Sunday, June 19, 2011

Emergency Room: Revolving Door or Backstop?

I received a call recently from an emergency room (ER) physician about a patient who presented there with rectal bleeding. Does this sound blogworthy? Hardly. We gastro physicians get this call routinely. Here’s the twist. The emergency room physician presented the case and recommended that the patient be discharged home. He was calling me to verify that our office would provide this patient with an office appointment in the near term, which we would. We had an actual dialogue.

This was a refreshing experience since the typical emergency room conversation of a rectal bleeder ends differently. Here’s what usually occurs. We are contacted and are notified that the patient has been admitted to the hospital and our in-patient consultative services are being requested. In other words, we are not called to discuss whether hospitalization is necessary, but are simply being informed that a decision that has already been made.

There is a tension between emergency room physicians and the rest of us over what constitutes a reasonable threshold to hospitalize a patient. I have found that many ER docs pull the hospitalization trigger a little faster than I do. What’s my explanation for this? Here are some possibilities.
  • Pressure from hospitals to fill beds
  • Pressure from admitting physicians who seek to increase their in-patient volumes
  • Belief that hospitalization markedly reduces medical malpractice risk of ER physicians
  • Desire to eliminate uncertainty that a benign complaint is masquerading as a serious condition. “It’s probably your heartburn, but let’s observe you overnight just to be sure.”
  • Pressure from patients and families to be hospitalized
  • Uncertainly that a patient will follow-up with a physician after ER discharge
  • ER physicians are making the proper judgment to admit the patient, while we specialists and primary care physicians cavalierly advise discharge.
What’s the harm of hospitalizing a patient for a day or two, ‘just to be sure’, or to expedite a medical evaluation that might take a few weeks to accomplish as an out-patient? Here are a few drawbacks to that option, and I’m sure that patients and physicians can add to the list.

  • Resource consumption
  • Risk of hospital acquired misadventures including infections, medication errors and side-effects
  • Overutilization of medical care. Hospitalized patients are routinely visited by numerous consultants who proceed to attack their organs of interest with zeal and enthusiasm
Every physician can attest to how much hospital illness is caused by hospital life and is unrelated to the original medical issue. We see this every day.

I understand the tension between the ER and the outside medical world. The ER is under a unique set of pressures and concerns, and the rest of us need to be mindful of this. Nevertheless, patients would be better served if there were more discussion and collaboration between medical colleagues to determine whether hospitalization or discharge is the preferred option. A recent study confirms that communication between ER physicians and primary care physicians needs healing.

Many patients and their families mistakenly think that hospitalization is the safer choice. Think again.


A. Bailey said...

As the realtors say, it's all about the location.

Here in Louisville, the ER docs at Baptist Hopital East do an excellent job of notifying the doctor of record about these kinds of situations. When they call me, if I can see the patient in a timely fashion, they will discharge the patient to home.

I don't envy their job. In my younger overworked and sleep deprived years I would make house-officer level protestations that only made their job harder. I regret having ever done that.

Now I never second-guess them, especially as they are laying eyes upon the patient and I'm at home watching TV or something.

I don't blame them a bit for erring on the side of caution, given the number of personal injury lawyers who aggressively advertize in our area.

I don't worry too much about a patient staying overnight. I guess it just depends on how good you think your hospital is (yes, that was a bit snarky, but I think your last paragraph is a bit meolodramatic for my tastes).

Anonymous said...

Over 40 and chest pain is an automatic overnight stay. Over 50 and rectal bleeding usually is an overnight stay. Show up with headache, numbness, arm or leg feeling "funny" results in an overnight stay.
I would not want to be an ER doc, as a lot of the care is simple self pay/no pay, medicaid, noncompliant patients, drug seekers, etc in my area. The ER waiting room scares most privately insured patients.
Thankfully I have some say in who gets to be seen in my office. The ER is forced to see anyone who walks in the door for whatever the presenting concern is. The ER really is a community clinic that often functions at a loss but makes up for this with the Medicare and private insurance admissions.

Michael Kirsch, M.D. said...

Agree that ER physicians are often in a tough spot. However, there are invisible agendas at play that patients are unaware of. This phenomenon is not restricted to the emergency room.

Toni Brayer, MD said...

Great post and I am hard pressed to find any "reasons" for admission that you left out. I have worked as an ER doc (back in the day) so I know what it is like to be pressured to make hasty decisions and to CYA by being very conservative. But the most important deterrent to knee-jerk admission is knowing the patient can be seen and followed up by a good clinician. If that follow up is there, the ER doctor can feel more assured about sending a patient out.

I love it when the ER calls about a patient. We are losing good Dr. to Dr.communication and we need to get back to talking about patients and planning care together.

Michael Kirsch, M.D. said...

Thanks TB for kind comments. Last post I wrote about ER docs didn't generate much support from ER world. I was wearing Kevlar for a few days!

Carolyn Thomas said...

Dr. Michael, I'm taking a wild guess here that you have never been on the other side of the gurney in the E.R. as a patient in mid-heart attack - as I have been. Textbook symptoms: crushing chest pain, nausea, sweating, pain radiating down my left arm. But when all cardiac tests (EKG, cardiac enzymes, treadmill stress test) came back "normal"(as they tend to do far more frequently with female cardiac patients), I was unceremoniously booted out the E.R. door within 5 hours misdiagnosed with GERD, feeling very, very embarrassed because I had just "made a big fuss over nothing".

Had I been a MALE patient, however - same age, same symptoms - current guidelines dictate 'keep overnight for observation'. Research published in the New England Journal of Medicine, in fact, suggests that women under the age of 55 are SEVEN TIMES more likely to be misdiagnosed in mid-heart attack and sent home from the E.R. than men in the same boat are.

I too felt that your last sentence warning us that we need to "think again" if we believe hospitalization is "safer" is not only "melodramatic", as A.Bailey wisely described it, but an affront to those of whose lives are quite literally put in peril by being sent home.

Unknown said...

It's so frustrating to read again and again about the pressure docs feel to fill beds and are fearful of being sued if they don't over-prescribe. May be tough to do in an ER setting, but we patients need to play an active part in the care of our health. Ask a lot of questions. Even questions about how much treatments and drugs cost, because it matters. I found this helpful in shaping questions:

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