Kicking Patients Out

[Snelgrave]

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Any advice on the best way to convince a patient to leave who adamantly believes something is wrong, but there is no objective evidence that dangerous pathology exists? I am not talking about the drug seekers or abusive patients, but the ones with non-specific complaints and negative workups (often with softer psych issues like depression).

Please don't just say "call security." I am looking a better script to get their a** out the door with less headaches and potentially less nasty letters.

 

[Hamhock]

Give them discharge papers.

I am only partially kidding.

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Give them a parting gift. A perscription. A referral. Extra concern/re-assurance.

I always give a parting gift and discharge papers and I haven't ever been faced with the situation you are asking about.

HH

Also, just ask them what they want...how they can be reassured.

 

[SoCuteMD]

Sometimes I just ask them what they hoped to accomplish by coming to the ER or, if they are pushing for admission, what they hope they will accomplish in the hospital. Then, you can often explain to them why that's not a reasonable plan, the risk of being in the hospital - mainly infection - etc.

 

[docB]

Agree with Socute, I frequently ask what they were hoping for.

I tell them that we looked and didn't find any evidence of anything dangerous so I'm going to get them referred to the proper doctor to follow up with. I also set the tone for this by saying at the beginning "We will do some testing right here in the ER to check for anything life threatening or dangerous."

When I frame the visit in terms of looking for problems that are "life threatening, dangerous or emergent" some will chuckle or gasp and say "Well I should hope not!" That opens them up for education along the lines of "Well that's why you come to the EMERGENCY Room or call an ambulance, right?"

When it's time to go I repeat these phrases with some others thrown in (e.g. "we didn't find anything that needs a surgery to fix.") and that usually gets them going. If it doesn't work it puts the ball in their court and they will often start adding to the history. I've had many who get to the end of a big work up (often for belly pain) and when I lay it out they then say how they've seen a dozen doctors for the same thing and no one has found the answer. I then document that and it makes me more sure there is not an emergent issue.

Anther strategy is to punt. Figure out which doctor they want to see and call them. I'll tell that doc "I've got your patient here and I think they can go home but they want to be admitted and have you see them." 9 times out of 10 they tell me to discharge the patient and they'll see them in the office. I then tell the patient I discussed their case with Dr. Whoever and they want to see them in the office.

 

[EctopicFetus]

As above.. I tell them we look for emergent conditions. We didnt find any today. I tell them how happy I am we didnt and make up some horrific possible outcome. Then I tell then I will refer them to a specialist and that person can help figure out whats going on and those guys are SOOOO much better at it than me. I have never had one refuse to leave.

 

[iridesingltrack]

I often find that setting expectations early helps. For pts with vague complaints, multiple work ups in the past etc I generally start with saying: "I am going to check for some low-hanging fruit to explain what you are experiencing; however, I suspect that this will be normal and we will still not have an answer. If this happens, you will need to follow up with your primary doctor who has access to more tools and time to work you up. In the ED I only have so many tools at my disposal." Most people get this.

If that fails, then I just discharge them and tell them flatly that we are done.

These are the most disatisfying patient encounters for me.

iride

 

[EM2BE]

I often find that setting expectations early helps. For pts with vague complaints, multiple work ups in the past etc I generally start with saying: "I am going to check for some low-hanging fruit to explain what you are experiencing; however, I suspect that this will be normal and we will still not have an answer. If this happens, you will need to follow up with your primary doctor who has access to more tools and time to work you up. In the ED I only have so many tools at my disposal." Most people get this.

If that fails, then I just discharge them and tell them flatly that we are done.

These are the most disatisfying patient encounters for me.

iride

I have a similar approach, especially if I don't expect to find anything. I'll even ask early on what their concern is / what they want to know so I can address it.

I now have problems getting people to leave when I don't write for narcs, or if I do, I don't write for enough per the patient. What do you do with these patients when they refuse to leave for those reasons? I know I've had security escort those patients out, but don't know if there is a tactful way of getting those patients out.

 

[RustedFox]

Bump for moar replies. I want/need to hear more input on this'n.

Does anyone else get the feeling that patients in general think that the "ER doc" is just like "their family doctor except way better because (s)he handles emergencies" ?... I get the sense that patients think that when you graduate, that you have the skill set of the 'family doc' at the very minimum, and if you go above and beyond that... that you're a rockstar.

 

[docB]

I have a similar approach, especially if I don't expect to find anything. I'll even ask early on what their concern is / what they want to know so I can address it.

I now have problems getting people to leave when I don't write for narcs, or if I do, I don't write for enough per the patient. What do you do with these patients when they refuse to leave for those reasons? I know I've had security escort those patients out, but don't know if there is a tactful way of getting those patients out.

I mention to the patient that I am concerned that they are "negotiating for more narcotics" and I use that phrase. I ask them about their history with narcs and who is prescribing their pain meds, etc. That redirects the conversation from what they want to talk about which is how bad their current pain is to a discussion of their chronic pain issues and leads nicely into telling them they need to follow up quickly. I then document this whole discussion.

Bump for moar replies. I want/need to hear more input on this'n.

Does anyone else get the feeling that patients in general think that the "ER doc" is just like "their family doctor except way better because (s)he handles emergencies" ?... I get the sense that patients think that when you graduate, that you have the skill set of the 'family doc' at the very minimum, and if you go above and beyond that... that you're a rockstar.

One thing we're up against here is that PMDs are much less likely to work up any acute condition as an outpatient any more. They send all acute problems to the ED and the usual reason they give is that we have more testing capabilities. We don't but we can get the tests without calling for pre approval. So the patient's start to get miseducated that PMDs are for refills and ERs are for anything new.

 

[ztaw15]

Off the original topic, but this is an interesting point that I would like to hear more about; that is, the issue of where to work up acute but non-emergent issues. I am in the ED this month, and even having seen it from both sides I don't know what the appropriate response is most of the time. I have spent a lot of time going back and forth between FM and EM for mainly this reason - i.e. I enjoy having "my own patients" but I also dislike the aversion to dealing with more urgent issues, and you invariably lose out on emergent ones; the ED is nice for the fun emergent stuff, but it gets old doing a w/u and then calling the admitting person or primary and they say "do X/Y/Z" and that's what gets done and you don't have much say in the matter. It also gets old seeing the things that don't necessarily need an ED visit, but that are too acute somehow for outpatient.

Someone comes in with increasing unilateral calf swelling. My suspicion for DVT is low, and for PE is very very low, but the attending is definitely going to have them go to the ED to get an US, and probably D-dimer/CT if they are unlucky. I have had this type of case crop up three times in FM clinic, and seen the same case in the ED a few times now too. So what is the best approach? They definitely need US, but can you direct admit them and do the w/u that way? It seems too risky to send them for outpatient imaging if you have suspicion at all, though I suppose you could do US in office. So anyhow they all get sent to the ED, are in WR for two-four hours, get US that's negative and then are annoyed with everyone.

Is the direct admit just severely under-utilized?

I swear if I could have a clinic with more of the stuff that is in ED terms non-emergent (lacs, fractures, acute but injuries, belly pain/chest pain/etc.) while also getting to do long term follow up and inpatient management, I would do FM. But it's also a nice rush to see dysrrythmias, GI bleeds, do intubations, lines - just can't get that many other places.

 

[VienneseWaltz]

What patients often don't realize is that almost all of the testing we do can be done outpatient. If someone has a suspected DVT, the PMD can, if so inclined, refer them for an often same-day OUTPATIENT ultrasound, follow it up, and deal with it. But it's easier (for the PMD, NOT the patient) to send them to the ED. A patient with chronic abdominal pain can have an outpatient CT, MRI, whatever done with in a week or so. People think if you need a CT scan the only place in the world to have it done is the ED.

To affirm what other posters have said, I set expectations in the beginning, saying that we will look for conditions that need emergent treatment but we often don't get an answer the same day, and for many conditions the tests needed wouldn't come back in time anyway.

When the work-up is negative, I list the serious things they do NOT have and tell them I am reassured by the following blah-blah-blah (able to eat normally, no fever, whatever). I tell them I do believe something real is going on (even if I don't) and that they should continue the work-up as an outpatient so that they get answers. I write down the appropriate specialty clinic number. If I still get pushback, then I ask what they were hoping we would do for them in the ED (or in the hospital if they insist on admission) and try to re-set that.

I still have the occasional sullen discharge, but I haven't had to get security to escort them out. The one case that I thought might need that signed herself back in immediately for SI...

 

[Khaos]

Can I ask why a DVT or even a PE that has normal vital signs needs to be diagnosed at that moment in the emergency department? If you suspicion is low, vital signs are normal, patient has no cp or sob, why not even order a D-dimer or an outpatient US. I see things like this all the time where the patient says tat even the PCP thinks they have a cellulitis or something different but sent the patient to the ED "to make sure they don't have a clot." There are more and more studies coming out now about small PE with normal vital signs being managed in an outpatient setting.

 

[CraftyMed]

Maybe I get away with it since I'm a younger female attending, but I often tell people that "We'll rule out the BIG SCARY STUFF today. And if everything looks okay, then you need to follow up with the specialists to find out more information."

Once everything comes back fine (as it usually does), I borrow a technique I learned from another attending. I walk in the room and say, "GOOD NEWS! Everything looks normal. We're going to get you out of here so you can get back home soon."

The combo seems to work for me.

 

[la gringa]

phrases i find myself using all the time:
- narc seekers/negotiators: i'm the acute pain dr, not the chronic pain dr
- chronic visitors: your xxx dr really is the specialist in lupus/fibro/whatever that causes a zillion sx. you really need to f/u with them to keep tabs on your condition. i have r/o life threats.
- cp: not sure what's causing your cp but it's not pe/mi/ptx/pna/dissection. here's a symptomatic tx, f/u etc etc
- belly pain: your ct/labs don't show anything surgical or that i can give a name to, but 1/2 of all the people who come to the ED w/ abdominal pain leave w/ dx of same. if you develop new sx etc etc...

 

[Daiphon]

Maybe I get away with it since I'm a younger female attending, but I often tell people that "We'll rule out the BIG SCARY STUFF today. And if everything looks okay, then you need to follow up with the specialists to find out more information."

Once everything comes back fine (as it usually does), I borrow a technique I learned from another attending. I walk in the room and say, "GOOD NEWS! Everything looks normal. We're going to get you out of here so you can get back home soon."

The combo seems to work for me.

Sounds a lot like me... how've ya been? d=)

Sent from my DROID BIONIC using Tapatalk

 

[The White Coat Investor]

Sounds a lot like me... how've ya been? d=)

Sent from my DROID BIONIC using Tapatalk

Use both those phrases all the time.

 

[eforest]

In some cases- I tell the patient that if they are admitted for something that does not need an admission, they may be forced to pay for the admission themselves. This works on people with insurance.

 

[NinerNiner999]

I give them the "specialist speech." It goes something like this:

"I'm glad you came today and I can safely tell you that as your emergency specialist, I am not concerned about a medical emergency. Just as a cardiologist is a specialist of the heart, and a neurologist is a specialist of the brain, my specialty is recognizing emergencies. This is good news - I think you can safely go home and see the specialist I am going to refer you to."

Then, I hand them their discharge papers. I usually bring the nurse in with me for this "talk" so they can get the patient out without delay. Don't leave the door open. Slam it shut politely....

 

[docB]

Can I ask why a DVT or even a PE that has normal vital signs needs to be diagnosed at that moment in the emergency department? If you suspicion is low, vital signs are normal, patient has no cp or sob, why not even order a D-dimer or an outpatient US. I see things like this all the time where the patient says tat even the PCP thinks they have a cellulitis or something different but sent the patient to the ED "to make sure they don't have a clot." There are more and more studies coming out now about small PE with normal vital signs being managed in an outpatient setting.

There is an additional insidious problem introduced by this course. It means I am left to treat whatever the problem is once the clot is "ruled out." Patient's want treatment and will often not accept referral back to their PMD who they already saw once for the same problem. Antibiotics for cellulitis are not that big of a deal although their primary knows their comorbidities and past med history better than I do. But when it's peripheral edema and they need a new diuretic or a chronic pain issue like arthritis or sciatica it would be better managed by their primary. When dump on us as diagnostic study procurement specialists they dump the whole patient, chronic problems and all.

 

[RustedFox]

But when it's peripheral edema and they need a new diuretic or a chronic pain issue like arthritis or sciatica it would be better managed by their primary. When dump on us as diagnostic study procurement specialists they dump the whole patient, chronic problems and all.

The edema thing REALLY tugs on my chain. I absolutely can't stand it when the patient comes in with "edema that's worse than it was yesterday", and expects me to do something drastic about it that will somehow undo their eleventeen year history of being a couch potato/smoker/poorly managed diabetic.

I see the patient/complaint combo pop up on the tracking board... "Janey McFatAss.... 'both legs swelling'." - and I just think to myself - "Bye! Why even come here ?!" I know its a bad habit, and I convince myself not to be so dismissive because of the fear of 'overlooking' some actual emergency... but 999/1000 times I just surrender to the "nothing to do here, duhhh-huhh" endgame after all is said and done, and all the I's are dotted and T's are crossed.

 

[EM2BE]

The edema thing REALLY tugs on my chain. I absolutely can't stand it when the patient comes in with "edema that's worse than it was yesterday", and expects me to do something drastic about it that will somehow undo their eleventeen year history of being a couch potato/smoker/poorly managed diabetic.

I see the patient/complaint combo pop up on the tracking board... "Janey McFatAss.... 'both legs swelling'." - and I just think to myself - "Bye! Why even come here ?!" I know its a bad habit, and I convince myself not to be so dismissive because of the fear of 'overlooking' some actual emergency... but 999/1000 times I just surrender to the "nothing to do here, duhhh-huhh" endgame after all is said and done, and all the I's are dotted and T's are crossed.

What do you mean swollen? Where is the edema demarcation in the fat? I hate those I can't even see the edema.

 

[RustedFox]

What do you mean swollen? Where is the edema demarcation in the fat? I hate those I can't even see the edema.

This.

Yet they SWEAR they weren't this big yesterday, thus constituting the emergency.

 

[alphaholic06]

What do you mean swollen? Where is the edema demarcation in the fat? I hate those I can't even see the edema.

This!

 

[jbar]

This.

Yet they SWEAR they weren't this big yesterday, thus constituting the emergency.

Fair enough, but I did have a lady I think in her 60s who came in with bilateral leg edema that she swore was much worse over the last 2 weeks. Stuck the ultrasound on her.

Big pericardial effusion with RV collapse. Ended up getting about 500ccs of blood drained by cardiology, and a lung CA was found on CT.

Since then I've been taking those edema patients a little more seriously.

 

[RustedFox]

Yeah - this is PRECISELY the patient that I worry about when I wrote in my above post "I don't wanna be so dismissive, etc - etc."

 

[WilcoWorld]

Fair enough, but I did have a lady I think in her 60s who came in with bilateral leg edema that she swore was much worse over the last 2 weeks. Stuck the ultrasound on her.

Big pericardial effusion with RV collapse. Ended up getting about 500ccs of blood drained by cardiology, and a lung CA was found on CT.

Since then I've been taking those edema patients a little more seriously.

I believe that, but the patient must have had something else too - if not chest pain at least shortness of breath, orthopnea, dyspnea on exertion, and some other physical findings, even if just a little tachycardia?

Otherwise you wouldn't have been doing an echo.

 

[tkim]

Once everything comes back fine (as it usually does), I borrow a technique I learned from another attending. I walk in the room and say, "GOOD NEWS! Everything looks normal. We're going to get you out of here so you can get back home soon."

Dylan. Heh.

 

[Arcan57]

I start by explaining the whole "we find dangerous or life-threatening causes that would require admission or emergent surgery". If the subject of prior evals for same problem comes up, I explain that I'm unlikely to make a diagnosis but I'm going to get them to a doctor that has a larger toolbox than what I have. I stress my tests are designed to look for the things from the first sentence.

This plus a couple of hours to contemplate going home means that most people are ok with leaving because I've met their (now lowered) expectations. Admittedly I don't have as many of the "I need an MRI and a GC/MS test for heavy metals", but I usually follow the same script plus I tell them I'll be calling their doctor when I get the test results back.

 

[CraftyMed]

Dylan. Heh.

You know it.

 

[Snelgrave]

Great discussion and many good suggestions. Thanks.

 

[AmoryBlaine]

Fair enough, but I did have a lady I think in her 60s who came in with bilateral leg edema that she swore was much worse over the last 2 weeks. Stuck the ultrasound on her.

Big pericardial effusion with RV collapse. Ended up getting about 500ccs of blood drained by cardiology, and a lung CA was found on CT.

Since then I've been taking those edema patients a little more seriously.

Totally different pick-up than the Fatty who says "my tree trunks are slightly larger today."

New onset peripheral edema always needs a big workup and in my mind will usually end up admitted since there are very few things that cause it that won't need extensive evaluation.

 

[Arcan57]

Totally different pick-up than the Fatty who says "my tree trunks are slightly larger today."

New onset peripheral edema always needs a big workup and in my mind will usually end up admitted since there are very few things that cause it that won't need extensive evaluation.

Most of the emergent causes of bilateral edema should show up or at least be hinted at during the ED eval. If they have no respiratory symptoms and good (within a couple of days) outpatient follow-up, then I think it's reasonable to send them home.

 

[GeneralVeers]

Most of the emergent causes of bilateral edema should show up or at least be hinted at during the ED eval. If they have no respiratory symptoms and good (within a couple of days) outpatient follow-up, then I think it's reasonable to send them home.

Had one yesterday. 50 yo lady with chronic edema in her legs for the last month. Says she has fatigue. On exam I can barely see any edema (cause she's fat). CBC, chem-12, CXR and TSH all neg so I sent her home.

If there are no respiratory symptoms, and vitals are normal I can't think of a compelling reason to admit. Even if there's a pericardial effusion it's likely compensated for in that scenario.

 

[ccfccp]

Back to the original question in this post:

"Smithers, release the hounds!"

 

[jbar]

Back to the original question in this post:

"Smithers, release the hounds!"

Wait, houndsfeld units? If you are kicking them out then why are you getting a CT?

 

[Ceke2002]

Can I ask why a DVT or even a PE that has normal vital signs needs to be diagnosed at that moment in the emergency department? If you suspicion is low, vital signs are normal, patient has no cp or sob, why not even order a D-dimer or an outpatient US. I see things like this all the time where the patient says tat even the PCP thinks they have a cellulitis or something different but sent the patient to the ED "to make sure they don't have a clot." There are more and more studies coming out now about small PE with normal vital signs being managed in an outpatient setting.

I was in a similar situation to this as a patient recently. Apart from the fact that my ankle no longer resembled an ankle, I felt fine. I initially went to a local GP to have it checked out (I'm thinking possible allergic reaction to a insect bite, get some antihistamines, I'll be fine) and he takes one look and insists I go to hospital, right now, by ambulance. I did go, mainly because the GP was so insistent he managed to freak me out , but I felt so bad being in there for a swollen ankle that was probably going to turn out to be nothing, when speaking to the orderlies I knew they were dealing with a couple of shootings, a major car accident, and were just preparing to tell a family that their 16 year old son had died. 🙁 Mostly I just tried to be as quiet and unobtrusive as possible, they ran tests, one of those came back positive for some marker of some sort, so they gave me a shot of blood thinners, and admitted me under the hospital at home scheme - which means I was able to go home, I just had district nurses checking on me until my outpatient appointment to get a leg ultrasound done. The ultrasound was clear, and I was left wondering why I just couldn't have been given blood thinners at the GP's office, and referred for an ultrasound from there, rather than having taken up the ED's time and resources. I do go to hospital whenever I'm instructed to, I just wish there was a way to actually tell when something is a potential emergency, and when it's just a Doctor being a bit too cautious.

 

[EdibleEgg]

I just wish there was a way to actually tell when something is a potential emergency, and when it's just a Doctor being a bit too cautious.

It's a tough job. The only way to really get a handle on the difference is medical school and residency.

One thing we're up against here is that PMDs are much less likely to work up any acute condition as an outpatient any more. They send all acute problems to the ED and the usual reason they give is that we have more testing capabilities. We don't but we can get the tests without calling for pre approval. So the patient's start to get miseducated that PMDs are for refills and ERs are for anything new.

I have never done this. The last time I sent a patient to the ED from my office, she was brady and hypotensive. If I had immediate access to a monitored bed, I would have skipped it then, but she wasn't stable enough to sit in admissions.

My office closes at noon on Fridays, and it never fails the unilateral leg swelling or right lower quadrant abdominal pain shows up at 11:30. It's a pain in the ass, but I can usually get stat labs and imaging and paged with results within a couple of hours.

The non acute attitude of some primaries is a product of the system. Hospitals, insurance companies make it more difficult to get tests done. The separation of inpatient/ out patient medicine and pressure to be a referral monkey makes some PCP's uncomfortable with anything more than an ingrown nail. If you punish people for working up acute issues, most will take the path of least resistance.