Transfusions in the ED

[docB]

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This has always been a problem but I've been seeing more of it lately. I'm talking about docs sending patients into the ED for routine stuff that should be done as an outpatient. Transfusions for chronic anemia and dialysis are the big ones but G tube, foley and PICC line placements as well as nursing home evals and studies like CTs and MRIs are all part of the problem.

One especially irksome part of this is when the primaries are reluctant to admit the patients. "Just transfuse her and send her home. That's why I sent her in." I get that a lot. But the fact is that in the ED the non-emergent transfusion of a few units of PRBCs will take 8+ hours. That's too long to tie up an ED bed just so the primary doesn't have to be bothered by it. Dialysis is even worse.

Anyway, I know this is a problem to some degree everywhere. I'm curious how EPs cope with it. I have seen everything from "If it's not emergent we don't do it in the ED period." to "What the heck it's another paying patient." How do you deal with these?

 

[NinerNiner999]

I'm still pretty new to the game, but I try to accommodate these requests with the caveat that I won't "board" any of these patients in the ED. Just the other day I had a patient sent to the ED from the NH for PICC line insertion for chronic UTI. Our department was a mess with patients (Monday). I placed an IV and called radiology to set up PICC line insertion outpatient in two days. I called the referring doctor and told him I was happy to place an IV and dose antibiotics, which could be continued at the nursing home through IV, but that I would be discharging the patient back to the NH. They were ok with this "middle road" path.

I'm pretty firm about transfusion requests, and I will politely suggest that if the referring physician does not want to admit the patient, I would be happy to pass them along to our hospital service. Many of our doctors are concierge physicians and will quickly agree to admit without further discussion.

What really makes me crazy are the patients who are sent to the ED already worked up for admission. For some reason, people like to send me appendicitis confirmed by CT and expect me to arrange the surgery consult and OR. I will politely give these doctors the on-call number of the surgeon and have them arrange a direct admission to the hospital for these. I do the same thing for patients with fresh labs who missed/did not get their required dialysis. I politely refer these to direct admission as well to wait for their HD. My standard reply is something along the lines of "It sounds like you already have your diagnosis and that having them stop by the Emergency Department would probably cause an unnecessary delay in their care. Would you like to arrange a direct admission? - I'm sure it would be quicker and safer."

NH evals are the bain of my existence and I have found these to be unavoidable where I live (SW Florida). I have pretty much succumbed to the fact that these are the inveitable roadblocks of my otherwise smooth day. But then again, sometimes these folks are really sick.

The docs in my town seem to work with me fairly well and understand that I consider my ED as my "office." Just as I wouldn't dump a hand laceration in their waiting room, they seem to be understanding that I won't be treated as their intern when they are too busy. Then again, there are exceptions to everything.

In my shop, I've got plenty of sick patients to see.

What do you like to do with these?

 

[WilcoWorld]

Well I'm working at a county hospital where there are pretty much never beds upstairs to allow for a direct admission, so I don't deal with that issue, but we get dumped on quite often. However, the worst case of ED abuse I think I ever saw was back in residency at a private hospital where an NH patient was sent in at midnight on Saturday for...wait for it... G tube REMOVAL. The patient was recovering from his initial surgery, which I have since forgotten, but I remember that he was alert, oriented & had no complaints. It was just time for his G tube to come out - no infection, pain, nuthin. The NH doc just decided that he needed the G tube out right away. We called him up to give him an earful for sending in such a thing in on a Saturday night & he responded "Does the ER stop providing patient care on weekends?" Grrrrr.

I ended up removing the G tube, but not for the NH doc's sake. It was basically so this guy wouldn't need yet another round trip ambulance ride for this incredibly simple, non-emergent condition.

 

[Jeff698]

I had a primary send me an elderly woman, s/p CVA who was failing to thrive, becoming dehydrated and needed a G-tube. For reasons beyond my current ability to remember (I'm being nice), this wasn't a direct admit.

As soon as they got to me, I called the hospitalist (we're all partners in a large group practice/"we are the Borg and you will be assimilated" sort of group) to admit and get the G-tube placed because there was no more room at my Inn. She promptly refused.

Now I'm stuck with an angry patient with a legitimate issue, a primary and a hospitalist and have nothing to offer the patient except one of my sorely needed beds.


Take care,
Jeff

 

[southerndoc]

In cases of appendicitis, perforated viscous, emergent dialysis, etc., it actually doesn't make sense to do a direct admission. Patients can be tied up for hours in the pre-admission process. My girlfriend was griping the other day that it took an hour of her time to get a patient admitted for pyelonephritis. HMO's balk at just about everything now.

 

[Midwest Medic]

We do not do any out patient transfusions, but do a bit of dialysis. Those are not too bad at our place though. The patient presents, we do a quick once over on them, then call the dialysis unit where they do the rest. Total time in the ED is about 10 minutes. The dialysis unit even does all the lab work on them. NH evals are another story. We only have one hospitalist group, and maybe 2 primaries that admit (if the sun and moon are aligned with Venus they will admit their own, otherwise they go to the hospitalist). A lot of the other primaries send people in to be evaled for NH placement...usually on a Saturday night.

The biggest pain of a dump is from vascular lab. The pt gets a outpt DVT workup, if it is + then to go the ED. We give them a script for Coumadin and Lovenox and away they go...if they can give themselves a shot and insurance covers it. If not we have to argue with the hospitalist on why this guy needs to come in.

 

[roja]

In both places I have worked, the ED has set a strict policy: transfusion and dialysis patients get admitted.

Sadly, it seems that if you open the door a tiny bit for that one or two exceptions it opens a floodgate.

 

[jlw2004]

I work in a rural (~23-25K annual visit) ED. We are the great dumping ground. We do transfusions, PICC lines, medical clearances for our senior psychiatric unit, long term IV antibiotics (that Vanco for osteo that you need daily but insurance won't pay for home nursing care - but will pay for you to come suck up one of my beds for 1-2 hours daily for SIX WEEKS!). Fortunately we got a new director who is trying to limit this. There are alot of advantages to working where I do (good access to primary care, appreciative pts, low cost of living) but this is something I didn't have to deal with working inner city. And our bed situation is usually pretty good. We don't often have multiple inpatient holds, so I guess it's a trade off.

 

[deleted109597]

We fight this battle every day.
1. Sickler comes in with a crit of who cares
2. Start dilaudid
3. Start blood
4. Call medicine
5. Have medicine tell us to call Heme-Onc
6. Call Heme-Onc
7. Have them tell us this is not a hematology problem per se and that they don't admit.
8. Call medicine again
9. Argue with medicine about what qualifies as an admission
10. By the time this is over, usually 1 unit is in.
11. Continue to push for bed
12. Finally get admission order
13. All beds full, pt sits in ED
14. Receives blood almost entirely
15. Medicine comes down and discharges from ED, usually 12-20 hours after they come in
16. Medicine asks us to write dilaudid Rx because they don't want their pristine records tainted by writing lowly narcotics

 

[waterski232002]

So Classic McNinja!