Syncope push back on admission....

[pinipig523]

So I had a patient who had a drop syncope... essentially standing in church and then the next thing he knew, he was sitting down with his head down, does not recall what happened and no recollection of the event.

I call it syncope.

The guy is >80yo and has hx of htn but no vt/vf or chf. VSS on presentation, no chest pain, abd pain or headache to suggest other emergencies, neuro intact on my exam.

So, I did my usual, normal labs including UA and normal EKG w/ normal QT and normal trop. Called for admission, and the pcp (who admits) told me that the syncope happened 2 days ago... and there is nothing they need to do inpatient that was emergent. If it had happened today or yesterday, then he said ok w/ admit but if it's been 2 days, then they should do this as an outpatient work up. I called the cardiologist and he also said that it's been 2 days and that the patient should be worked up as outpatient.

I was just dumbfounded - this was a syncope patient w/o prodrome w/ obvious cardiac risk factors and over the age of 65... yeah, there was no vt/vf or sbp <90 per SF syncope rules, but all signs point to r/o cardiac arrhythmia (i.e. non sustained vtach) until proven otherwise. The 2 days delay in presentation does, I guess, diminish the emergent nature of the presentation and if something were to happen, then it should've happened.

But I was not trained that way and so I still pushed for admission which they did.

What do you guys think? Was I over-conservative? Would you have sent an 85yo home w/ syncope w/o prodrome simply because ED work up was negative and the event occurred 2 days prior?

Interested in hearing your thoughts... thanks!

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[Birdstrike]

What do 80+ year olds have a knack for doing?

Dying.

They have sentinel events like a 20 beat run of non-sustained v-tach like you mention, leading up to sustained V-tach episodes that progress to VFib. They also get weak and dizzy easily, too.

From an EM (and medico-legal perspective) perspective it's a slam-dunk admit. But, I can guarantee you that if that patient walks into the office of a competent internist or cardiologist's office, with the same exact story, they will work it up outpatient and not admit the patient.

It's not black and white. It's a matter of context.

It's one of those things where if you have a history with the other physicians and trust each other you will come to a much more comfortable decision. If you are unfamiliar, it's more contentious.

The expectations are different in the two settings.

The ED is expected to be the super sensitive filter that picks up any severe pathology. A discharge from the ED is seen almost like a 6 month car warrantee. "Couldn't be anything wrong, he went to the ED and they CLEARED him. I guess they must have missed something!"

Whereas if someone arrests 2 weeks after being in the office it's: "That's so shocking. He hadn't even been sick or in the hospital in three years. Nothing was wrong with him. No major complaints, admissions or even any ED visits recently."

Outpatient docs and patients forget that the bar is set much higher in the ED. They're probably right, that he only got a little dizzy in church. But he could still die soon, too. He's 80+ years old!

You're also right, that you (and the patient) gain little if he goes gone and v-fib's because they blew him off. (Of course the Canadian docs will come on here and say we're crazy to admit and CT people like this, because they don't have to worry about med mal.)

It's the art of medicine in 2013





(What would Press-Ganey say you should do?!)

 

[southerndoc]

It's been a while since I've read the SF rules, but didn't they evaluate adverse outcomes in the first 24 hours?

If the syncope happened 2 days ago, then I probably wouldn't have even called the PMD. I would've just sent him home with PMD/cards referral.

 

[pinipig523]

It's been a while since I've read the SF rules, but didn't they evaluate adverse outcomes in the first 24 hours?

If the syncope happened 2 days ago, then I probably wouldn't have even called the PMD. I would've just sent him home with PMD/cards referral.

I think there have been several studies that looked at 7 and 30 day adverse outcomes... (http://www.ncbi.nlm.nih.gov/pubmed/16631985), but I'm not sure of the exact parameters of the original SF Syncope Rule study.

 

[glorfindel]

Good thread.

I'd probably do what the OP did and push to admit him, for the reasons that Birdstrike gave, and some.

This guy was concerned enough about it that he came to the ER, and he's presenting with a condition that could kill him (instantly) --> admit. On the other hand, he wasn't concerned enough to come to the ER right after the event, or even on the same day. What was the matter? Why did he come to the ER now rather than just go see his PMD?

I'm a little uncertain about why the SF syncope rules are relevant at all -- weren't they a set of (subsequently unable-to-be-validated) decision rules that were designed to identify pts at "high risk" for "serious" outcome? They were never really an admit-or-discharge rule, but until the validation study was done, probably functioned as such.

http://www.ncbi.nlm.nih.gov/pubmed/18282636

"... Rule performance to predict serious outcomes was sensitivity 74% (95% CI 61% to 84%), specificity 57% (95% CI 53% to 61%); negative likelihood ratio 0.5 (95% CI 0.3 to 0.7) and positive likelihood ratio 1.7 (95% CI 1.4 to 2.0).
CONCLUSION: In this independent validation study, sensitivity and negative likelihood ratio of the San Francisco Syncope Rule were substantially lower than reported in the original studies and suggest that the rule has limited generalizability."

So what does this guy need asap to minimize the risk of death?

Echo?
Cardiology consult for new meds?
What else?

It's a little disheartening to see pushback on admitting the old syncopal guy, when we continue to tolerate the admission of everyone with vague chest pain.

 

[pinipig523]

It's a little disheartening to see pushback on admitting the old syncopal guy, when we continue to tolerate the admission of everyone with vague chest pain.

I agree.... I seriously thought this was a perfect slam dunk admit.

I mean the guy's not dying, not septic... but has adverse outcome potential nonetheless.

The worst part? The guy's PCP's office TOLD him to come to the ER because this was NOT something to mess with. Then I call the PCP for admission and he's like - send him home.

I was like... WTH? :thumb down:

Way to put me between a rock and hard place, man..

 

[TrumpetDoc]

This is only gonna get waaaay worse.

If you don't have an OBS unit (we don't) then it will be....well not good.
I don't see how hospitals/ERs will be able to function without an OBS unit with the pressures coming to not admit people.
We will only have precious few slam dunk admits coming up (stemi, intubation, etc).
We even have some that already push back on sepsis pts!!...just put PICC, and send home/rehab with IV Abx get palliative consult...I almost lost it at that point!

 

[pinipig523]

We even have some that already push back on sepsis pts!!...just put PICC, and send home/rehab with IV Abx get palliative consult...I almost lost it at that point!

Not cool man.. I don't mind if that's how we've been trained and we're used to that sort of disposition (in addition to the additional litigation that we may face), however, this isn't even how things are supposed EM is supposed to be practiced. This is ridiculous.

 

[EM2BE]

All our hospitalists are also PCPs in the outpatient world. They split and do both. I find them under even more stress trying to balance everything. In addition, they tend to downplay everything we try to admit. Part of it is that they already have a full census and are pushed as much as they can be, and the other part is that they pull the "if I saw them in my office, I wouldn't admit them." The reason they never see anything too bad is because we transfer out the really sick people that need specialists (like emergent dialysis, any head bleeds, any trauma, any overdose, any transplant eval for rejection).

They usually take sepsis without much argument. I found if the patient is intubated, I rarely get any push back. Only time they push back then is if they think the patient may have overdosed. They were never trained in tox and fear getting any sort of tox case. I had to convince them to take a benzo OD because they just needed to be watched and weren't sick enough to transfer. The pts they usually get are the CP, pneumonia, TIA/CVA r/o and sometimes ischemic CVAs, syncope, septic, resp issues, STEMI. They get sick of the same admissions over and over, but don't want to try anything new.

I even had one tell me that they don't deal with allergic reactions. And the patient was already admitted to their service and I was making a courtesy phone call since the patient was boarding and was getting worse again and to let them know I wrote for more IM epi and to consider epi drip for frequency of required IM epi.

 

[glorfindel]

All our hospitalists are also PCPs in the outpatient world.

OMG, that's too bad. Makes me feel lucky to have the hospitalists that I do, who are all either a) just hospitalists and not overstressed with clinic b) newer IM grads doing some hospitalist work, waiting to do fellowship. Comfortable with the whole range of sickies, even benzo ODs.

I found if the patient is intubated, I rarely get any push back.

Whew. That's a relief.

I even had one tell me that they don't deal with allergic reactions. And the patient was already admitted to their service and I was making a courtesy phone call since the patient was boarding and was getting worse again and to let them know I wrote for more IM epi and to consider epi drip for frequency of required IM epi.

Just intubate the guy, citing worsening clinical condition and impending airway compromise... No, wait, you said he was already admitted. Forget what I just said.

 

[EM2BE]

Just intubate the guy, citing worsening clinical condition and impending airway compromise... No, wait, you said he was already admitted. Forget what I just said.

Ha. I almost told him that I'll just have the nurse call him in the future for all patient needs.

 

[glorfindel]

Ha. I almost told him that I'll just have the nurse call him in the future for all patient needs.

I seriously do this, all the time, for boarding patients. They're not my patients -- if the nurse has a treatment question, he/she should ask the treating doctor just as if they were in their comfy ICU or floor bed, instead of being in the ED.

Sure, I'll rush in there when they code due to hypoepinephrinemia, but ordering meds on inpatients (which is what boarders are) is not something I often choose to do.

Sounds like your hospitalist that night was pretty weak.

 

[EM2BE]

I seriously do this, all the time, for boarding patients. They're not my patients -- if the nurse has a treatment question, he/she should ask the treating doctor just as if they were in their comfy ICU or floor bed, instead of being in the ED.

Sure, I'll rush in there when they code due to hypoepinephrinemia, but ordering meds on inpatients (which is what boarders are) is not something I often choose to do.

Sounds like your hospitalist that night was pretty weak.

Just an A**. Well known for this. He was trying to complain about how many patients he had that day and that we better pick and choose wisely about admissions because the beds are full. He even asked me one day if I was going to actually get the patient a bed. I told him as soon as he discharged one.

 

[glorfindel]

He was trying to complain about how many patients he had that day and that we better pick and choose wisely about admissions because the beds are full. .

I like to say when told this (and I have been several times), "Of course! I *always* pick and choose wisely about admissions! Tonight will be no different! Have a nice day!"

Being busy is a poor way to get me to not admit to you. If you ask nice and say, "gee, I'm swamped today, I'm sure you know the feeling" then I'll try my damnedest to admit patients to cardiology, etc, or send them home -- I'm on your side! But if you just give me **** on the phone, I'm not going to go out of my way to help you.

No one that I give **** to on the phone goes out of their way to help me. Seems like a ubiquitous human phenomenon. Surprised this guy wasn't aware of that.

 

[EctopicFetus]

Regarding the OP... Why did the patient come to the ED that day?

 

[glorfindel]

Since it's late and my discussion with EM2BE has tangentialized somewhat....

Here's Z-Dogg MD demonstrating how to block an ED admit:

[YOUTUBE]http://www.youtube.com/watch?v=G78CDQFcw5o[/YOUTUBE]

 

[deleted109597]

Yeah, it would go home at our place unless it was uninsured and had no way to get follow-up.
You've done what you can, make your peace with it and move on. Think of it like a two day stress test. His enzymes didn't bump, he didn't have another event. It was still likely orthostatic hypotension that got him, but you can't admit everyone, and we shouldn't.
God I love Texas.

 

[alreadylernd]

I agree.... I seriously thought this was a perfect slam dunk admit.

I mean the guy's not dying, not septic... but has adverse outcome potential nonetheless.

The worst part? The guy's PCP's office TOLD him to come to the ER because this was NOT something to mess with. Then I call the PCP for admission and he's like - send him home.

And this is the Primary Care Office Two-Step that drives me nuts! If they sent him in, they can DC him (yes, actually come in, see the patient and give him his DC instructions) or admit it. No workup that you did in the ER was any different from what the PCP could have done in the office, and yet they sent him in. Therefore, the only "extra" workup you can offer is prolonged telemetry, possibly expedited echo etc - all done with an admission. If the PCP didn't feel the patient needed that workup, they shouldn't have sent him in.

I love when PCP offices' play up concerns to the patient, "Oooh, that sounds really bad, you need to get to the ER right away for X, Y, and Z" (of course never giving the ER the heads up the patient is coming in) and then when it comes time to admit the patient, suddenly it's no big deal, they should be sent home. Not to go too far off topic, but "Chest Pain" is probably the most common of this scenario (though I guess this guy's syncope is a close relative).

The thing you have to be careful of with these send-ins is if anything goes wrong, just remember, the PCP will remind everyone how concerned they were and that's why they sent the patient to the ER in the first place.

 

[gutonc]

And this is the Primary Care Office Two-Step that drives me nuts! If they sent him in, they can DC him (yes, actually come in, see the patient and give him his DC instructions) or admit it. No workup that you did in the ER was any different from what the PCP could have done in the office, and yet they sent him in. Therefore, the only "extra" workup you can offer is prolonged telemetry, possibly expedited echo etc - all done with an admission. If the PCP didn't feel the patient needed that workup, they shouldn't have sent him in.

I love when PCP offices' play up concerns to the patient, "Oooh, that sounds really bad, you need to get to the ER right away for X, Y, and Z" (of course never giving the ER the heads up the patient is coming in) and then when it comes time to admit the patient, suddenly it's no big deal, they should be sent home. Not to go too far off topic, but "Chest Pain" is probably the most common of this scenario (though I guess this guy's syncope is a close relative).

The thing you have to be careful of with these send-ins is if anything goes wrong, just remember, the PCP will remind everyone how concerned they were and that's why they sent the patient to the ER in the first place.

FWIW, often it's a nurse in the PCP office that does all this, sometimes without the physician even being aware of it until after the fact (like when the ED calls the office to talk to the PCP).

Not excusing, just explaining.

 

[Doctor Bob]

There are a few approaches that I use. This is assuming a syncopal event over 24 hours ago.

If the patient came in by themselves and my workup is negative, then I send them home with a referral to see their PCP, or come back if things change. But I also have a discussion with them about how my tests only show current state and so I can't really say what happened a day or two ago; could be something dangerous, could be something benign and I have no way of knowing what it was.

If the patient was sent by the PCP I always call them and engage them. For me it doesn't matter if the person was sent in by the PCP, by their RN, or by the teenager staffing their after-hours call center; that PCP is getting a phone call. In this kind of patient (unless I think they need to be admitted of their own accord... see situation 1) I tell the PCP the results of my workup, how the patient looks now, and what my plan for the person is. If I think they can go home but the PCP wants to admit them I have no problem with that. If I want to admit them and the PCP says they can go home then we have another discussion.

A reasonable PCP who knows their patients well, who perhaps would not have sent this person in if they had fielded the initial office query themselves can often sway my decision making and I'll send the person home with close followup. An unreasonable PCP who gets irritated that I'm suggesting admission will be given the option of coming in to discharge the patient within the 1hr proscribed by the hospital, or agreeing to the admission over the phone.

 

[EM_Rebuilder]

Yeah, it would go home at our place unless it was uninsured and had no way to get follow-up.
You've done what you can, make your peace with it and move on. Think of it like a two day stress test. His enzymes didn't bump, he didn't have another event. It was still likely orthostatic hypotension that got him, but you can't admit everyone, and we shouldn't.
God I love Texas.

+2 for Texas.


I'd agree, he was high risk, but he was sort of obs for 2 days and has close verbal direct FU with a PCP. Pick your battles, I don't think this is the ideal one to pick.

Document well as we'll as the consultant discussion. That documentation CAN aid you in a suit opposed to popular belief. It's has to be documented explicitly "I d/w Dr PCP, I conveyed my concerns of an underlying cardiac event. dr understood my concerns, wishes to FU in his clinic on Wed at 3PM." Some say its throwing under the bus, but I call it protecting my family.

 

[gutonc]

If the patient was sent by the PCP I always call them and engage them. For me it doesn't matter if the person was sent in by the PCP, by their RN, or by the teenager staffing their after-hours call center; that PCP is getting a phone call.

I wasn't suggesting they shouldn't get a call, just that getting mad at a doc who "sent the patient in" when they didn't actually send the patient in is counterproductive.

 

[Croooz]

So I had a patient who had a drop syncope... essentially standing in church and then the next thing he knew, he was sitting down with his head down, does not recall what happened and no recollection of the event.

I call it syncope.

If you were Pentecostal/Charismatic you'd say he was "slain in the Spirit."

 

[gman33]

I thought > 80 = admission no matter what they came in for

 

[Cerberus]

I thought > 80 = admission no matter what they came in for

If that was true my hospital would have like a 60% admission rate

 

[Arcan57]

I wasn't suggesting they shouldn't get a call, just that getting mad at a doc who "sent the patient in" when they didn't actually send the patient in is counterproductive.

How so? The office worker that sent the patient to the ED was employed by that doc (in most cases) and was acting as that doctor's agent. If the doc fails to provide clear guidelines on when to refer patient to the ED (vs. getting in touch with the patient themselves) then they are culpable. It's a convenient shield to hide behind, but using it to avoid responsibility for the outcome of an unnecessary ED visit is all too common.

 

[Old_Mil]

(Of course the Canadian docs will come on here and say we're crazy to admit and CT people like this, because they don't have to worry about med mal.)

This.

Friend of mine who is an FP is currently getting sued. Short story: Overweight pt in his 50s comes to him complaining of intermittent non-exertional chest pain. No active symptoms at the time of his office visit. He orders an EKG, labs, and a stress test. Aside from high cholesterol, all these are normal - including the stress test. So he works with the guy, gets him on a statin, gets him to lose weight. Six months out, this guy drops dead.

Lawsuit. So the guy probably had balanced multi-vessel disease and a false negative stress test and had his MI. Should he have referred the patient? Would a cardiologist have done the same thing, or taken him to the cath lab and discovered this and sent him for his CABG?

In the end, the disposition for all this - whether it is our admission of a syncope patient or an FM either sending someone to the ER or to a cardiologist - is all about having a chair to sit in when the music stops.

 

[napster]

+2 for Texas.


Document well as we'll as the consultant discussion. That documentation CAN aid you in a suit opposed to popular belief. It's has to be documented explicitly "I d/w Dr PCP, I conveyed my concerns of an underlying cardiac event. dr understood my concerns, wishes to FU in his clinic on Wed at 3PM." Some say its throwing under the bus, but I call it protecting my family.

Actually, it seems like throwing yourself under the bus. I am always leery of documenting a conversation with a PCP or consultant in which I state my concern for serious illness in patient X yet I am convinced to discharge him because of my discussion with said PCP/consultant who has not done a bedside evaluation of pt.

 

[RustedFox]

If that was true my hospital would have like a 60% admission rate

Ha ha.... I work on the gulf coast of Florida. I'm an "admittedly, nyuk-nyuk" admit-happy doc.

I would admit 85+ percent of my patients if this were true.

 

[Rendar5]

Ha ha.... I work on the gulf coast of Florida. I'm an "admittedly, nyuk-nyuk" admit-happy doc.

I would admit 85+ percent of my patients if this were true.

Which county if you don't mind my asking? I'm over in Pinellas. Curious where the FL docs practice.

 

[RustedFox]

Which county if you don't mind my asking? I'm over in Pinellas. Curious where the FL docs practice.

PM'ed.

 

[Doctor Bob]

I wasn't suggesting they shouldn't get a call, just that getting mad at a doc who "sent the patient in" when they didn't actually send the patient in is counterproductive.

Yes, that's true. Sometimes they're just as surprised when I tell them the patient was sent here.

 

[pinipig523]

Yes, that's true. Sometimes they're just as surprised when I tell them the patient was sent here.

I basically told the PMD that he put me in a bind. That his sending the patient to the ER has essentially tied my hands behind my back. That a syncope is not to be messed with and although the patient has "obs'd" himself from the event 2 days ago, a non sustained vtach is still in the differential and still a possibility and for this, he must be admitted and a work up be done.

He agreed and the patient was admitted.

Nothing came of the admission, however, and I spoke to the PMD again a few days later. He agreed that I was placed in a tough spot and I told him that sending home a patient for syncope work up from the Er is much different than sending home a patient for syncope work up from the PMD's office. One is an outpatient work up no matter what you do, the other is an inpatient w/up from the Er.