Outpatient handoff

[Oo Cipher oO]

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I am an outpatient military PCP working in a remote military treatment facility. We have a local small community hospital within 30 minutes and a large level II trama center 90 minutes away. I will occasionally send my patients to the ER for whatever reason and I always try to call to give a handoff the to the ER. Most of the time it seems the ER staff I am talking to is frankly annoyed that I bothered to call in. Usually the ER physician is “not available” to speak to and I end up giving the handoff to one of the nurses. I give a very brief overview of the patient and my clinical concerns and they will say “ok thank” and hang up usually before I’ve even given them the patient’s name or other info.

I know the ER is busy and I want to optimize my handoff for the sake of the ER staff and patient. Do you find it helpful or a waste of time when the PCP calls ahead to give a handoff of their patient? Should I push a bit harder to talk to the ER physician or do you feel comfortable with the ER nurse taking the call? I try to keep my handoff as brief and coherent as possible but what are the most important aspects you want to hear from the PCP?

 

[Groove]

I am an outpatient military PCP working in a remote military treatment facility. We have a local small community hospital within 30 minutes and a large level II trama center 90 minutes away. I will occasionally send my patients to the ER for whatever reason and I always try to call to give a handoff the to the ER. Most of the time it seems the ER staff I am talking to is frankly annoyed that I bothered to call in. Usually the ER physician is “not available” to speak to and I end up giving the handoff to one of the nurses. I give a very brief overview of the patient and my clinical concerns and they will say “ok thank” and hang up usually before I’ve even given them the patient’s name or other info.

I know the ER is busy and I want to optimize my handoff for the sake of the ER staff and patient. Do you find it helpful or a waste of time when the PCP calls ahead to give a handoff of their patient? Should I push a bit harder to talk to the ER physician or do you feel comfortable with the ER nurse taking the call? I try to keep my handoff as brief and coherent as possible but what are the most important aspects you want to hear from the PCP?

It’s incredibly helpful and most certainly not a waste of time. I always appreciate the courtesy of a call from local PCPs sending pt’s to the ER as there is a certain degree of time wasted trying to figure out why they were sent in the first place and the pt is rarely a good historian. Anybody giving you a hard time is making life difficult for themselves. For instance, if you sent them for admission and they end up getting discharged, all it takes is one call to the CMO with a complaint and the ED doc is suddenly on the hot seat. Assuming you’ve been doing this for awhile, sure...a brief chat about the pt is all it takes as the ED is usually pretty busy but I always make time to talk with my PCPs about pt’s they are sending to the ER. It’s not like you’re the only person sending pt’s to the ER. I get calls from my neurologists, neurosurgeons, cardiologists, etc.. It’s helpful because we generally write a transfer note so that if a different doc picks up the pt they can see the documented discussion that we had and know what to do.

 

[Jabbed]

I can guarantee that your report to the ED RN isn't contributing to anything useful. If for some reason you cannot get a hold of an attending or at the very least a MLP to take report, I would personally prefer having a note attached to the patient along the lines of: "Patient with hx of xxx, please evaluate/admit for xxx, please call xxx-xxx-xxxx with any questions."

As a courtesy, give a direct contact line. Please don't make me hold for 5 minutes with your office staff.

 

[VA Hopeful Dr]

Along those same lines, do y'all actually look at any of the office notes us PCP types write on patients we send in?

 

[Lexdiamondz]

Along those same lines, do y'all actually look at any of the office notes us PCP types write on patients we send in?

yes, 100%. especially if it was written by an actual PCP rather than a minute-clinic midlevel.

As Jabbed mentioned, it's most helpful if you give a direct line for callback - it's just as frustrating to us to have to go through your clerk who's trying to do as little work as possible when we really need to reach the referring physician for specific questions.

 

[GeneralVeers]

I don't want to talk to the sending physician for run-of-the-mill chest pain, pneumonia, acute renal failure etc. If it's common and self-evident then it's a waste of time.

I do want to talk to the sending physician if it's complex, or an unusual presentation.

 

[BoardingDoc]

I can guarantee that your report to the ED RN isn't contributing to anything useful. If for some reason you cannot get a hold of an attending or at the very least a MLP to take report, I would personally prefer having a note attached to the patient along the lines of: "Patient with hx of xxx, please evaluate/admit for xxx, please call xxx-xxx-xxxx with any questions."

As a courtesy, give a direct contact line. Please don't make me hold for 5 minutes with your office staff.

This is completely shop dependant. Our RNs are very good at taking down a quick pertinent call in. Unless the patient is super complex, I don't need/want to speak to the sending physician. Agree with the format you presented completely. Give a quick blurb with patient name, your name and contact info and one liner about clinical concern and goal. I will definitely read this.

 

[Groove]

Along those same lines, do y'all actually look at any of the office notes us PCP types write on patients we send in?

Most of the time I don’t have access to the PCP note. It doesn’t arrive with the pt (usually POV) and the clinic EMR is not interfaced with the hospital EMR. Therefore, the phone call from the PCP is even more valuable as it is the only opportunity I have to document the concern and expected disposition. Hospitals want to keep PCPs happy so they will keep sending their patients there for admission and it’s a wise EM doc who can have the emotional IQ to figure out that keeping the PCP happy is good for job security. They can generate CMO complaints and peer reviews, unfounded or not, that make life most uncomfortable. I try to keep them happy. This comes in handy when I admit their occasional pt to the wrong doc and instead of complaining to c-suite they give me a break assuming I didn’t realize it was their pt. (I didn’t.), etc..

 

[bravotwozero]

When a PCP's office sends over a patient, I will do pretty much what they want or ask. Usually their concerns are reasonable (as long as it's not a midlevel, then all bets are off), and they have a specific diagnostic and disposition plan and evaluating their patients becomes pretty straightforward. This is doubly so for a PCP who admits their own patients. At that point, it's their baby and they're responsible for whatever they want to order or get done.

 

[bravotwozero]

As a courtesy, give a direct contact line. Please don't make me hold for 5 minutes with your office staff.

This! Either a direct phone call or cell number is key.

Along those same lines, do y'all actually look at any of the office notes us PCP types write on patients we send in?

Absolutely I do.

 

[VA Hopeful Dr]

I don't want to talk to the sending physician for run-of-the-mill chest pain, pneumonia, acute renal failure etc. If it's common and self-evident then it's a waste of time.

I do want to talk to the sending physician if it's complex, or an unusual presentation.

That's generally my approach from the outpatient end. If my nurse can explain it enough in 1 sentence (CHF exacerbation, pneumonia that failed outpatient treatment, worrisome chest pain), I let her.

If its something weird, I call personally.

 

[Zebra Hunter]

I almost never get calls from PCPs sending patients our way, so I am always pleasantly surprised whenever I get that call, even if it’s a run-of-the-mill diagnosis...actually, especially for those. I feel that the complex issues are generally easy enough to recognize as something that needs admission; however, I am always left perplexed why I was sent an uncomplicated DVT, uncomplicated pneumonia, etc. The routine stuff being sent to me for admission is almost always the cases that are the most frustrating to deal with because most of the time I have no clue why they need to be admitted.

 

[RoyBasch]

What I find less helpful is sending a patient to the ED with a laundry list of tests to be performed such as, "Obtain CBC, CMP, CRP, ESR, INR, TSH, UA, lactate, CTA and MRI." The patient then expects all these tests performed even if I don't feel all or any are indicated emergently, which then sometimes leads to an uncomfortable conversation with the patient.

Agree. I promise I will never refer a patient to you again if you write the tests or treatment as orders on a prescription pad for me.

I think you set the next physician up for failure when you give them a very sure expectation of the clinical course that then cannot or is not met for whatever reason and now they have to back track.

When I speak to patients where I am getting a consult or referral I always tell them "I do not know for certain what another physician will or will not do, especially a surgeon, will or will not operate, I believe they need to see you and they will determine the next course of action. That being said, here are some likely possibilities (procedure, medical management, more diagnostics, etc.)"

Even if it's something that seems pretty straight forward like requesting a consult from general surgery for appendicitis. For all I know, the surgeon may be up on the most recent literature and be managing these with ABx only and then interval appendectomy later. Or there may be a good reason not to operate not obvious to me (patient is a poor operative candidate by some criteria, etc.) I firmly believe only a surgeon can truly determine who needs surgery. Once the surgeon sees and evaluates the patient in full consultation, the responsibility for doing or not doing the procedure is on them.

 

[RoyBasch]

I almost never get calls from PCPs sending patients our way, so I am always pleasantly surprised whenever I get that call, even if it’s a run-of-the-mill diagnosis...actually, especially for those. I feel that the complex issues are generally easy enough to recognize as something that needs admission; however, I am always left perplexed why I was sent an uncomplicated DVT, uncomplicated pneumonia, etc. The routine stuff being sent to me for admission is almost always the cases that are the most frustrating to deal with because most of the time I have no clue why they need to be admitted.

If it's a physician who admits their own patients, then I don't care. If they are sending them to be admitted by someone else like our already over-burdened hospitalist service, then I take some umbrage.

 

[GeneralVeers]

A simple DVT is one I don't understand. It is not an emergency. The PCP could just as easily start Eliquis outpatient and follow.

 

[RoyBasch]

A simple DVT is one I don't understand. It is not an emergency. The PCP could just as easily start Eliquis outpatient and follow.

These always got admitted in the pre-DOAC era for a heparin bridge to coumadin. Some old school docs never changed their practice after DOACs that don't require bridging became widely available.

 

[bravotwozero]

A simple DVT is one I don't understand. It is not an emergency. The PCP could just as easily start Eliquis outpatient and follow.

I had a patient come in with a post op dvt. I called his ortho, AND his PCP, and asked both of them if they're cool with me sending the patient home on elliquis. Both agreed with the plan, so that's what I did.

2 hours later while i'm still on shift, the patient is back. His insurance won't cover elliquis. Sub q lovenox and into the hospital he goes 🙄

 

[gamerEMdoc]

I don't want to know about basic stuff (cp, want to r/o ACS) but if a concern is specific, I definitely want to know. I can't tell you how many times a patient has been sent in by a nursing home or outpt office, I work them up for their complaint, then get ready to dc them only to find out later that the reason they were sent in was something completely different than what the patient said.

Just yesterday I had a patient brought in for aspiration on water from a nursing home. Per the patient and EMS. I called the nursing home to inquire about a med list (that they forgot to send) and they told me they sent the patient in bc they thought she may have COVID.

Communication in healthcare is completely broken.

 

[gamerEMdoc]

A simple DVT is one I don't understand. It is not an emergency. The PCP could just as easily start Eliquis outpatient and follow.

Even without DOACs, this should never need admitted. LMWH has been around for like 30 years now. It's preferred in DVT treatment guidelines over heparin. Patients needing bridged to coumadin just shouldn't need to be hospitalized. Unless there is some reason (renal failure) they can't give themselves lovenox.

 

[GeneralVeers]

Even without DOACs, this should never need admitted. LMWH has been around for like 30 years now. It's preferred in DVT treatment guidelines over heparin. Patients needing bridged to coumadin just shouldn't need to be hospitalized. Unless there is some reason (renal failure) they can't give themselves lovenox.

Right. We have the 30-day starter coupon for Eliquis that we give people.

 

[VA Hopeful Dr]

Even without DOACs, this should never need admitted. LMWH has been around for like 30 years now. It's preferred in DVT treatment guidelines over heparin. Patients needing bridged to coumadin just shouldn't need to be hospitalized. Unless there is some reason (renal failure) they can't give themselves lovenox.

Getting lovenox covered by insurance outpatient is extremely difficult. I can count on one finger the number of times I've managed to do it. But insurance would cover the inpatient stay. Go figure.

This was pre-DOAC of course.

 

[AMEHigh]

I had a patient come in with a post op dvt. I called his ortho, AND his PCP, and asked both of them if they're cool with me sending the patient home on elliquis. Both agreed with the plan, so that's what I did.

2 hours later while i'm still on shift, the patient is back. His insurance won't cover elliquis. Sub q lovenox and into the hospital he goes 🙄

Yep, that's the biggest reason I've seen for people going to hospital and getting admitted. It's always an insurance problem. So ridiculous.

 

[AMEHigh]

As far as the OP's question, where I work the ED's are too hectic, so I never call now because I doubt the person I talk to will be the one who sees the patient.
I've only had to send a handful of people to the ED the past year, but I do always finish and send my note with a sentence about why I'm sending them. I emphasize with the patient to show the ED the note, not sure how often it happens and if the ED reads it. However, I think written communication is often better, so there's no confusion or forgetfulness, so that's why I send a note.

 

[GeneralVeers]

As far as the OP's question, where I work the ED's are too hectic, so I never call now because I doubt the person I talk to will be the one who sees the patient.
I've only had to send a handful of people to the ED the past year, but I do always finish and send my note with a sentence about why I'm sending them. I emphasize with the patient to show the ED the note, not sure how often it happens and if the ED reads it. However, I think written communication is often better, so there's no confusion or forgetfulness, so that's why I send a note.

I think that's appreciated. I definitely read anything a patient brings me. Would rather have a clinical note than a list of ransom demands on a RX script.

 

[pkwraith]

I am surprised that there's still EDs out there now where there's not random piles of elliquis and xarelto 30 day coupons lying around.

If I have access to the urgent care and pcp notes, i do read them, if so I can see what kind of liability **** they're trying to dump on me (pharyngitis sent for Dissection evaluation, benign appearing hand cellulitis send for MRI to r/o tensynovitis and osteomyelitis) so I can document appropriately.

 

[BoardingDoc]

I am surprised that there's still EDs out there now where there's not random piles of elliquis and xarelto 30 day coupons lying around.

If I have access to the urgent care and pcp notes, i do read them, if so I can see what kind of liability **** they're trying to dump on me (pharyngitis sent for Dissection evaluation, benign appearing hand cellulitis send for MRI to r/o tensynovitis and osteomyelitis) so I can document appropriately.

Ugh, we have a local NP who frequently refers in patients with notes like: "Patient presented to urgent care with back pain and headache after lifting a box. Can not rule out ACS, aortic dissection, PE, SAH, Stroke. Sending to ED for urgent cardiac/neurologic workup and advanced imaging."

I then have to write a Homeric epic in my MDM explaining why absolutely none of these things are indicated.

She did send me an actually sick person one time. I almost had a stroke when the note was spot on.

I still hate her.

 

[Apollyon]

I wonder what your post said before it was mod edited.

 

[BoardingDoc]

I wonder what your post said before it was mod edited.

I had minor profanity in it that wasn't caught by SDNs filter and turned into asterisks. Mods removed it. The content is otherwise unchanged.

 

[BoardingDoc]

I'm also curious.

See, you don't have to lock threads, delete posts or ban people. Just edit the size of the font. I can live with this type of modding.

The font size is unedited. I did that intentionally.

 

[RuralEDDoc]

If I have access to the urgent care and pcp notes, i do read them, if so I can see what kind of liability **** they're trying to dump on me (pharyngitis sent for Dissection evaluation, benign appearing hand cellulitis send for MRI to r/o tensynovitis and osteomyelitis) so I can document appropriately.

That seems a little harsh but I understand where it’s coming from. When I used to work for Kaiser we’d get patients sent from the advice line. The advice line would document things with boiler plate language, so all chest pain referrals would state that the patient had crushing chest pain. Every one. So I’d have to spend time document the true history, then reference the call center note and refute the language written there. A big waste of time.

 

[RoyBasch]

I had a patient come in with a post op dvt. I called his ortho, AND his PCP, and asked both of them if they're cool with me sending the patient home on elliquis. Both agreed with the plan, so that's what I did.

2 hours later while i'm still on shift, the patient is back. His insurance won't cover elliquis. Sub q lovenox and into the hospital he goes 🙄

Whenever I have a DVT that I'm planning on outpatient management, this is one of the rare situations in the ER where I specifically ask about insurance status and if the patient can afford the medicine. Even if they have no commercial insurance there are usually coupons or something. I have had a patient like this and I told the hospitalist, "if you can find a way for this patient to physically obtain the medicine, they do not need to be admitted. lo, and behold, the hospitalist came to the ER with actual starter packs of the eliquis pills from their outpatient office.

 

[RoyBasch]

Even without DOACs, this should never need admitted. LMWH has been around for like 30 years now. It's preferred in DVT treatment guidelines over heparin. Patients needing bridged to coumadin just shouldn't need to be hospitalized. Unless there is some reason (renal failure) they can't give themselves lovenox.

Lovenox is prohibitively expensive as well, it's about 100 bucks per dose. It seems wrong to spend thousands on a hospitalization to bridge to coumadin compared to $500 of outpatient lovenox, but that's just another casualty of our completely dysfunctional healthcare system.

 

[GeneralVeers]

Lovenox is prohibitively expensive as well, it's about 100 bucks per dose. It seems wrong to spend thousands on a hospitalization to bridge to coumadin compared to $500 of outpatient lovenox, but that's just another casualty of our completely dysfunctional healthcare system.

I've never understood this with Medicare. Seems to me it's low-hanging fruit if they want to cut reimbursement costs....

 

[KGflyboy]

I like to hear from the pcp because the patients are notorious for having no clue why they were sent to the ED. When a nurse or doctor calls from the clinic, the ED charge nurse usually takes a note with basic info, but for some reason that note rarely makes it to me.

On the rare occasion a doctor and to speak with me before sending a patient in, the charge nurse facilitates that. I would say that is really rate though. I would much rather take that call myself from the clinic doctor then have the charge nurse take the call and not down a note that magically evaporates by the time the patient arrives.