testing: Systematic review and meta-analysis - PubMed

Honestly...if they don't have a super concerning story and have a normal or unchanged EKG, and a few negative troponins it's actually safe to send these patients home. Even with a HEART score of 4-6. 6 might be hard to do...but the Kaiser study showed the rate of adverse events 30 days after discharge with a HEART of 4 is < 1%. They do have to meet certain criteria though...namely having no chest pain in the ED. It's hard to discharge a HEART score of >= 5 if they have ongoing chest pain despite a normal EKG and negative trops...and even then after they are admitted it's basically never an MI.

High sensitivity trops are great if they are negative!

The caveat is you have to be good at reading EKGs and even subtle changes can indicate ongoing ischemia.

 

[thegenius]

The fact is we admit way too much chest pain, I think ER docs gestalt for those who need to be admitted vs not is probably pretty good (although I have no proof), and we are trying to find a way to not admit as much and have appropriate legal protection.

Another fact is that there will always be a douchebag ER doc who would testify that says they would have admitted that same patient. I hate ER docs who testify against other ER docs.

 

[deleted239798]

I’m curious what people’s approach to recurrent chest pain patients with HEART scores of 4-6 is. Are you discharging patients with negative stress tests in the past year if negative hs-troponin and normal EKG?

Major adverse cardiac events after emergency department evaluation of chest pain patients with advanced testing: Systematic review and meta-analysis - PubMed

With a recent cards note saying nothing to do and a recent negative stress I will discharge and document the heck out of it. Otherwise I admit. Anecdotally, my colleagues who have been sued usually have the same story of trying to send the low risk chest pain, or the low risk TIA home and being burned by it. Fact is, there patients with unstable angina are hot potatoes and someone is going to be left holding the bag, and there is definitely another ED doc who will gleefully testify that they had a HEART score of 5 and cash their expert fee. I see little to be gained by the minimalist approach. I am a relatively new attending so I will probably become a little more cavalier with time, but anecdotally, my colleagues who have been sued have similar stories of trying to do the right thing by sending a low risk person home and later being burned. Sad fact is, our healthcare system offers no recognition to the guy who effectively allocates admissions and CT scans. Instead, the person who scans and admits everything avoids the suit while the person who is judicious with resource allocation gets screwed by the 1% bad outcome. Specifically for HEART score of 5 who has just been discharged for the umpteenth time, I will write a long MDM that carefully explains my rationale for the dc and get a delta trop. But every moderate risk HEART score deserves a few admissions a year, but probably not admission every month.

 

[thegenius]

With a recent cards note saying nothing to do and a recent negative stress I will discharge and document the heck out of it. Otherwise I admit. Anecdotally, my colleagues who have been sued usually have the same story of trying to send the low risk chest pain, or the low risk TIA home and being burned by it. Fact is, there patients with unstable angina are hot potatoes and someone is going to be left holding the bag, and there is definitely another ED doc who will gleefully testify that they had a HEART score of 5 and cash their expert fee. I see little to be gained by the minimalist approach. I am a relatively new attending so I will probably become a little more cavalier with time, but anecdotally, my colleagues who have been sued have similar stories of trying to do the right thing by sending a low risk person home and later being burned. Sad fact is, our healthcare system offers no recognition to the guy who effectively allocates admissions and CT scans. Instead, the person who scans and admits everything avoids the suit while the person who is judicious with resource allocation gets screwed by the 1% bad outcome. Specifically for HEART score of 5 who has just been discharged for the umpteenth time, I will write a long MDM that carefully explains my rationale for the dc and get a delta trop. But every moderate risk HEART score deserves a few admissions a year, but probably not admission every month.

That's fine. Just remember that when you are sued...you will probably have done everything right and still lose.

Honestly I try to do what is best for the patient. It matters not if you send them home, admit them, get 1 EKG, get 3 EKGs, get 5 high sensitivity troponins, rule out PE, rule out dissection, write 1 paragraph, write 3 paragraphs, call one cardiologist, call 5 consults. You can even admit to the ICU. It doesn't matter.

If there is a bad outcome, doctors will get sued. Regardless if everything is done properly.

It just doesn't make sense to admit these patients who have a less than 1% chance of having a MACE in 30 days. There are so many unintended consequences with this...and namely it clogs the hospital which therefore clogs up the ER and everybody suffers. Maybe you would have had an ER room for the next guy coming in with CP, but you don't because the ER is filled with boarders waiting to get their stress tests...and then the guy in the ER waiting room codes. Then you get sued. What's your defense then? I've admitted all these low risk chest pain patients who are boarding in the ER and that's why there wasn't room?

 

[deleted239798]

That's fine. Just remember that when you are sued...you will probably have done everything right and still lose.

Honestly I try to do what is best for the patient. It matters not if you send them home, admit them, get 1 EKG, get 3 EKGs, get 5 high sensitivity troponins, rule out PE, rule out dissection, write 1 paragraph, write 3 paragraphs, call one cardiologist, call 5 consults. You can even admit to the ICU. It doesn't matter.

If there is a bad outcome, doctors will get sued. Regardless if everything is done properly.

It just doesn't make sense to admit these patients who have a less than 1% chance of having a MACE in 30 days. There are so many unintended consequences with this...and namely it clogs the hospital which therefore clogs up the ER and everybody suffers. Maybe you would have had an ER room for the next guy coming in with CP, but you don't because the ER is filled with boarders waiting to get their stress tests...and then the guy in the ER waiting room codes. Then you get sued. What's your defense then? I've admitted all these low risk chest pain patients who are boarding in the ER and that's why there

That's fine. Just remember that when you are sued...you will probably have done everything right and still lose.

Honestly I try to do what is best for the patient. It matters not if you send them home, admit them, get 1 EKG, get 3 EKGs, get 5 high sensitivity troponins, rule out PE, rule out dissection, write 1 paragraph, write 3 paragraphs, call one cardiologist, call 5 consults. You can even admit to the ICU. It doesn't matter.

If there is a bad outcome, doctors will get sued. Regardless if everything is done properly.

It just doesn't make sense to admit these patients who have a less than 1% chance of having a MACE in 30 days. There are so many unintended consequences with this...and namely it clogs the hospital which therefore clogs up the ER and everybody suffers. Maybe you would have had an ER room for the next guy coming in with CP, but you don't because the ER is filled with boarders waiting to get their stress tests...and then the guy in the ER waiting room codes. Then you get sued. What's your defense then? I've admitted all these low risk chest pain patients who are boarding in the ER and that's why there wasn't room?

I guess it comes down to how you define low risk. No I won’t admit a HEART score of 3 and below. 4-6 is by definition not low risk if you’re using it to stratify. 4 is generally a soft admit barring other factors and can be a 3 if you want it to. I’m talking about not being cavalier with the people with a 5 who may have had a negative work up a few months ago (a few weeks or 1 month ago is a different story). I think admitting these people is still standard of care, even if their risk of MACE is low. I try not to admit the chronic unstable angina people who cards has said nothing to do for. I think an important question is what the utility of a negative stress from 6 months, a year, 2 years, etc is. I know the data is conflicting on that.

 

[thegenius]

There was a graph posted here about a year ago about the actual outcomes from that Kaiser study. I think I posted it but I don't know how to find it. It's quite interesting that it's really the 7, 8, and 9 people who really are at risk. Like 5-10%.

Lemme see if I can find it.

EDIT:
Here it is. Chest Pain (to D/c or not to D/c)

HEART 1 = 0.16%
HEART 2 = 0.20%
HEART 3 = 0.31%
HEART 4 = 0.66%
HEART 5 = 1.09%
HEART 6 = 1.82%
HEART 7 = 2.45%
HEART 8 = 3.77%
HEART 9 = 8.70%
HEART 10 = 11.11%

So you can define risk anyway you want. This notion that someone is "Low Risk" between 1-3 and "Medium Risk" between 4-6 is just nonsense. What is the difference between 0.31% and 0.66%? Nothing. Nada. Even a heart score of 6 is only a 1.82% for 30 day MACE.

Moreover...the 30 day DEATH or AMI for the high risk group is 3%!!! That's it! For intermediate risk it's 1%. These numbers are very small.

Now granted...we see 3-5 chest pain's per shift, but we don't see 3-5 intermediate or high risk chest pain's per shift.

What I find interesting is that when I make a shared decision about these "low" to "medium" risk chest pain patients about admission vs. discharge...I'd say 80% want to be discharged. Makes my life a little easier.

 

[Groove]

There was a graph posted here about a year ago about the actual outcomes from that Kaiser study. I think I posted it but I don't know how to find it. It's quite interesting that it's really the 7, 8, and 9 people who really are at risk. Like 5-10%.

Lemme see if I can find it.

EDIT:
Here it is. Chest Pain (to D/c or not to D/c)

HEART 1 = 0.16%
HEART 2 = 0.20%
HEART 3 = 0.31%
HEART 4 = 0.66%
HEART 5 = 1.09%
HEART 6 = 1.82%
HEART 7 = 2.45%
HEART 8 = 3.77%
HEART 9 = 8.70%
HEART 10 = 11.11%

So you can define risk anyway you want. This notion that someone is "Low Risk" between 1-3 and "Medium Risk" between 4-6 is just nonsense. What is the difference between 0.31% and 0.66%? Nothing. Nada. Even a heart score of 6 is only a 1.82% for 30 day MACE.

Moreover...the 30 day DEATH or AMI for the high risk group is 3%!!! That's it! For intermediate risk it's 1%. These numbers are very small.

Now granted...we see 3-5 chest pain's per shift, but we don't see 3-5 intermediate or high risk chest pain's per shift.

What I find interesting is that when I make a shared decision about these "low" to "medium" risk chest pain patients about admission vs. discharge...I'd say 80% want to be discharged. Makes my life a little easier.

I practice very similar. I used to admit all of these early in my career before experience and comfort level improved. Nowadays, I do shared decision making for the moderate risk atypicals who I am offering the ability to go home. I have a little speech and technically offer/recommend admission but kind of encourage them if they want to go home. Most do. I document a solid smartphrase about discussed risks/benefits, risks including but not limited to X,Y,Z, etc... pt verbalized understanding, demonstrated medical decision making capacity, etc.. yada yada and I cut them lose.

The funny thing is that FM docs do this kind of stuff all the time. We all think they are sending out 100% of their chest pain to the ED but they aren't. They get an EKG, they schedule a stress test in 3-4 days for the pt and if needed, schedule them with a f/u cardiology appointment. Occasionally, they get a STEMI in the office which they will transfer or something that sounds like unstable angina. If they get someone that sounds like a PE but is stable? They schedule a stat PE study that afternoon at an imaging center. The docs my SO (NP) works with absolutely hate sending pt's to the ED and will avoid it at all costs. It was actually very difficulty for her to get on board with that culture because she came from the world of EM where everything needs an immediate work up with a gazillion rule outs and that's just not how the real world works in outpatient medicine.

 

[turkeyjerky]

I guess it comes down to how you define low risk. No I won’t admit a HEART score of 3 and below. 4-6 is by definition not low risk if you’re using it to stratify. 4 is generally a soft admit barring other factors and can be a 3 if you want it to. I’m talking about not being cavalier with the people with a 5 who may have had a negative work up a few months ago (a few weeks or 1 month ago is a different story). I think admitting these people is still standard of care, even if their risk of MACE is low. I try not to admit the chronic unstable angina people who cards has said nothing to do for. I think an important question is what the utility of a negative stress from 6 months, a year, 2 years, etc is. I know the data is conflicting on that.

Yet, those are the patients who are most likely to benefit from being admitted. As I like to remind the hospitalist all the time, we're not admitting for workup (can be done as an outpatient) or therapy (not necessarily needed), but for monitoring. Chronic, or recurrent, noncardiac chest pain, even in a patient with CAD or r/f's for such, won't benefit from being admitted. The problem with shared decision making in these folks is that there's often something else going on that's driving their presentation to the ER, so they typically want to come in. Recently, I've been using the ED-ACS score more often than the HEART, as it allows for a little bit more fine-tuning.

 

[deleted239798]

Yet, those are the patients who are most likely to benefit from being admitted. As I like to remind the hospitalist all the time, we're not admitting for workup (can be done as an outpatient) or therapy (not necessarily needed), but for monitoring. Chronic, or recurrent, noncardiac chest pain, even in a patient with CAD or r/f's for such, won't benefit from being admitted. The problem with shared decision making in these folks is that there's often something else going on that's driving their presentation to the ER, so they typically want to come in. Recently, I've been using the ED-ACS score more often than the HEART, as it allows for a little bit more fine-tuning.

So you admit these people every time? Every place I've been there are the same 10 patients who have known cardiac disease who come in biweekly. Some docs get delta trops and dc, others admit them every single time. If the cardiologist wrote that there's not going to be any intervention I fail to see the utility in constantly bringing them in. For what? In case they just happen to go into v-tach or have a STEMI while they are on the monitor before the hospitalist discharges them in the morning? Honest question, maybe I should admit them.

And the Kaiser study seems to have a much lower MACE than what is reported in other validations of the HEART score. I think a 1% miss rate is a pretty standard cutoff, which corresponds to a HEART score of 5 and above being admitted, which is generally my practice pattern.

 

[WilcoWorld]

I like to just talk to the patient (and their likely present family). Explain that generally they are a priori high risk, but all our tests are really reassuring. Show that I care, have put effort in, and am not omniscient. Involve them. The great majority want to go home, and I’m agreeable. Shared decision making. Make sure they have a low threshold to come back.

You’ll get a feel for those that aren’t comfortable leaving, that have some type of social, psychological or physical secondary reason to be at the hospital.

One of those things that sitting and talking for 3-4 minutes can lift the fog and shine a light upon the right move.

This is my strategy - collaborate with the patient to share the risk.

 

[DocEspana]

Oh, I agree.
In both cases; nothing... NOTHING was done incorrectly. But the lawsuits still came, and depositions were still taken, and settlements still happened (or will happen).

The expert witness in one of my cases was the Greek God of [Subspecialty], decreeing that no negligence occured.

Didn't matter.

Real moral of the story…don’t work in f***ing Florida.

Ive dodged any suits so far (5+ years strong as an attending!) but i already had a case go to peer review and x y and z with risk management (and everyone except for my hospital CMO, more on that in a second) stating I did zero wrong. Literally had a patient *abscond* from the ED having an NSTEMI and I documented that I believed they were having one - they left before testing. I called the patient to come back. Got the whole family on the phone to make sure they forced the patient back. The patient DID come back. Got admitted. Survived 2 days upstairs and died due to a mistake made by the inpatient team. A freak chance death, but still one directly due to inpatient team (over)intervention.

But I get dragged before the review committee and a million meetings. Why? The only thing the family remembers is that the patient who died really liked the inpatient team, but complained that the ER doctor was heartless and refused to give their parent the ativan and percocet refill that they initially came in for and that *this* was what made her sprint out of the ED. Yup, initial chief complaint was medication refill of 2 narcotics.

Turns out they told the hospital they intended to sue me, and only me, and the hospital was desperate to find a way to pin it on me. Upon finding no reasonable way to do so, they just asked me to leave. Literally. Just told me quite openly that they would do everything in their contractual power to make me continuing to work there difficult because they wanted this **** up by a different department to go away and they knew if I didn't 'go away' the family would come after more than just me and the hospital would get caught up in it.

lesson here: you can't avoid this ****. You can literally go above and beyond and someone ELSE can **** up and you can still take the fall. "Its all business and the bottom line" as my old director told me as he got me interviews everywhere else in town to soften the blow. find a way of practicing that makes you comfortable and just dont do boneheaded things. None of my actual errors have *ever* come back to haunt me in 5 years (thankfully), yet every problem case has been one where I did nothing wrong but freak chance events happened or someone had very bizarre optics on how "perfect" could be better.

 

[turkeyjerky]

So you admit these people every time? Every place I've been there are the same 10 patients who have known cardiac disease who come in biweekly. Some docs get delta trops and dc, others admit them every single time. If the cardiologist wrote that there's not going to be any intervention I fail to see the utility in constantly bringing them in. For what? In case they just happen to go into v-tach or have a STEMI while they are on the monitor before the hospitalist discharges them in the morning? Honest question, maybe I should admit them.

And the Kaiser study seems to have a much lower MACE than what is reported in other validations of the HEART score. I think a 1% miss rate is a pretty standard cutoff, which corresponds to a HEART score of 5 and above being admitted, which is generally my practice pattern.

I don't think we're communicating properly. Based on your above posts, I'd reckon that you admit more chest pain patients than I do. However, cards isn't infallible, two examples from my personal experience:
1) 50ish year old guy w/ h/o CAD comes in w/ concerning but not classic intermittent chest pain overnight. Initial trop negative, repeat slightly bumped. Same day stress negative and pt is discharged (w/o further trending trop). Dies the next night. In hindsight, the EKG did show some subtle signs of anterior ischemia that had gone unrecognized by all involved (including the med-mal expert called by the plaintiff's attorneys).
2) 80ish year old guy comes in for recurrent exertional chest pain 1-2 days after being discharged for the same. Stress during that stay was abnormal, but no angio performed b/c of patient's age and comorbities. Trop/ekg negative. Hospitalist refuses the admission from the resident "b/c it cards isn't going to do anything". I have to repage the Hospitalist and he kindly accepts after I review the pertinent facts of the case with him.

 

[Jabbed]

I’m glad that there’s such diversity in opinion on this. In my shop we cover the obs unit and I still routinely see 30 year olds with low HEART scores getting admitted. My current practice is now closer to @thegenius though and I’ll reference recent stress testing and anatomical imaging and prior cards recs in my MDM and discharge moderate risk patients.

I do find it interesting though that despite all these changes in risk stratification and expedited testing the overall rate of missed MIs has not changed appreciably over the past 20 years (~2%).

 

[thegenius]

Ive dodged any suits so far (5+ years strong as an attending!) but i already had a case go to peer review and x y and z with risk management (and everyone except for my hospital CMO, more on that in a second) stating I did zero wrong. Literally had a patient *abscond* from the ED having an NSTEMI and I documented that I believed they were having one - they left before testing. I called the patient to come back. Got the whole family on the phone to make sure they forced the patient back. The patient DID come back. Got admitted. Survived 2 days upstairs and died due to a mistake made by the inpatient team. A freak chance death, but still one directly due to inpatient team (over)intervention.

But I get dragged before the review committee and a million meetings. Why? The only thing the family remembers is that the patient who died really liked the inpatient team, but complained that the ER doctor was heartless and refused to give their parent the ativan and percocet refill that they initially came in for and that *this* was what made her sprint out of the ED. Yup, initial chief complaint was medication refill of 2 narcotics.

Turns out they told the hospital they intended to sue me, and only me, and the hospital was desperate to find a way to pin it on me. Upon finding no reasonable way to do so, they just asked me to leave. Literally. Just told me quite openly that they would do everything in their contractual power to make me continuing to work there difficult because they wanted this **** up by a different department to go away and they knew if I didn't 'go away' the family would come after more than just me and the hospital would get caught up in it.

lesson here: you can't avoid this ****. You can literally go above and beyond and someone ELSE can **** up and you can still take the fall. "Its all business and the bottom line" as my old director told me as he got me interviews everywhere else in town to soften the blow. find a way of practicing that makes you comfortable and just dont do boneheaded things. None of my actual errors have *ever* come back to haunt me in 5 years (thankfully), yet every problem case has been one where I did nothing wrong but freak chance events happened or someone had very bizarre optics on how "perfect" could be better.

This is so sad

 

[Apollyon]

In hindsight, the EKG did show some subtle signs of anterior ischemia that had gone unrecognized by all involved (including the med-mal expert called by the plaintiff's attorneys).

If no one saw it, then, who DID? I mean, if the hired gun expert didn't see it, how can you say it was there?

 

[thegenius]

And the Kaiser study seems to have a much lower MACE than what is reported in other validations of the HEART score. I think a 1% miss rate is a pretty standard cutoff, which corresponds to a HEART score of 5 and above being admitted, which is generally my practice pattern.

I think the Kaiser study is more real world than other validations of HEART....Kaiser used 30,000 pts and their data, I suspect, regressed more to the mean than other validations.

But just a few things:
- If 1% is your cutoff, thats fine. I'm not going to argue that. On some level we all practice by having a "cutoff" for whatever disease we are managing. I do the same thing for lots of diseases. Just note that there really isn't any clinically meaningful difference between HEART 5 (1.1%) and HEART 6 (1.8%). So one guy gets admitted and one guy doesn't. This is just statistics BTW.

- I do think one criticism of the Kaiser study is the mean age in their groups...Kaiser pts tend to skew younger. But I don't have that data in front of me. Might be part of that link though.

- It's remarkable how nice the curve is though...that's what happens when you have 30,000 people enrolled. And the data makes conceptual sense.

 

[thegenius]

If no one saw it, then, who DID? I mean, if the hired gun expert didn't see it, how can you say it was there?

Shh: It didn't really happen.

If a tree lands on a squirrel in the forest and kills it, but nobody witnessed it, did the squirrel make a noise?

 

[Apollyon]

Shh: It didn't really happen.

If a tree lands on a squirrel in the forest and kills it, but nobody witnessed it, did the squirrel make a noise?

Reminds me of a joke: in the woods, bear sees a rabbit, and asks it, "Rabbit, does your poo stick to your fur after you go?" Rabbit says, "Nope, no problem with that!" So, the bear picks up the rabbit, and wipes his butt with it!

 

[thegenius]

I’m glad that there’s such diversity in opinion on this. In my shop we cover the obs unit and I still routinely see 30 year olds with low HEART scores getting admitted. My current practice is now closer to @thegenius though and I’ll reference recent stress testing and anatomical imaging and prior cards recs in my MDM and discharge moderate risk patients.

I do find it interesting though that despite all these changes in risk stratification and expedited testing the overall rate of missed MIs has not changed appreciably over the past 20 years (~2%).

I would clarify the following. When I trained in 2010-2014....we were taught that the rate of 30 day MACE in LOW RISK GROUPS was ~2% (maybe my training sucked?). It's actually more like 0.5%. It's the high risk groups with HEART 7-10 that has a MACE of 3%. And I doubt nobody is discharging high risk groups.

 

[turkeyjerky]

If no one saw it, then, who DID? I mean, if the hired gun expert didn't see it, how can you say it was there?

Sorry, should have specified. I noticed it at the dep. The defense attorneys were like, ‘ugh, keep that on the down-low if you end up getting called”. I wasn’t named, they only went after cards, who ended up prevailing (which I was very happy about since he’s a genuinely good guy).

 

[RustedFox]

Ive dodged any suits so far (5+ years strong as an attending!) but i already had a case go to peer review and x y and z with risk management (and everyone except for my hospital CMO, more on that in a second) stating I did zero wrong. Literally had a patient *abscond* from the ED having an NSTEMI and I documented that I believed they were having one - they left before testing. I called the patient to come back. Got the whole family on the phone to make sure they forced the patient back. The patient DID come back. Got admitted. Survived 2 days upstairs and died due to a mistake made by the inpatient team. A freak chance death, but still one directly due to inpatient team (over)intervention.

But I get dragged before the review committee and a million meetings. Why? The only thing the family remembers is that the patient who died really liked the inpatient team, but complained that the ER doctor was heartless and refused to give their parent the ativan and percocet refill that they initially came in for and that *this* was what made her sprint out of the ED. Yup, initial chief complaint was medication refill of 2 narcotics.

Turns out they told the hospital they intended to sue me, and only me, and the hospital was desperate to find a way to pin it on me. Upon finding no reasonable way to do so, they just asked me to leave. Literally. Just told me quite openly that they would do everything in their contractual power to make me continuing to work there difficult because they wanted this **** up by a different department to go away and they knew if I didn't 'go away' the family would come after more than just me and the hospital would get caught up in it.

lesson here: you can't avoid this ****. You can literally go above and beyond and someone ELSE can **** up and you can still take the fall. "Its all business and the bottom line" as my old director told me as he got me interviews everywhere else in town to soften the blow. find a way of practicing that makes you comfortable and just dont do boneheaded things. None of my actual errors have *ever* come back to haunt me in 5 years (thankfully), yet every problem case has been one where I did nothing wrong but freak chance events happened or someone had very bizarre optics on how "perfect" could be better.

Wait. Until. You. Hear. About. My. Last. Lawsuit.

It's in the "settlement" phase right now.

It is stupidity, squared. Remember that I said that. Stupidity raised to the second power.

 

[WildEMDoc]

Here’s a question that I’ve been struggling with. I’m a few years out of residency right now, and with the shift to HS trops at my sites has really had me dealing with lots of positive troponins signed out to me by older docs who seem to order them almost indiscriminately.

Pre-pandemic it would be easy enough to admit them for observation and trending but now I often don’t have beds at 2 of my sites with my 3rd site (regional referral center) being closed to transfers from OSHs.

For example, we’ll say COVID(+) in the ED for basically feeling sick with nausea. 65yo with moderate risk factors and Hx of CAD, no true angina symptoms. HS trop of 80 with a repeat that is stable. Felt better after meds and wanted to go home. My choice is often either call 10+ hospitals to find a bed and hope an EMS crew is available or discharge.

I feel like these high sensitivity trops are good when ordered in chest pain patients but what to do with these arguable inappropriately ordered ones has been bothering me recently.

 

[DocEspana]

Wait. Until. You. Hear. About. My. Last. Lawsuit.

It's in the "settlement" phase right now.

It is stupidity, squared. Remember that I said that. Stupidity raised to the second power.

not sure which "reaction" I wanted to use. considered thumbs up, the frown, the angry face, and the thinker.

I think "care" was the most appropriate one. Because I know that feel oh so well. and somehow I know you'll top mine.

 

[RustedFox]

Here’s a question that I’ve been struggling with. I’m a few years out of residency right now, and with the shift to HS trops at my sites has really had me dealing with lots of positive troponins signed out to me by older docs who seem to order them almost indiscriminately.

Pre-pandemic it would be easy enough to admit them for observation and trending but now I often don’t have beds at 2 of my sites with my 3rd site (regional referral center) being closed to transfers from OSHs.

For example, we’ll say COVID(+) in the ED for basically feeling sick with nausea. 65yo with moderate risk factors and Hx of CAD, no true angina symptoms. HS trop of 80 with a repeat that is stable. Felt better after meds and wanted to go home. My choice is often either call 10+ hospitals to find a bed and hope an EMS crew is available or discharge.

I feel like these high sensitivity trops are good when ordered in chest pain patients but what to do with these arguable inappropriately ordered ones has been bothering me recently.

What's worse is that these new HS trops near always fall in the "indeterminate" range in anyone with 1 comorbidity, and the flowsheet/guidance that we get from HCA has an insanely low cut-off for "rule out". Thus, it can be argued that sending someone home with trops of 32 and 36 is deviating from the recommendations.

 

[RustedFox]

not sure which "reaction" I wanted to use. considered thumbs up, the frown, the angry face, and the thinker.

I think "care" was the most appropriate one. Because I know that feel oh so well. and somehow I know you'll top mine.

Just fugging wait.

What I will say in a few weeks is reason enough, alone, to give up on society.

 

[turkeyjerky]

Here’s a question that I’ve been struggling with. I’m a few years out of residency right now, and with the shift to HS trops at my sites has really had me dealing with lots of positive troponins signed out to me by older docs who seem to order them almost indiscriminately.

Pre-pandemic it would be easy enough to admit them for observation and trending but now I often don’t have beds at 2 of my sites with my 3rd site (regional referral center) being closed to transfers from OSHs.

For example, we’ll say COVID(+) in the ED for basically feeling sick with nausea. 65yo with moderate risk factors and Hx of CAD, no true angina symptoms. HS trop of 80 with a repeat that is stable. Felt better after meds and wanted to go home. My choice is often either call 10+ hospitals to find a bed and hope an EMS crew is available or discharge.

I feel like these high sensitivity trops are good when ordered in chest pain patients but what to do with these arguable inappropriately ordered ones has been bothering me recently.

Yeah, widespread problem. Ironic how a new technology gets instituted, ostensably for improved patient flow, and leads to the exact opposite.

Personally, I think you're fine if you document that presentation was non-cardiac in nature, HS-trops were ordered for unclear reasons and are stable w/o a trend to suggest ACS or an absolute level concerning for Type II MI. On an insituitonal level, this should get dealt with by department leadership to disencourage people from indiscriminate ordering.

 

[GassYous]

Here’s a question that I’ve been struggling with. I’m a few years out of residency right now, and with the shift to HS trops at my sites has really had me dealing with lots of positive troponins signed out to me by older docs who seem to order them almost indiscriminately.

Pre-pandemic it would be easy enough to admit them for observation and trending but now I often don’t have beds at 2 of my sites with my 3rd site (regional referral center) being closed to transfers from OSHs.

For example, we’ll say COVID(+) in the ED for basically feeling sick with nausea. 65yo with moderate risk factors and Hx of CAD, no true angina symptoms. HS trop of 80 with a repeat that is stable. Felt better after meds and wanted to go home. My choice is often either call 10+ hospitals to find a bed and hope an EMS crew is available or discharge.

I feel like these high sensitivity trops are good when ordered in chest pain patients but what to do with these arguable inappropriately ordered ones has been bothering me recently.

Order a few more trops and then sign it back out to them when they come back