Transfer or admit?

[Old_Mil]

Elderly closed hip fracture as an isolated injury comes in to your community ED. Ortho is out of town for the weekend and the ortho PA is taking call. The actual MD is available by phone only. PA is willing to come see the patient but the actual MD won't be able to for at least 24 hours. PA cannot admit and wants the unassigned patient admitted to family medicine with an ortho consult.

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[Rendar5]

honestly, hospitalist routinely admits this at my shop. wouldn't be an issue for me. though I may look for another ortho doc in the area for a favor if this would lead to a delay in operative care.

 

[Birdstrike]

Admit, but to ortho. "PA can't admit" sounds like a cop out and a dump. It's BS that you are out in the middle of this.

 

[RustedFox]

Holy balls. I'll admit the patient (if I had privileges). Its not hard to write holding orders for a day.

I get it. Ortho does a tough job. A job that I couldn't do. But for realsies.

ADC VANDALISM. (If you don't know what this means, you're probably not a MS 3/4 yet).

 

[Rendar5]

you do have the option of calling the orthopedist by phone and asking if it can be admitted under his name with his PA to see him for now.

 

[Old_Mil]

Well, first I transferred. On call for me means that you are available to manage the patient locally, and not sitting on a lake with your PA fielding calls with no ability to provide definitive care. One of those deals where the outcome determines everything. If everything goes well, and life is good. If the patient takes a turn for the worse or dies - and the mortality on these things is pretty high for old folks - you are the goat for admitting to a facility where the nearest ortho was a few hours away.

I love the no win situations you face in this field on a daily basis.

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[EM_Rebuilder]

Older folks with multiple medical problems... I think they are better admitted to IM.

So what if they dont get their hip fixed for 24 hours; we have in house everything and a busy Ortho service.. so busy that I bet most of our hips get fixed 24-48 hours post admission.


I think transferring was ok to; but I think keeping them would have been ok. I see no reason for Ortho to need to see them in the EC...

 

[RustedFox]

Correct me if I'm wrong. And I can be wrong: but... a simple closed hip fx can sit for a day or two before going to the OR. I remember being on my IM rotations and "holding" the patient for "medical optimization" for longer for "this, and other surgical procedures".

 

[Apollyon]

Admit, but to ortho. "PA can't admit" sounds like a cop out and a dump. It's BS that you are out in the middle of this.

There is no ortho attending - if the PA does not have admitting privileges, your advice is not applicable.

It would be nice to do that, but I, for one, live in a more realistic world, where, when I DO happen to have ortho on call, they will NOT admit if the patient has comorbidities, which is supported by the primary care admitting docs, and administration.

There is NO ortho coverage. How do you admit to ortho? I would have to transfer out this patient (which is what I do on weekends when we have no ortho coverage).

 

[Siggy]

Older folks with multiple medical problems... I think they are better admitted to IM.

[YOUTUBE]http://www.youtube.com/watch?v=39xiIgUXIpE[/YOUTUBE]

 

[EM2BE]

Just a few years ago, our IM attendings weren't even in house at night. A phone call was made by the resident to attendings at home and pt was admitted to their service and they would see them the following day. We still have this happen with surgery, ortho, OB/GYN, peds, urology, etc. Not sure how this is any different. Then again, not sure how okay it is that no one is in house at the hospital either. They do have the ability to come in if needed though - supposed to be within 30 min of hospital and available.

 

[The White Coat Investor]

Give me a break. Admit it to the hospitalist. Ortho takes it to the OR in 24-48 hours. What's so hard about that? The PA has nothing to do with any of it.

 

[Arcan57]

Give me a break. Admit it to the hospitalist. Ortho takes it to the OR in 24-48 hours. What's so hard about that? The PA has nothing to do with any of it.

Old hip fractures do better when admitted to IM vs. ortho. In terms of delay, I had always been taught that early=less M&M but a quick lit search prior to this post shows that the evidence is quite on both sides of the argument.

 

[Socrates25]

I dont understand everybody stating that IM is a better admission option than ortho.

If the pt has unstable medical problems, then sure, admit to IM. If her blood pressure is out of whack thats one thing.

But if everything else is fine and literally the only thing she needs is hip surgery and to continue her regular 20 medications that she's been on the same dose of for the last 10 years then admitting to ortho is a better option. The ortho PA/resident can enter those 20 medications in the computer just as easily as the IM intern can.

Yes, I know ortho doesnt want to run their own service, they just want everybody admitted to other services so they can "consult" and not have to do any discharge paperwork or get paged to bedside out of their cases the next day. Yes I guess I just called them lazy.

 

[Old_Mil]

My issue was admitting to or consulting a specialist with the real world availability of a nighthawk radiologist...not making one service or another primary.

 

[Arcan57]

I dont understand everybody stating that IM is a better admission option than ortho.

If the pt has unstable medical problems, then sure, admit to IM. If her blood pressure is out of whack thats one thing.

But if everything else is fine and literally the only thing she needs is hip surgery and to continue her regular 20 medications that she's been on the same dose of for the last 10 years then admitting to ortho is a better option. The ortho PA/resident can enter those 20 medications in the computer just as easily as the IM intern can.

Yes, I know ortho doesnt want to run their own service, they just want everybody admitted to other services so they can "consult" and not have to do any discharge paperwork or get paged to bedside out of their cases the next day. Yes I guess I just called them lazy.

Academics vs. community. In the community without residents and an ortho attending that hasn't managed any medical problems besides post-op pain in 10 years, the IM attending is a better fit. Probably a quarter of those 20 meds are going to need to be held or adjusted due to NPO status and post-operative condition. And nobody on 20 meds is really "stable" from a medicine standpoint, at least to a level of reliability sufficient to ward off occasional serious safety events.

 

[dchristismi]

I have an all-or-nothing ortho situation (no midlevels), but if I have ortho coverage within 24h, I will try to sell it to medicine rather than transfer. I have a lot of old folks, no residents (either ortho or IM), and as was mentioned, community medicine ain't the ivory tower. My ortho guys won't admit anyone under 50 it seems. I'd MUCH rather have my hospitalists looking over granny, even if ortho won't make it in for 24. She's going to need cardiac clearance, and possibly have her anticoagulants changed - ortho won't be taking her for at least 24h anyway.

I'd be comfortable admitting. But that's just me.

 

[glorfindel]

As an ER doc, I ask myself: "what makes me more comfortable about admitting to ortho vs family or internal medicine?" The answer is, the attending orthopedic surgeon confidently requests admission to him/her self.

Anything else, I like to admit to the FM/IM with ortho consult.

As an elderly patient, I'd also be far more comfortable if I were on an FM or IM service with ortho consulting.

So in answer to the original question: I'd be equally comfortable admitting to FM or transferring. For me, pushing for a primary ortho admit is 3rd place, given the scenario you described.

 

[cpants]

Academics vs. community. In the community without residents and an ortho attending that hasn't managed any medical problems besides post-op pain in 10 years, the IM attending is a better fit. Probably a quarter of those 20 meds are going to need to be held or adjusted due to NPO status and post-operative condition. And nobody on 20 meds is really "stable" from a medicine standpoint, at least to a level of reliability sufficient to ward off occasional serious safety events.

This. The reality is that we are a supersubspecialized world these days. I strongly believe that in most cases that it's not the best thing for these old patients with 20 meds/comorbids and an isolated surgical problem to be managed by the surgical team. If it's a 20 year old with cholecystitis, yes I understand the feeling that it's a dump. But if it's a 75 year old with cardiomyopathy, CHF, afib, poorly controlled DM, and a million other things now with gross hematuria, don't you at least want a team with people in-house to be taking care of them? In the real world, medicine loves these admits anyway. It's generally not much work for them and they actually make their money from admits and rounding unlike the surgeons. I also don't feel that it's "lazy" as it's basically the same amount of work for the surgical team no matter who the patient gets admitted to. I still go in and see the patient, do a consult, operate, round on the patient daily. At best I'm getting out of a few phone calls and a discharge summary.

 

[Bostonredsox]

Stop it, we admit all of them. Ortho doesnt admit anything themselves except a 45 year old trauma with an isolated Tib fx or fem neck fx. Anyone over the age of 60 who is on more than 4 medicines they say 'admit to medicine and consult us'. They do not want to do the work of actually seeing the pt, writing all the admit orders, Doing an H/P, getting the pt a SNF spot for rehab at D/c, writing all the D/C orders and scripts, and then doing a DC summary. They want to show up the next morning, have their PA dictate a 2 paragraph consult saying, "femur broken, will fix, rest of care per medicine", then take them to the OR, then sign off. That is the way of the world at every hospital that doesn't have ortho residents. Community attendings do not want to be bothered with the work of admitting a pt, despite it taking me all of 15 minutes, nor managing their meds. I used to bitch and bitch about this as it is a pure dump, same as gen surg having me admit acute GB's with a consult to them for the LC. I have now realised it is easier for me to just admit them myself, preop risk stratify them and get all of their ducks in a row/meds managed, have ortho see them and operate on them vs let ortho admit them, then consult me to fix everything they ignored on admission. And their is data that shows that the elderly high co-morbidity pt do better in the hands of the hospitalist pre and post op then under the guise of the surgeon with a medicine consult. Less post op CHF and COPD flares, shorter LOS, etc.

 

[WilcoWorld]

Stop it, we admit all of them. Ortho doesnt admit anything themselves except a 45 year old trauma with an isolated Tib fx or fem neck fx. Anyone over the age of 60 who is on more than 4 medicines they say 'admit to medicine and consult us'. They do not want to do the work of actually seeing the pt, writing all the admit orders, Doing an H/P, getting the pt a SNF spot for rehab at D/c, writing all the D/C orders and scripts, and then doing a DC summary. They want to show up the next morning, have their PA dictate a 2 paragraph consult saying, "femur broken, will fix, rest of care per medicine", then take them to the OR, then sign off. That is the way of the world at every hospital that doesn't have ortho residents. Community attendings do not want to be bothered with the work of admitting a pt, despite it taking me all of 15 minutes, nor managing their meds. I used to bitch and bitch about this as it is a pure dump, same as gen surg having me admit acute GB's with a consult to them for the LC. I have now realised it is easier for me to just admit them myself, preop risk stratify them and get all of their ducks in a row/meds managed, have ortho see them and operate on them vs let ortho admit them, then consult me to fix everything they ignored on admission. And their is data that shows that the elderly high co-morbidity pt do better in the hands of the hospitalist pre and post op then under the guise of the surgeon with a medicine consult. Less post op CHF and COPD flares, shorter LOS, etc.

Citations please.

 

[BJJVP]

Stop it, we admit all of them. Ortho doesnt admit anything themselves except a 45 year old trauma with an isolated Tib fx or fem neck fx.

Actually, in the case you mention above, most orthopedic surgeons I've dealt with will say 1) isolated tib fx's should go home and return for signs of compartment syndrome or 2) admit to Trauma Team because they don't know how to handle pts with alcohol intoxication/withdrawal.

 

[Groove]

I'd get the Orthopod on the phone given that scenario and have him tell me what his PA is telling me, that he wants pt on FM for medical management, pre-op, pain control, PA consult, blah blah and I would be sure to document that. I'd then talk to FM and and facilitate it that way if FM was amenable. I'm not looking at any literature but I think that sounds reasonable. Most of those don't ever seem to go straight to the OR anyway, especially with old folks.

If any hairiness or if it paralyzed my decision making ability for any more than 10 secs, I'd have done like you did...transfer and be done with it.

Next patient.

 

[cpants]

While I think an FM admit is reasonable, I also think it's reasonable for FM to refuse to admit on the basis of having no ortho coverage. No orthopedic surgeon seeing the patient for 48 hours wouldn't be acceptable to me if I were admitting the patient. Nor would no coverage on the weekends. I know I wouldn't want to be on my own managing a hip fracture for a couple of days. It's also pretty enabling to the orthopod if his weekend consults just get to fill up his monday OR schedule without his actually evaluating the patients or being available all weekend

 

[Bostonredsox]

Ok multiple responses here,

Wilco, I will look for the data for you, it was presented a few months back by our hospitalist director when several of the hospitalists were bitching about all the ortho dumps we were getting.

I used Tib Fx as an example, but lets say acetabular fx, femoral neck fx, any of those, ortho will still admit to medicine most places I have been. We do not have a trauma team. It is whatever GS is on in collaboration with whatever orthopod is on. And unless it is something that will take them to the OR that night, they get admitted to medicine.

Now, if their is no ortho backup, and it was something that could be remotely construed as unstable, IM/FP could reasonably say please ship that pt. If it was a pubic rami fx you are essentially admitting for pain control and rehab, I would probably take that pt even without ortho backup.