Pushback in the community

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TonyC219

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Recent grad here, in my first year out of residency. Just wanted to get the input from the docs working in community shops. How much pushback do you guys get for admissions? I feel like I'm getting a lot of pushback from the hospitalists at my current job, even more than I got during residency and it's starting to get frustrating. Some of it I understand (I get nobody likes the weak, dizzy elderly patient) and some of it I don't really understand (elderly syncope, moderate to high risk chest pain, etc.). Basically was just wondering what the norm was out in the community. Thanks.
 
That's pretty abnormal. That's one of the perks usually of community practice. No one fights admissions and consultants are happy to see patients. Everyone understands that you're putting food on their table.


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Agreed. Now where I work the beds upstairs are getting full pretty often, so I understand the urge to attempt to manage some things outpatient. We have ED case management, can call PT down, do brief OBS in the ED all to try and keep people out who don't need to be in-- purely weak and difficult ambulating elderly don't need an acute care hospital, they need rehab or excellent home services. This, of course, requires the hospital to invest resources to let you try and place these people straight out of the ED.

So for that type of patient, I understand the hospitalists' pushback. However, them pushing back in the middle of the shift isn't going to help anything-- you need them to engage the hospital in a multidisciniplary approach to find alternatives to admission.

For the high risk syncope... well they need to be in. Sometimes its helpful to quote a particular decision rule (San Fran or Boston syncope in this case). If their continues to be issues talk to your leadership.
 
$100 says your hospitalists are salaried with no productivity bonus.

That said, I would talk to your partners. If you're the only one getting push back, find out why. If you're not, get your leadership to talk with the hospitalist leadership and find a way to fix this.
 
You probably work at my old job lol

I remember being told in residency about how easy admissions and consults would be as an attending in the community... all lies.. I still have yet to meet an orthopedic surgeon that doesn't cry about getting consulted to the ER.

Also agree with above...I bet your hospitalists are salaried
 
erdoc00 said:
You probably work at my old job lol

I remember being told in residency about how easy admissions and consults would be as an attending in the community... all lies.. I still have yet to meet an orthopedic surgeon that doesn't cry about getting consulted to the ER.

Also agree with above...I bet your hospitalists are salaried
Click to expand...

Why do you need an orthopod in the ER?
 
Lot has to do with the Hospitalist pay model!

Also, it is hospital/system dependent. Since this ACA/ACO crap accouple of hospital systems I worked for previously really pushed back on admissions of all kinds and wanted a lot more done in the ED to discharge patients, and not ponying up resources to do it. At the same time still wanting us to keep stays down. I did not last long at those shops, just not the type environment I want to work in.
I currently work for the hospital system that actually encourages admissions which is incredibly relieving, they don't push admits, but there is NEVER a lick of pushback.
I'm having a hard time understanding hospital system's reluctance on admits. Isn't that where the money is?
I know of a local hospital that was in the red financially and since getting taken over with a hospital system that encourages admits (not any shady thing like FL, but a much higher admission rate since take over) now they're doing well! My hospital now, in good shape. Just makes no sense.
Hospitals are not going to be able to "save the system money" and stay viable. They need to look out for themselves😉
 
I work in the community, first yr out. I get tons of push back. Hospitalist are salaried. They get upset that I don't consult everything correctly straight out of the ED AND don't have everything in a tight little bundle. Part of the gig I suppose. I cannot get crap consulted in the ED. Ortho never comes in, surgery doesn't want to come in, optho either.

Guess I need to work somewhere else. Even bread and butter high risk chest pains can be a nightmare. Lots of IM primadonnas. Yes, I am often wrong with my assessments and plans and sometimes the patient needs something else. But I didn't send a patient home that needs to be admited. Hospitalist have MD after their name too.

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Talk to your fellow docs.
See if they are having the same issues.

If so, go to your admin.

There were some similar issues at my shop.
Admin made this go away.

The hospitalists were told their job is to admit patients and they basically can't refuse anything.
That being said, I don't mind having a discussion about a borderline case.
 
TonyC219 said:
Recent grad here, in my first year out of residency. Just wanted to get the input from the docs working in community shops. How much pushback do you guys get for admissions? I feel like I'm getting a lot of pushback from the hospitalists at my current job, even more than I got during residency and it's starting to get frustrating. Some of it I understand (I get nobody likes the weak, dizzy elderly patient) and some of it I don't really understand (elderly syncope, moderate to high risk chest pain, etc.). Basically was just wondering what the norm was out in the community. Thanks.
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One of the things you'll find is there is no "norm" in the community. Community hospitals run according to how the current administrative team wants them to run. If you're in a difficult to staff location that has difficulty holding on to staff and uses locums, you're probably going to see administration let people who don't want to work get away with a lot. But understand that a "difficult to staff" location is a reflection on administration in and of itself. It's another way of saying that the hospital is offering a package that cannot overcome obstacles to hiring and despite this is unwilling to fix pay, work hour, or cultural issues that keep them from attracting staff.

The place I left had awful pushback for admission. The hospitalist service was chronically understaffed (and underskilled). The first 2-3 patients you could get admitted without a problem. After that, it was like pulling teeth. Specialists were no better. It really depends on your particular facility.

If you can go somewhere that the hospitalists aren't salaried but are RVU based, I expect this will improve.

Nothing pisses me off quite as much as a physician who is somewhere else, who has not seen the patient, and knows nothing about the case aside from what a referring physician is telling him on the phone saying that a patient does not need to be seen/admitted.
 
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Old_Mil said:
One of the things you'll find is there is no "norm" in the community. Community hospitals run according to how the current administrative team wants them to run. If you're in a difficult to staff location that has difficulty holding on to staff and uses locums, you're probably going to see administration let people who don't want to work get away with a lot. But understand that a "difficult to staff" location is a reflection on administration in and of itself. It's another way of saying that the hospital is offering a package that cannot overcome obstacles to hiring and despite this is unwilling to fix pay, work hour, or cultural issues that keep them from attracting staff.

The place I left had awful pushback for admission. The hospitalist service was chronically understaffed (and underskilled). The first 2-3 patients you could get admitted without a problem. After that, it was like pulling teeth. Specialists were no better. It really depends on your particular facility.

If you can go somewhere that the hospitalists aren't salaried but are RVU based, I expect this will improve.

Nothing pisses me off quite as much as a physician who is somewhere else, who has not seen the patient, and knows nothing about the case aside from what a referring physician is telling him on the phone saying that a patient does not need to be seen/admitted.
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Docs who haven't seen a patient, or written a formal consult, think everyone can go home.
Once their name is really on the chart, the recommendations usually change.

I'm rarely calling for advice on a patient who can go home.
I'm calling for a procedure or for an admit.
 
Your hospitalists suck.

Mine are cool. Except one. He sucks too. Then I met him in person. Now he's ok. I suggest trying that.
 
I think admitting to hospitalists varies tremendously between hospitals for certain diagnoses.
For example, the 2 you mentioned can be managed a variety of ways: syncope (with negative ER workup) and chest pain (with normal trop/ddimer).
If someone has an arrythmia or shock or elevated trops its easy for the hospitalists to admit because we can all point to the dx. Its harder to admit just a symptom that can be something serious, but often is not.
I used to stress a lot about these cases... now I try to do my 'due diligence' and have a thorough work up for syncope, and cp usually with a 6 h repeat trop and if negative try to arrange some type of follow up for the patient.
Sometimes a specialist can help you with these: like a cardiologist, nephrologist (for HD pt), or oncologist (for CA pt) may want the pt admitted for 'observation' then at least you can hand that off to the hospitalist. It will make both your jobs easier.
Also check in with the hospitalists and the other ER docs to see what they are recommending for cases like this.
That's my impression. Hang in there. It gets easier... usually
 
erdoc00 said:
You probably work at my old job lol

I remember being told in residency about how easy admissions and consults would be as an attending in the community... all lies.. I still have yet to meet an orthopedic surgeon that doesn't cry about getting consulted to the ER.

Also agree with above...I bet your hospitalists are salaried
Click to expand...

That's probably because when the orthopods were doing consults as residents at the academic centers, the ER residents kept telling them "well, of course we would NEVER consult you for this in the COMMUNITY!" And now they are realizing that this is a lie. Everything is a lie. Nothing ever changes.
 
n2b8me said:
I think admitting to hospitalists varies tremendously between hospitals for certain diagnoses.
For example, the 2 you mentioned can be managed a variety of ways: syncope (with negative ER workup) and chest pain (with normal trop/ddimer).
If someone has an arrythmia or shock or elevated trops its easy for the hospitalists to admit because we can all point to the dx. Its harder to admit just a symptom that can be something serious, but often is not.
I used to stress a lot about these cases... now I try to do my 'due diligence' and have a thorough work up for syncope, and cp usually with a 6 h repeat trop and if negative try to arrange some type of follow up for the patient.
Sometimes a specialist can help you with these: like a cardiologist, nephrologist (for HD pt), or oncologist (for CA pt) may want the pt admitted for 'observation' then at least you can hand that off to the hospitalist. It will make both your jobs easier.
Also check in with the hospitalists and the other ER docs to see what they are recommending for cases like this.
That's my impression. Hang in there. It gets easier... usually
Click to expand...

You can obs a patient 6 hours in your ED? Or do you have a seperate area.
 
gro2001 said:
That's probably because when the orthopods were doing consults as residents at the academic centers, the ER residents kept telling them "well, of course we would NEVER consult you for this in the COMMUNITY!" And now they are realizing that this is a lie. Everything is a lie. Nothing ever changes.
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What? When I moonlight or when I rotate at our community affiliate, I've never seen ortho....I call them a lot, but it's either to have them admit and operate in the morning after giving the nurse orders or to get follow up.
 
Thanks all for the responses. It's definitely been the most frustrating part of my first year out, just having to fight for everything. Good to know I'm not completely crazy for thinking the amount of pushback I'm getting is abnormal.

I'm sure the money aspect has something to do with it. I currently practice is Maryland and as far as I understand it, reimbursement for admissions is capped, so I'm sure there's no financial incentive for admissions. I didn't realize this prior to taking my job here.

I've talked to the other docs in my shop and they all say pretty similar things, that it's a pain to get people admitted. Maybe it doesn't bother them as much as it does me. I've talked with my director a little bit about it, guess I'll just have to talk to him again and see what happens.
 
shoal said:
I work in the community, first yr out. I get tons of push back. Hospitalist are salaried. They get upset that I don't consult everything correctly straight out of the ED AND don't have everything in a tight little bundle. Part of the gig I suppose. I cannot get crap consulted in the ED. Ortho never comes in, surgery doesn't want to come in, optho either.

Guess I need to work somewhere else. Even bread and butter high risk chest pains can be a nightmare. Lots of IM primadonnas. Yes, I am often wrong with my assessments and plans and sometimes the patient needs something else. But I didn't send a patient home that needs to be admited. Hospitalist have MD after their name too.

Sent from my VS986 using Tapatalk
Click to expand...

Maybe we work at the same hospital. LOL.
 
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If you're doing reasonable care, it is actually your director's job to fix this, or you should leave. If every admit is a headache, that makes working no fun.
 
TimesNewRoman said:
What? When I moonlight or when I rotate at our community affiliate, I've never seen ortho....I call them a lot, but it's either to have them admit and operate in the morning after giving the nurse orders or to get follow up.
Click to expand...

Our Ortho guys use PA's in house and they want to be called on all fractures. Just how they want it. The PA's come down, cast and arrange follow up.

That being said, I've seen exactly 2 attending Ortho guys in the ED in 6 years, both to consult on other attendings in the health system.
 
Greenbbs said:
Our Ortho guys use PA's in house and they want to be called on all fractures. Just how they want it. The PA's come down, cast and arrange follow up.

That being said, I've seen exactly 2 attending Ortho guys in the ED in 6 years, both to consult on other attendings in the health system.
Click to expand...

It's funny I said that. I literally had an ortho attending come to see a patient today while moonlighting in a moderate sized community hospital.

To be fair, I was calling to get follow up. He said "eh, I'm operating today and my schedule is light. I'll come see her so I can add her on."

Mind you, when I called him at 9PM he asked me to reduce, splint and send to clinic. Lol. We should have done something that doesn't require nights/weekends.
 
First, it helps if they make more money for each admit. The owner of the hospitalist group will take any admission and trolls the ED for more. If he can justify it, he'll take it. His employees, not so much. They'll take the admission, but it's almost passive aggressive- they take 2-3 hours to get the orders in sometimes. But I know who to call....he just has a hard time hiring.

Second, get to know them all personally. That helps.

Third, don't blow smoke. If it is a soft admission, tell them. If you just can't figure out what to do with a guy, ask for help. If it's general surgery or ortho dumping on them, tell them that. It's a short term relationship with the patient, but a long-term one with the hospitalist.

Fourth, be competent. Don't be that guy who's always forcing them to take an admit. If you find you're arguing with them every week and your partners rarely are, you might be the problem. Know what needs to be admitted and what can be worked up as an outpatient. Just because you admitted a bunch of chest pain in residency doesn't mean that's the way it has to be done at your new shop. Maybe at your new shop the incidence of CAD is way lower and you can get a 1-2 day stress test easily.
 
n2b8me said:
6 hours in the ED. We don't have any observation areas.
Click to expand...

The nurses would cut off my head if I did this. In general, either a patient is low-risk enough to discharge with normal EKG/negative and one negative troponin, or high risk enough for obs admission.
 
1. We don't have an ED obs. Some docs I work with do 2 hr trop and decide. I think this is just silly. I am sure it decreases you unstable angina discharges, but not enough for me. Plus another 2 hr in the ED is silly. I do one set and decide either way.

2. Admission via the hospitalists is hospital dependent and you have to go by community care. Some are easy to admit, some are hard. If working in a place that is hard goes against your fiber, then you can find one that is easy. My main job is easy to admit. I can admit a sprained knee if I had to. My locums are more difficult so I have to take alittle more risk. But at the end of the day, you are taking the liability when you discharge someone b/c the hospitalists refuse. When I feel that someone should be admitted and I get a big wall, I pull the "Can you come, evaluate the pt, and discharge them". Most of the time, orders are in before I can go back to surfing the internet. Sometimes they will come, see the pt, and discharge them which is fine with me.

There is a reason I charge a much higher rate working at these difficult hospitals.
 
emergentmd said:
1. We don't have an ED obs. Some docs I work with do 2 hr trop and decide. I think this is just silly. I am sure it decreases you unstable angina discharges, but not enough for me. Plus another 2 hr in the ED is silly. I do one set and decide either way.

2. Admission via the hospitalists is hospital dependent and you have to go by community care. Some are easy to admit, some are hard. If working in a place that is hard goes against your fiber, then you can find one that is easy. My main job is easy to admit. I can admit a sprained knee if I had to. My locums are more difficult so I have to take alittle more risk. But at the end of the day, you are taking the liability when you discharge someone b/c the hospitalists refuse. When I feel that someone should be admitted and I get a big wall, I pull the "Can you come, evaluate the pt, and discharge them". Most of the time, orders are in before I can go back to surfing the internet. Sometimes they will come, see the pt, and discharge them which is fine with me.

There is a reason I charge a much higher rate working at these difficult hospitals.
Click to expand...

Strongly disagree that a 2h trop is silly.
 
emergentmd said:
1. We don't have an ED obs. Some docs I work with do 2 hr trop and decide. I think this is just silly. I am sure it decreases you unstable angina discharges, but not enough for me. Plus another 2 hr in the ED is silly. I do one set and decide either way.
Click to expand...

In fairness to your partners, pretty much every established guideline on the evaluation of low risk chest pain requires a second enzyme, either that or you admitting an awful lot of chest pain.
 
goodoldalky said:
In fairness to your partners, pretty much every established guideline on the evaluation of low risk chest pain requires a second enzyme, either that or you admitting an awful lot of chest pain.
Click to expand...

In most cases a 2hr troponin would be worthless, unless the onset of chest pain was 6 hours. We know that it takes about 8 hours after an episode of ACS for the troponin to approach 100% sensitivity. Most of the patients I see fall into two categories:

1. Chest pain approximately 1-2 hours prior to arrival, which means they get admitted for obs after 1 troponin.
2. Chest pain > 8 hours duration, which means they can go home after negative troponin.
 
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The White Coat Investor said:
First, it helps if they make more money for each admit. The owner of the hospitalist group will take any admission and trolls the ED for more. If he can justify it, he'll take it. His employees, not so much. They'll take the admission, but it's almost passive aggressive- they take 2-3 hours to get the orders in sometimes. But I know who to call....he just has a hard time hiring.

Second, get to know them all personally. That helps.

Third, don't blow smoke. If it is a soft admission, tell them. If you just can't figure out what to do with a guy, ask for help. If it's general surgery or ortho dumping on them, tell them that. It's a short term relationship with the patient, but a long-term one with the hospitalist.

Fourth, be competent. Don't be that guy who's always forcing them to take an admit. If you find you're arguing with them every week and your partners rarely are, you might be the problem. Know what needs to be admitted and what can be worked up as an outpatient. Just because you admitted a bunch of chest pain in residency doesn't mean that's the way it has to be done at your new shop. Maybe at your new shop the incidence of CAD is way lower and you can get a 1-2 day stress test easily.
Click to expand...
I ran this by my hospitalist wife, and she really likes #3. There is one EP at her hospital that always tries to upsell admissions and it universally hated for it, most of the others will say stuff like "little old lady, family just dropped her off for placement, nothing really wrong but I'm in a bind" and get the admission taken care of with only a few choice words about lazy families.
 
VA Hopeful Dr said:
I ran this by my hospitalist wife, and she really likes #3. There is one EP at her hospital that always tries to upsell admissions and it universally hated for it, most of the others will say stuff like "little old lady, family just dropped her off for placement, nothing really wrong but I'm in a bind" and get the admission taken care of with only a few choice words about lazy families.
Click to expand...
THIS.
Tell me it's a soft social admit and I won't be happy about it... I'm just not unhappy at the ED with it.
 
6 hour troponin? In any community ER?! = LOLZ. Admit. I'd be fired if I did this more than twice.

CP + 8 hours of symptoms with any risk factors = unstable angina... Admit.
 
Siggy said:
THIS.
Tell me it's a soft social admit and I won't be happy about it... I'm just not unhappy at the ED with it.
Click to expand...

I asked one of our hospitalists to help me come up with the correct icd 10 diagnosis for someone with no acute complaints who needs admission for placement. They definitely prefer honesty.
 
TimesNewRoman said:
We (collectively) over diagnose unstable angina.
Click to expand...

This is true. You know what else is true? How attorneys over-sue all of us. If you've not yet been a part of this; I don't want to hear any argument from you.
 
TimesNewRoman said:
We (collectively) over diagnose unstable angina.
Click to expand...

Furthermore, I used to be the stalwart of the academic argument... until I sent a man younger than myself (31 at age 33) to the cath lab for his widowmaker LAD lesion.

I can say this with honesty. I called up my attending-buddies from residency and told them about the case. I said this: "Dude; I felt your hand slap me across the face when I considered not calling the cath lab with this patient. I actually, physically moved after you spiritually hit me. Thanks for that."
 
RustedFox said:
6 hour troponin? In any community ER?! = LOLZ. Admit. I'd be fired if I did this more than twice.
CP + 8 hours of symptoms with any risk factors = unstable angina... Admit.
Click to expand...

It all depends on which is more full, your hospital or your ED. We keep running out of hospital beds. If we are boarding patients for admission, it makes complete sense to do serial troponin in the ED (I prefer 3hr...) and if low risk (HEART <=3, etc) send them home with outpatient followup.

The hospitalist think we over admit chest pain, until they seen the huge number of chest pains we actually send home...
 
Janders said:
It all depends on which is more full, your hospital or your ED. We keep running out of hospital beds. If we are boarding patients for admission, it makes complete sense to do serial troponin in the ED (I prefer 3hr...) and if low risk (HEART <=3, etc) send them home with outpatient followup.

The hospitalist think we over admit chest pain, until they seen the huge number of chest pains we actually send home...
Click to expand...

Hey, sounds good. I would have sent my HEART <3 guy right home... or to the cath lab...

Young people aren't healthy anymore. People who don't have risk factors, have undiagnosed risk factors. I never feel bed about admitting these guys for their 12-hour trops. Until "standard of care" changes, and we can't be sent up for (at least, a minimum) a "hit" on the database... eff that noise. Full gig; 12-hour trops... cardio consult... THEN home.
 
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Why did you send him to the cath lab? Benign EKG? Negative trop? Was he truly HEART <3 and you talked cards straight into a cath without a stress?

I see SO many people every day with low risk chest pain. I physically could not admit them all. I agree, the malpractice climate is horrible, but we've done what we can to assuage it-- made a hospital pathway, delineating the HEART score, and a shared decision making handout for the patient to agree with. And certainly if you WANT to admit someone because they make the hair on the back of your neck stand up, that's OK too.

But yeah, I've seen STEMIs in patients who are in their 20s. I've seen two STEMIs the day after the patient passes a stress test. I've seen a STEMI a day after a cath due to a coronary dissection. I've seen a healthy 31yo woman with no risk factors who was HEART <3 but her second trop was 0.02... so we kept her of course and she turned out to be a spontaneous coronary dissection!

Its a crap job, but someone has to do it?
 
Janders said:
Why did you send him to the cath lab? Benign EKG? Negative trop? Was he truly HEART <3 and you talked cards straight into a cath without a stress?

I see SO many people every day with low risk chest pain. I physically could not admit them all. I agree, the malpractice climate is horrible, but we've done what we can to assuage it-- made a hospital pathway, delineating the HEART score, and a shared decision making handout for the patient to agree with. And certainly if you WANT to admit someone because they make the hair on the back of your neck stand up, that's OK too.

But yeah, I've seen STEMIs in patients who are in their 20s. I've seen two STEMIs the day after the patient passes a stress test. I've seen a STEMI a day after a cath due to a coronary dissection. I've seen a healthy 31yo woman with no risk factors who was HEART <3 but her second trop was 0.02... so we kept her of course and she turned out to be a spontaneous coronary dissection!

Its a crap job, but someone has to do it?
Click to expand...

Here's the abridged version. Chest pain, 31 year old male. Sweaty hispanic guy; no shortage of those in the summer in FL. No risk factors. EKG is benign except for what the cardiologist called a "persistent juvenile T-wave pattern" at the end of it all. Guy is pouring sweat, looks pale, looks... BAD, and has that fist tight over the precordium. If those ST-segments weren't up, they just weren't up... yet.

99% LAD. Boom goes the dynamite.
 
RustedFox said:
Hey, sounds good. I would have sent my HEART <3 guy right home... or to the cath lab...

Young people aren't healthy anymore. People who don't have risk factors, have undiagnosed risk factors. I never feel bed about admitting these guys for their 12-hour trops. Until "standard of care" changes, and we can't be sent up for (at least, a minimum) a "hit" on the database... eff that noise. Full gig; 12-hour trops... cardio consult... THEN home.
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Makes me think of an argument I have with my residents on a frequent basis:

Slightly concerning history, normal EKG, young, no RF, trop > 3ULN = HEART of 2, so low MACE...

...but what ED doc in their right mind would ever send home a positive troponin? Even if you don't send them to angio-land, it's still a mother-lovin positive trop!!!

I pretty much use a HEAR score. The T seems ludicrous as stratified & should be binary, with negative = home if HEAR otherwise < 3 & if positive = admit. Full stop. Let someone else figure out why. Too much mental masturbation chafes. d=)

-d

Semper Brunneis Pallium
 
RustedFox said:
If you want to take it that way, then fine. A more useful response would be "hey; let me learn from this".
Click to expand...

I generally don't say "hey, please teach me something" after someone tells me to STFU.
 
RustedFox said:
Hey, sounds good. I would have sent my HEART <3 guy right home... or to the cath lab...

Young people aren't healthy anymore. People who don't have risk factors, have undiagnosed risk factors. I never feel bed about admitting these guys for their 12-hour trops. Until "standard of care" changes, and we can't be sent up for (at least, a minimum) a "hit" on the database... eff that noise. Full gig; 12-hour trops... cardio consult... THEN home.
Click to expand...

I have a hard time believing he'd be less than a 3. Story would give him 2. Abnormal ekg gives him 1. Likely had positive family hx or smoked which gives him another point. Total of 4 I'd guesstimate. Would have done fine by HEART.
 
CanadianEM said:
I have a hard time believing he'd be less than a 3. Story would give him 2. Abnormal ekg gives him 1. Likely had positive family hx or smoked which gives him another point. Total of 4 I'd guesstimate. Would have done fine by HEART.
Click to expand...

You're good to argue this; I couldn't believe it, either.

Story gives him 2.
I'll allow the EKG for "1" argument; but the hyperacute T-waves really weren't that impressive. I've seen much worse.
Zero points for age, risk factors, or TnI.

Total =3.

He would not have done fine. He had a 99% proximal LAD. If I would have sent him home; he likely would have boomeranged, likely worse.
 
RustedFox said:
Super convincing anecdote #eleventy billion
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While I don't dispute that you apparently work in the sickest population in the world, that patient isn't the one you should hang your hat on. HEART wasn't made to send him home. It's made to safely send home the 35 year old who had 10 seconds of pain 8 days ago and now "wants to be checked out."
Clinical decision instruments aren't binding, and you don't have to follow them blindly. We aren't robots. If you think they need admission, admit them. Or make the consult send them home. If you don't think they need it, CDIs are good tools to buff your chart with.
 
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