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.