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docB

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So now under the new JCAHO "ED Medication Reconciliation Program" or whatever EPs are expected to create a full list of each patient's outpt meds with dosages, routes, etc. and to independently verify these with each patient's pharmacy and primary care doc and them to make a recommendation on each med about whether they should keep taking it as is, stop it or change the dose. Every patient, every med. We figure this mess will cost us at least 2 to 3 patient visits per doc per day. Oh well, if the EPs aren't forced to do the primary care who will?

And before everyone comes back with "Well you're suppose to do that anyway." no one is routinely listing every med, every dose and making a recommendation on each drug for every visit. And remember that JCAHO wants this to be a doc chore, not a nurse chore.

On a side note I did have some fun a JCAHO's expense last week. I did a full, idiotic, JCAHO style time out before a conscious sedation and reduction of an angulated ankle fracture in the ED. We had two nurses verify that we were doing it to the correct patient (we figured it was the one with the ankle pointing to the side but we checked anyway). I signed my name on the ankle (otherwise I might have tried to reduce the non fractured, non angulated ankle, thanks JCAHO!). We verified that the patient was in the correct position (who put him in the ventral lithotomy position?!). We verified that we were using the correct devices (we were originally going to try to splint him with foley catheters, lucky thing we checked! Whew, thanks again JCAHO!). It was a hoot. Everyone was laughing including the patient. He even came to chuckling after the etomidate wore off. Great fun. Stupid policy.
 

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The correct response to this requirement is that every drug is toxic.
My handy epocrates can list 10-30 adverse effects for every drug on a given patients list. I cannot confirm every diagnosis previously given therefore I certainly cannot recommend the pharmaceutical txs.

The appropriate response form will read:
"Given the subjective account of your history, I cannot recommend any of the poisons listed and previously prescribed by your primary care physician, pa, shaman or wal-mart employee. In my professional opinion, given the limited information available on this dark night, you should follow your judgement regarding the efficacy of your previously paid for drugs and the trust you have in your pcp. I recommend the following rxs. for your emergent complaint.

If this is not satisfactory, please have a seat by drunk #4 until 8am when your pcp that could not see you in the first place is available to defend his decision making."
 
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doctawife

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I've been doing "time outs" for the last several years, 'cause our inspection was in 2005-2006 - but then again, I'm in a pedi ER. So basically, I have a sticker I fill out for every LP I do. And a different sticker for conscious sedations. But it isn't hard.

However, if I had to verify every med and every dose for a congenital heart disease child or multiply handicapped MRCP child or whatever I would go INSANE. I can't even imagine how stupid verifying medications sounds to an adult EM doc.

Damn, I'm glad I'm only interested in children. <shudder>
 

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JACHO is an organization which serves no purpose. All they do is make it harder, more expensive, and more time-consuming to do our jobs. Many of the rules they make up have no rational basis.

I'm still convinced the "no eating or drinking in a patient care area" was contrived by a disgruntled nurse to make ER docs lives miserable. How many of us have the time on a busy shift to leave the ED to go and eat? Furthermore the patients get to eat in a "patient care area", and I assure you most of them are less hygenic, and none wash their hands afterwards.
 

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I've been in acute hospital pharmacy for 30 years & I have to admit I've seen some particularly ill thought out ideas from JCAHO (I won't say stupid - that diminshes whatever good they might do).

BUT - this lastest version of medication reconcilliation is nothing less than paper pushing for absolutely NO identifiable reason whatsoever!

No one on the other end (ie - discharge) looks at it (except the pts primary and I have my doubts on that as well)! Additionally....JCAHO seems to think the only health care providers are the pts primary care physician. But, upon discharge....the record of drug changes doesn't go to that pts dentist, ophthalmogist, gynecologist, urologist, dermatologist AND....the person who sees that individual every month - the outpt pharmacist!!! Does the pt remember the changes???? I can tell you - no they cannot!

It is just a mechanism for employees to write, rewrite & rewrite yet again the same information which, IMO, albeit limited experience of following hospitalized pts & their drug orders - always was rewritten when the pt changed level of service (ie post-op to ICU to TCU to medicine to snf...)

The fact that this silly paper pushing has been "dumped" on pharmacists is certainly not welcomed by us! We were always pretty good at calling to get the dopamine standing order stopped when the pt tx to medicine if it was forgotten - we aren't completely without sense!

AAAaaah - in my next life I'll be a JCAHO inspector & check off any d*#n box I want!
 

danielmd06

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So now under the new JCAHO "ED Medication Reconciliation Program" or whatever EPs are expected to create a full list of each patient's outpt meds with dosages, routes, etc. and to independently verify these with each patient's pharmacy and primary care doc and them to make a recommendation on each med about whether they should keep taking it as is, stop it or change the dose. Every patient, every med. We figure this mess will cost us at least 2 to 3 patient visits per doc per day. Oh well, if the EPs aren't forced to do the primary care who will?

And before everyone comes back with "Well you're suppose to do that anyway." no one is routinely listing every med, every dose and making a recommendation on each drug for every visit.

First, I've got to say that you have a wonderful signature. ;)

Second, I would like to be very clear that I have great respect for Emergency Medicine docs.

My POV as a prelim IM this year over this issue?

My biggest gripe with the majority of admissions I took for IM was the consistent lack of a medication list from the ER.

The list was never included in an EP's note, and rarely included in a nurse's note. I could count on one hand the number of instances that the list of medications on the nurse's note was complete, correct, and included dosages for the year so far.

My point? It would be immeasurably helpful if I could consistently get a complete and accurate list of medications from the ED, and I don't believe that it is inappropriate to expect that information to be acquired by ED personnel prior to calling an admitting service.

Now about the other JCAHO ideas...
 

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First, I've got to say that you have a wonderful signature. ;)

Second, I would like to be very clear that I have great respect for Emergency Medicine docs.

My POV as a prelim IM this year over this issue?

My biggest gripe with the majority of admissions I took for IM was the consistent lack of a medication list from the ER.

The list was never included in an EP's note, and rarely included in a nurse's note. I could count on one hand the number of instances that the list of medications on the nurse's note was complete, correct, and included dosages for the year so far.

My point? It would be immeasurably helpful if I could consistently get a complete and accurate list of medications from the ED, and I don't believe that it is inappropriate to expect that information to be acquired by ED personnel prior to calling an admitting service.

Now about the other JCAHO ideas...
Good points but I respectfully disagree. In the ED we are usually (not sometimes but usually) functioning in a vacuum of info. Patients only know they take the little white pill, they don't know dosage if they do know the name and they are often wrong about what meds they take altogether. Patient charts are slow in coming and PMDs don't know what the patient is on unless they are in the office looking at the outpt chart. It is appropriate for me to know the RELAVENT meds, eg. the bleeder on coumadin, plavix, etc. but to ask the ED to create a comprehensive list of every patient's meds is just too cumbersome. It will impede patient flow and is an unwise use of resources.
 

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First, I've got to say that you have a wonderful signature. ;)

Second, I would like to be very clear that I have great respect for Emergency Medicine docs.

My POV as a prelim IM this year over this issue?

My biggest gripe with the majority of admissions I took for IM was the consistent lack of a medication list from the ER.

The list was never included in an EP's note, and rarely included in a nurse's note. I could count on one hand the number of instances that the list of medications on the nurse's note was complete, correct, and included dosages for the year so far.

My point? It would be immeasurably helpful if I could consistently get a complete and accurate list of medications from the ED, and I don't believe that it is inappropriate to expect that information to be acquired by ED personnel prior to calling an admitting service.

Now about the other JCAHO ideas...


Our goal in the ED is to evaluate the patient, stabilize any emergent conditions, and then either discharge the patient or admit the patient. If the patient is there for cellulitis of the arm and needs admission for IV antibiotics, I personally don't care what anti-hypertensives or psych meds the patient is on. Going through each medication and verifying it with the patient prior to admission is a poor use of ED physician time. In fact, it's something that's within the realm of the IM doctor admitting the patient, as during the hospital stay the patient will have their medications optimized.
 

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I have practiced both in an academic inner city setting as well as presently doing some time in a community setting. I can say that there is night and day difference in accomplishing this task.

What some hospitals have started to do is to hand the patients a sheet of paper asking all of the info including medicines and dosage, when they were started on the meds, who the primary care doctor is, which pharmacy they use is, etc. The nurses then confirm this and the physician then just circles the little box indicating see nurses' notes.

What really helps is when patients carry around a listing of their medicines that can then easily be copied.

So, for those primary care doctors, the best thing you can do to help the EM people in turn help the admitting team is to get the patients a listing of their meds that they can keep in their wallet at all times.
 

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First, I've got to say that you have a wonderful signature. ;)

Second, I would like to be very clear that I have great respect for Emergency Medicine docs.

My POV as a prelim IM this year over this issue?

My biggest gripe with the majority of admissions I took for IM was the consistent lack of a medication list from the ER.

The list was never included in an EP's note, and rarely included in a nurse's note. I could count on one hand the number of instances that the list of medications on the nurse's note was complete, correct, and included dosages for the year so far.

My point? It would be immeasurably helpful if I could consistently get a complete and accurate list of medications from the ED, and I don't believe that it is inappropriate to expect that information to be acquired by ED personnel prior to calling an admitting service.

Now about the other JCAHO ideas...

I can't tell you the last time I met a patient who knew their medication doses. If the patient doesn't know them and is not within the hospital system, how is the EP supposed to get meds and doses? Call the patients PCP? I'm sure they'd LOVE that. If the patient is already IN the hospital system, the meds should be in there anyways.
 

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Excellent points...and I greatly appreciate the politeness of your response, DocB.

However, I would submit that an admitting physician is operating under the exact same vacuum of information that the ED physician is. Now, your contention about patient flow and use of resources is perfectly understandable to me. I would make that same argument for both of us.

I rarely get a single admission at a time, and it is extremely difficult to handle multiple admissions simultaneously while tracking down twenty medications per patient.
 

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Maybe it's just daydreaming.... but wouldn't it make more sense for there to be an accessible online database e.g. that pharmacists and PMDs update that all EPs, etc could look at? This seems to be a better solution, than with each change of care there having to derive it from phone calls, discussions with family, etc.

All other industries have some type of standardization of processes, why shouldn't medicine? Particularly, on things like medical records, medications, allergies, etc.
 
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danielmd06

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Our goal in the ED is to evaluate the patient, stabilize any emergent conditions, and then either discharge the patient or admit the patient. If the patient is there for cellulitis of the arm and needs admission for IV antibiotics, I personally don't care what anti-hypertensives or psych meds the patient is on. Going through each medication and verifying it with the patient prior to admission is a poor use of ED physician time. In fact, it's something that's within the realm of the IM doctor admitting the patient, as during the hospital stay the patient will have their medications optimized.

I didn't realize that there would be so many posts between my last and DocB's.

My contention is not that an ED doc should obtain a medication inventory for every single patient that enters the ED. I feel that this would be unrealistic and unreasonable.

But the patients who are actually going to be admitted to the hospital? I respectfully feel that in this situation it is appropriate to expect a complete medication list to be included in the chart given to the admitting physician.
 

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I didn't realize that there would be so many posts between my last and DocB's.

My contention is not that an ED doc should obtain a medication inventory for every single patient that enters the ED. I feel that this would be unrealistic and unreasonable.

But the patients who are actually going to be admitted to the hospital? I respectfully feel that in this situation it is appropriate to expect a complete medication list to be included in the chart given to the admitting physician.

Keep expecting.

mike
 

danielmd06

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Maybe it's just daydreaming.... but wouldn't it make more sense for there to be an accessible online database e.g. that pharmacists and PMDs update that all EPs, etc could look at? This seems to be a better solution, than with each change of care there having to derive it from phone calls, discussions with family, etc.

All other industries have some type of standardization of processes, why shouldn't medicine? Particularly, on things like medical records, medications, allergies, etc.

I agree.

If radiology reports, op reports, and a multi-year history of lab work can be obtained through a computer database, then why not a list of medications?
 
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I agree.

If radiology reports, op reports, and a multi-year history of lab work can be obtained through a computer database, then why not a list of medications?

Because the rads, operations, and lab work are static - they're done and done. If the patient needs a new one, it's not a 10-second thing (which I can - literally - write a prescription in) - the rads or lab or OR takes a finite amount of time and has a macro, concrete result. With a list of 10 medications, for example, it becomes functionally infinitesimal as to dosages and frequencies, and changes, additions, and subtractions are fluid. Moreover, the labs, operations, and rads are in a singular place, whereas there are - literally, again - hundreds of times as many doctor's offices, duplicating as much of electronic recordkeeping would be prohibitively expensive, in conjunction with, for whatever reason, providers not complying.

Possible? Theoretically. Logical? Yes. Practical? Not in the foreseeable future.
 

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Maybe it's just daydreaming.... but wouldn't it make more sense for there to be an accessible online database e.g. that pharmacists and PMDs update that all EPs, etc could look at? This seems to be a better solution, than with each change of care there having to derive it from phone calls, discussions with family, etc.

All other industries have some type of standardization of processes, why shouldn't medicine? Particularly, on things like medical records, medications, allergies, etc.

This is not a new idea & has & is being discussed in depth.

You can get some insight into the legal, ethical & privacy issues by googling icmcc which is the international council on medical & care compunetics.

One huge issue is the digital format. It took 15 years to have all third party payers utilize one digital format for pharmacy reimbursement. Can you imagine interfacing all the other players? Each provider must be able to access & put on the significant digital data in the same format - a monumental task right now.

Likewise......there are a significant number of ER pts who do NOT want their entire pharmaceutical history told & for a specific reason. How many times do you not get an accurate hx from the pt - sometimes its by design.

The bottom line....someone needs to obtain the drug hx - if it is significant to the dx & further tx. But, as someone said...the ER is not necessarily the time nor the place - similarly to the social hx - if the pt has support at home or has a religious affiliation - that can often come later.

No one argues that the drug hx is important....but, JCAHO has come up with a tremendously cumbersome method & one which, if you look at its purpose, was designed to be sure all players knew what the pt was on & what was changed.

However - it does not do what it was intended to do - no other provider knows what that pt is discharged with since copies of the discharge summary are only sent to the primary or designated specialists (surgeons, etc). Each admit starts over from scratch.
 

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King/Drew had the most psychotic, reactionary way of dealing with JCAHO guidelines I've ever seen. They instituted a medication reconciliation form over a year ago. This was usually filled out by the triage nurse in triage. Any medications given to the patient were added to the form by the patient's nurse. The ED physician's duty was to verify the accuracy of this data and sign the paper. Since our patients don't know what drugs they are on, and don't have a primary doctor, it was futile to reconcile it with them. Therefore we would usually just sign the form. It took 30 seconds.

I will never call up a PMD for every patient and verify what drugs they are on. If that becomes expected practice, then I will quit medicine altogether.
 

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....I will never call up a PMD for every patient and verify what drugs they are on. If that becomes expected practice, then I will quit medicine altogether.


Admittedly (no pun intended), the ER is just about as much of a dumping ground as the medicine ward. I respect the fact that multiple admissions can be maddening, but the ER is most definitely NOT the place for medication reconciliation. For the past two days, we've had over 30 patients waiting to be triaged... no available beds.... And what's worse, I'm actually doing my "community ED" rotation!!! In between two cardiac arrests, one symptomatic bradycardia patient requiring a transvenous pacer, an older woman in florid pulmonary edema in need of intubation, and ten thousand pregnant and bleeding patients, I have NO spare time to reconcile someone's list. Its actually quite painful probing the depths of a dialysis patient's memory to figure out the identity of their "five little pink pills." Predictably, this mental exercise occurs while trying to conjure up new and interesting ways to effect intravenous access. Its quite sad that these rules are created by people who obviously have no clue about the daily chaos that takes place in a busy emergency department... Sigh.

-push

PS: Done venting for now... almost. Speaking of absurd compliance regulations, how many times have you violated HIPPA laws today? I've never talked about patients by name in a hospital elevator, but I most definitely have been forced to take patient histories behind a curtain. I don't think that curtain was soundproof, either. :)
 

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So are we going to get dings for discharging a pt without upping their bp meds if it is not at goal too?
 

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Excellent points...and I greatly appreciate the politeness of your response, DocB.

However, I would submit that an admitting physician is operating under the exact same vacuum of information that the ED physician is. Now, your contention about patient flow and use of resources is perfectly understandable to me. I would make that same argument for both of us.

I rarely get a single admission at a time, and it is extremely difficult to handle multiple admissions simultaneously while tracking down twenty medications per patient.

We NEVER get just 1 patient at a time and the difference between you and us is that your patients are STABLE, where ours have yet to be assessed. I would think that if either of us has the extra time to track down the doses of medications that are not essential to the disposition then it would be the admitting service.

danielmd06, I am actually amazed with how nice the posters thus far have been in respect to your comments. I suspect that many more of us are thinking about saying many worse things. I guess that I am sorry that we have taken a completely undifferentiated patient and stabilized that patient, come up with a diagnosis, and begun the treatment of that patient. If only we could have filled out his/her hospital H and P and written all the admission orders too, then you could get 10 hrs of sleep on call and just rounded on the patient the next morning (again probably dissing our ability to do your job).

I agree with the point made by the original poster...that this is a complete waste of time. We tried to do this for a couple of months here in our ED until everyone from nursing to attendings gave up because it was so useless and difficult to accomplish. This isn't hard to accomplish when you have a reliable patient population that actually have PMDs and carry around their list of medications with them. With my patient population when I ask about medications I usually get "well I take 4 medications for my pressure but I can't remember what they are and I ran out of them 3 months ago" and then the guy has a BP or 240/160 and a Cr of 4.2.
 

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I rarely get a single admission at a time, and it is extremely difficult to handle multiple admissions simultaneously while tracking down twenty medications per patient.

Most EM docs rarely balance fewer than 4 patients during any given hour - probably two awaiting lab results/further studies and 2 new patients in any given hour. Even the interns at the teaching hospital I've done research at are expected to see and dispo 1 patient per hour, 1.5 by the time June rolls around. Experienced attendings are expected to treat ~2 pts per hour in any given shift - for a total of 16-24 (depending on shift length) patients seen, treated, and sent in one direction or another. While some of those will be "sore throat, runny nose" some will be more complicated and some will be coding or balancing precariously on the verge of needing resuscitation.

Have you done your EM month yet? I spent my summer in an inner city teaching hospital ED that had both an EM residency and an IM residency. I spent a day with an IM resident in the ED, and while she was a VERY nice woman, she was by far the least efficient doctors in the ED that day. The ED is not about providing primary care, it's about stabilizing and treating emergent, life-threatening conditions. Although we all know is that the reason for ED overcrowding is lack of access to/underutilization of primary care, the answer to the problem is not to make EM physicians fill the role. It's not the focus of our training, so we make (as someone on this board puts it) "Very expensive, very poor primary care docs."
 
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docB

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In a perfect world we (EPs) could provide consultants with a complete history and med list but it often just isn't feasible. Beyond that it really doesn't fall within the purview of "Emergency Medicine" for us to make recommendations on stuff like long term BP control or outpatient diabetic regimens.

Now in terms of this JCAHO pipe dream, which is that it sure would be great if every patient got a frequent and comprehensive review of their polypharmacy nightmares, it just isn't appropriate for the ED to do it. Now it really isn't appropriate for the admitting docs to do it either. It is appropriate for the PMDs to do it but that would require them to see fewer than 68 patients per hour which they can't do without increased primary care reimbursements or acceptance that they'll make less than if they worked at a busy car wash (sometimes with primary care it is tough to tell the difference). The fact is that when some agency, be it JCAHO, CMS, etc., want to create a new unfunded mandate for services they shouldn't just reflexively dump it on the ED.

In private practice the call docs usually do get plenty of sleep. We stabilize their patients and in my situation we do write all the admit orders (it's an old culture thing that shows no signs of changing despite ACEP's recommendations).
 
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I will never call up a PMD for every patient and verify what drugs they are on. If that becomes expected practice, then I will quit medicine altogether.

If I had to field those calls from you guys, I'd quit right behind you. ;)

In all seriousness, though, this is just one more thing that's going to require electronic health records in order to do it right. Even if we're not all hooked up to the same network/database, if a PCP has an EHR, it's a trivial task for them to provide a patient with a med list. With the Continuity of Care Record (CCR), an ED can receive a "snapshot" of the patient, as well.
 

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I am actually amazed with how nice the posters thus far have been in respect to your comments.

I think that most posters are answering with professionalism and respect because I'm trying to do the same. When I first saw this thread, I thought it was interesting - and I am rarely happy about anything related to JCAHO. I decided to offer a POV that was inevitably going to be against the grain in an ED forum, and I fully expected to get multiple posts arguing against my view.

What was I ultimately hoping for? To consider the opportunity to change my viewpoint - courtesy of people who might eloquently convince me otherwise. For the record...it's convincing so far.

And your post? You're saying that there are often multiple patients in the ED? I agree. And I am always impressed at how ER docs manage to process such a heavy work load. That's not a bad point. But how many of those patients are actually admitted? I stated earlier that think it's silly to expect anyone to obtain complete lists of medications for the entire ED population. But for those selectively admitted? Yes, I still think it is not too much to expect a list to be provided by ED workers. At the very least, someone could attempt to get a complete list of medications, right? Wouldn't that be considered pertinent? You cannot know what medications are unimportant if you don't ask which ones they are taking to begin with, right? And it would ultimately take less than five minutes of your time. Then, when the surgeon, medicine doc, specialist, or whomever showed up, they would have that much more data to work on quickly (along with labs and any notes gleaned from the ED note) to formulate a plan of attack for the history and physical.

Yes, I practice what I preach. When I worked in an outpatient primary care clinic, and I wanted to admit a patient to the hospital, I obtained a list of all medications that the patient is taking to the best of my ability. If they could not remember, I called someone who might know (pharmacist, family member, spouse, etc). If I couldn't get the list...I couldn't get the list. At least I made an effort. And it was a tremendous help to those admitting.

Your sarcasm? You know perfectly well that I wouldn't sleep for 10 hours on call regardless of whether or not you attempted to get a list of medications, right? There are many more medicine patients on service (and being admitted) that an on-call intern is covering for than just those in the ED.
 

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The ED is not about providing primary care, it's about stabilizing and treating emergent, life-threatening conditions. Although we all know is that the reason for ED overcrowding is lack of access to/underutilization of primary care, the answer to the problem is not to make EM physicians fill the role.

For the record, I am a prelim...not a categorical IM intern. And I agree with your assessment about the longer, more meticulous history and physical-taking skills of the typical IM resident that I have met.

I agree that the ED is not the proper place for primary care. Wholeheartedly. But I think that a majority of patients in large, tertiary care ED's aren't exactly following with PCP's on a regular basis. I also think that JCAHO's regs might help those underserved patients.

Unfortunately, these regs place ED docs in a role that inconveniences them and was not originally considered to be their purview. Despite the intentions.
 

danielmd06

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In a perfect world we (EPs) could provide consultants with a complete history and med list but it often just isn't feasible. Beyond that it really doesn't fall within the purview of "Emergency Medicine" for us to make recommendations on stuff like long term BP control or outpatient diabetic regimens.

Now in terms of this JCAHO pipe dream, which is that it sure would be great if every patient got a frequent and comprehensive review of their polypharmacy nightmares, it just isn't appropriate for the ED to do it. Now it really isn't appropriate for the admitting docs to do it either. It is appropriate for the PMDs to do it but that would require them to see fewer than 68 patients per hour which they can't do without increased primary care reimbursements or acceptance that they'll make less than if they worked at a busy car wash (sometimes with primary care it is tough to tell the difference). The fact is that when some agency, be it JCAHO, CMS, etc., want to create a new unfunded mandate for services they shouldn't just reflexively dump it on the ED.

In private practice the call docs usually do get plenty of sleep. We stabilize their patients and in my situation we do write all the admit orders (it's an old culture thing that shows no signs of changing despite ACEP's recommendations).

I agree with every single word you said.

And I would like to reiterate that I appreciate both your candor and respectful response.

What do you personally think would be a logical solution to this? Do you think global, computerized records are feasible and practicable?
 

la gringa

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where i am we have patients who can barely come up with the name of the clinic, much less the doctor who saw them. often it's an intersection, like i know what clinic is at harlem and armitage... their meds change by whomever they manage to see that month. not to mention my patients who aren't in my hospital's system seem to have the worst PCP's known to man (clonidine as monotherapy for benign HTN, insane insulin regimens, referrals to the ED for colonoscopy and EGD for "rectal bleeding" without doing a CBC nor a rectal exam first...!!!). how is one to reconcile that???
 

GeneralVeers

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The answer to the problem is implantable microchip devices in the wrist of every patient. The microchip would list their current PMD, medical problems, and medication list. Every ER and doctors office in the country would have a "chip programmer" machine in house that would read the patient's chip on admission, and update it on discharge. The machine would be backed up by a computer software tech, engineer, nurse, programmer, and general surgeon. The whole budget for the setup would have to come out of the E.D., as JCAHO doesn't like to actually pay for anything itself.
 

docB

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What do you personally think would be a logical solution to this? Do you think global, computerized records are feasible and practicable?
The global electronic med record would be the ticket to fix all of this. It is feasible and the technology is old hat. Veers is correct that the most comprehensive solution would be to tie the emr to an implantable device but that's a little too Orwellian for most for now.

In classic governmental fashion though the gubmint screwed up this whole idea before it could have been a reality by implementing HIPAA. Now anyone trying to create a global emr is dissuaded by the staggering liability involved.

Solution: Create a special exception to HIPAA for such an emr, create it under the authority of CMS so that there will be limited liability, make it secure using the readily available security tools used everyday by financial institutions, allow any clinician access to the info and if one of us abuses it then we are subject to penalties from our licensing bodies. It's really straight forward but it would require money and cooperation. Sometimes it's hared to figure out what's more difficult to come by.
 

coldcoldworld

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I know that the city of Indianapolis has kind of a mini version of a global EMR. They currently have 5 major hospital systems online which includes 11 hospitals and over 100 clinics and same day surgery centers. I believe it allows access to diagnoses, labs, pathology, etc. and even some of the outpatient pharmacies. HIPAA concerns are alleviated by getting consent from the patient before accessing the city-wide EMR. You can read more about the system at http://www.regenstrief.org/medinformatics/inpc
 
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GeneralVeers

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I know that the city of Indianapolis has kind of a mini version of a global EMR. They currently have 5 major hospital systems online which includes 11 hospitals and over 100 clinics and same day surgery centers. I believe it allows access to diagnoses, labs, pathology, etc. and even some of the outpatient pharmacies. HIPAA concerns are alleviated by getting consent from the patient before accessing the city-wide EMR. You can read more about the system at http://www.regenstrief.org/medinformatics/inpc

I've used their system and it's great. The county hospital, teaching hospital, and tertiary care hospital all use the same system. The private community hospitals can then access the system over VPN, as most patients in the city use either Clarian or Wishard for some aspect of their healthcare.

I had expected California to be very technologically advanced, as all the techie people are out here, but most hospitals here don't even have an EMR, and are a good 5-10 years behind the midwest and eastern facilities.
 

roja

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I think that you will see some practice variation on the process of writing doses based on variables such as: pt population, access to pmd's, and most importantly VOLUME.

I work in a hospital that is level 1, sees 120K/pts a year and admits ~20% of those. Our other 'small' hospital sees approx 65K/yr and an admission rate of about 15%. At our level 1 hospital, we usually have 4-5 ICU patients being evaluated, traumas and on average 40-50 pts being evaluated (not including 'fast track'). Most of my pts coming in for admission give the 'little pill story' or don't know the doses or bring in every prescription bottle they have every recieved in the last 5 years.

If a pt can reliably tell me thier doses, I don't have several patients crashing or a list of 5-10 pts waiting to be seen, I try and write the doses down. While medicine services are definately busy, they have plenty of time to chase all thsi stuff down. I don't. I have to keep patients moving so that wehn my next train wreck comes in, pts who are stable and either need to go home, or go upstairs are not stuck.

Until you work in the ED, it is difficult to understand. It seems like an easy enough thing. However, I notice that even when our medicine residnets rotate with us, the NEVER write down dosages.
 

Annette

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Med reconcilliation is NOT an EP's job. However, it is very nice when they know the drugs the patient is on:D The hospital I'm at now has an admitting nurse that contacts the patient's pharmacy(ies) and confirms drugs and doseages. Certainly limits duplication of work. The info is shared with the ED, and goes with the chart so that it can be updated when the patient is discharged. The changes are dictated in the discharge summary which goes to the PCP and chart. A copy is given to the patient. (The nurses rewrite the information so the patients can read them. Just a little of duplication.) Still a lot of duplication of work, but in the end, slightly better for the patients.

But from the ED???????? Too much work in the wrong place.
 

edinOH

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Our triage sheets (as most do I'm sure) have a blank for the patients primary physician.

Perhaps we should be asking them about their primary pharmacy. It's funny how many pts. don't know who their doc is but many know which pharmacy they go to. Usually the same place they buy groceries. While I hate it when the pt or their family hands me two bags of meds when I ask them what medications they take, (I hate thumbing through it, much prefer the printed list!), I do like the fact that it instantly gives me a pharmacy name and phone number. Of course not all pts. frequent only one.

A simple solution would be if pharmacies, as a service to their pts, would provide each pt with a wallet sized laminated card of all their meds each time they had a prescription filled. It could provide the date filled, amount, and of course doses. Nothing a simple word program couldn't handle with ease. The data already is in their system. Would of course be a minor burden to them no doubt. Wouldn't address the issue of "polypharmacies".

Nice thing about nursing home pts. is that they all seem to make it to the ED with a copy of their MAR. Prior H&P or D/C summary is just gravy!!
 
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OPerhaps we should be asking them about their primary pharmacy.

With the rise of mail-order pharmacies, good luck getting Merck Medco on the phone at 3AM. ;)

A simple solution would be if pharmacies, as a service to their pts, would provide each pt with a wallet sized laminated card of all their meds each time they had a prescription filled.

Great idea, but the patient would actually have to bring the wallet card with them to the ED. They could make the list themselves, for that matter, or one of their family members could do it for them. It's amazing how few people are motivated to take such simple steps to ensure that they or their loved ones receive good care. All political correctness aside, this is why I think any system that relies on information being put in the hands of the patient is doomed to fail.

By the way, any time you see a laminated medication card (or one that is visibly yellowing), you should be concerned that it may no longer reflect what medications the patient is actually taking. ;)
 

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With the rise of mail-order pharmacies, good luck getting Merck Medco on the phone at 3AM. ;)



Great idea, but the patient would actually have to bring the wallet card with them to the ED. They could also make a list themselves, for that matter. It's amazing how few of them are motivated to take such simple steps to ensure that they receive good care. All political correctness aside, this is why I think any system that relies on information being put in the hands of the patient is doomed to fail.

:laugh: :laugh: :laugh: I took me >1 hr wait time on the phone at 10AM CA time to get a transfer from Merck! I could have gotten a new rx from the prescriber in less time (it was a Wed-prescriber's day off:( ).

Nope......personally, I believe there should be a magnetic strip card that gets "swiped" each time a pt visits a health care individual. That way...you could see I haven't filled lisinopril since Aug '05 - pts been on valsartan since then. It would also give a dentist directions for pre-med rather than place a phone call to each ortho for a hip replacement pt. As part of mail order participation, the pt would need to "swipe" their card on their personal card reader before the medication is shipped. There should be a feature where you can actually access info from the card without the individual - ie knowing the ID & the PIN so you can get that info from an unresponsive John Doe.

It can be done...but its a huge task & each provider needs to add technology so its expensive up front (not so much to pharmacies since we already have it). There's also all that HIPAA stuff - troublesome!
 
8

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I had an elderly patient the other day whose daughter provided me with a folder in which I found a complete list of his medications, the date they were started, all of his doctors and their phone numbers, as well as copies of his last several discharge summaries for prior hospitalizations at other hospitals.

Hell must have frozen over.
 
D

deleted109597

By the way, any time you see a laminated medication card (or one that is visibly yellowing), you should be concerned that it may no longer reflect what medications the patient is actually taking. ;)
As you can see (or probably not because it is too small now), this laminated scheduled list is 26 items long, and the PRN list is 12 items long. It also has Percocet scheduled and PRN, as well as IM Demerol PRN. What person writes for IM Demerol for a patient?

Also, those are cigarette burns on the side.
 

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Jeff698

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My biggest gripe with the majority of admissions I took for IM was the consistent lack of a medication list from the ER.

Or, just as a wacky thought, you could actually do the H&P yourself and not rely on the ED to do it for you.

I'm just guessing that those lazy folks in your ED don't get the complete PMH either.

Take care,
Jeff
 

Jeff698

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And your post? You're saying that there are often multiple patients in the ED? I agree. And I am always impressed at how ER docs manage to process such a heavy work load. That's not a bad point. But how many of those patients are actually admitted?


Wrong question. These patients don't come in to the ED with a "admit me" or "send me home" neon sign on their forehead. The nature of undifferentiated patients in the ED is that each of them them must be assumed to be dying and in need of emergent intervention until proven otherwise. The "admit me" or "send me home" label only lights up after we've evaluated them.

And it would ultimately take less than five minutes of your time. Then, when the surgeon, medicine doc, specialist, or whomever showed up, they would have that much more data to work on quickly (along with labs and any notes gleaned from the ED note) to formulate a plan of attack for the history and physical.

Daniel, maybe you don't realize this but this is actually sort of insulting. What you are saying here is that your time is more valuable than ours. While you may obviously think so, I hope you'll understand that I disagree.

Again, do your own H&P. I'm sorry it takes a long time.

Take care,
Jeff
 

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Daniel, maybe you don't realize this but this is actually sort of insulting. What you are saying here is that your time is more valuable than ours. While you may obviously think so, I hope you'll understand that I disagree.

Again, do your own H&P. I'm sorry it takes a long time.

Take care,
Jeff

In that 5 minutes, I could potentially see another patient, write script, and send them home. If we took an extra 5 minutes for every patient we saw, it would really cut into our productivity. If that happened, I'd be more inclined to just call medicine for every patient, rather than actually work them up.
 

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What person writes for IM Demerol for a patient??

I have a picture (couldn't believe it so I took a picture, I'll see if I can blur the name and post it here) of a prescription bottle for IV PROPOFOL! Yes, the patient (a 35 year old female, non-terminal, non-hospice) had a port placed for her idiopathic chronic pain syndrome and had a prescription for PRN IV Propofol. Transferred in to us for continued evaluation of her persistent weakness and tiredness (I kid you not).

- H
 

Jeff698

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Yes, the patient (a 35 year old female, non-terminal, non-hospice) had a port placed for her idiopathic chronic pain syndrome and had a prescription for PRN IV Propofol.

Wow. That's impressive. If this isn't the definition of a life-force-stealing, soul-sucking patient, I don't know what is.

You walk in that room and within 5 seconds know your shift has taken a decidedly unpleasant turn.

Take care,
Jeff
 

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I wonder if JCAHO would give you a waiver if you have every patient pi## into a mass spectroscope and reconcile whatever is in their system that way...

And I actually disagree with the assertion made earlier that the patients who have a folder with their meds, discharge summaries etc are usually not sick. Around here these tend to be the smarter of the cancer patients.

I do like the implantable chip idea. We can do it with dogs and cattle, no reason it couldn't work in humans.
 

docB

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As you can see (or probably not because it is too small now), this laminated scheduled list is 26 items long, and the PRN list is 12 items long. It also has Percocet scheduled and PRN, as well as IM Demerol PRN. What person writes for IM Demerol for a patient?

Also, those are cigarette burns on the side.
I encountered a patient on PRN IM Demerol. The patient I met had overused just a tad to the tune of 900 MG in a 4 hour period. Believe it or not she was altered and had a seizure.
 

Jeff698

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Speaking of electronic medical records, our place really does have an outstanding system. One of our docs apparently is quite the geek. He built a web based system that has all dictated reports, lab values, meds, etc for anyone ever seen in our system. It also builds, in real time, a nice summary sheet with their current meds, allergies, PMH, Social, Family history etc.

I'm so spoiled. When I see a patient, I ask them if they get all of their care from within our system (the vast majority of our patients). If they say yes, most of my information is done and I can actually focus on the stuff that is clinically relevant for that visit.

I do feel everyone's pain when we get a 'virgin' to our system with many medical problems. I actually had to request a paper chart from an outside hospital a couple of months ago. Oh, the horrors!

And, if most of the 'real world' is like that, there's no way on God's green earth I'm spending all that time to reconcile meds for the admitting team. Sorry, Charlie.

Take care,
Jeff
 
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