Urgent care to ER: who has to be sent?

[EMEDPA]

5 hours ago, d2305 said:

AMA info http://blog.thesullivangroup.com/ama-patients-who-leave-against-medical-advice

thank you. nice summary.

[mmiller3]

5 hours ago, d2305 said:

AMA info http://blog.thesullivangroup.com/ama-patients-who-leave-against-medical-advice

From that link: "Take the AMA process seriously. The ultimate goal is to have the patient stay and complete the recommended treatment. If they still want to leave AMA, your best ally is thorough chart documentation AND a signed AMA form. Without these, the only defense you will have in a suit will be your word against that of everyone else".

So, it would appear that AMAs can protect you from a malpractice suit, provided you exercise common sense (and chart the heck out of the encounter).

 

[d2305]

This is what you shouldn't do, 

• Don’t just ask the nurse to have the patient sign a generic AMA form and leave. This course of action provides little protection for the practitioner.

[lkth487]

For AMA, I also have a witness sign (e.g. a nurse ) AND have them put in a separate note, just to make sure the patient understood what they were doing and all the risks were understood, just in case.  Thankfully we don't have to do it too often in pediatrics, but we see enough patients over 18 that it happens to me once a month or so.  

[Guest UVAPAC]

I think it is difficult to determine who should go to the emergency room and who shouldn't.  (Obviously you try to use your best clinical judgement, and there are some which are slam dunk cases, but there are also borderline cases.)  

 

For instance, I will present a case that I recently had...

Healthy 17 y/o F in college, no medical problems.  Came to urgent care (accompanied by a parent that drove several hours to attend appointment)... chief complaint of UTI symptoms x 1 week.  Why treatment was delayed so long, who knows... U/A showed roaring UTI.  Clinically had pyelonephritis (CVA tenderness, low grade temperature hovering around 100.0, other vital signs stable.  Was tolerating PO, no vomiting reported.

 

Do you send to the ED or not?  Obviously if this patient went to the emergency room they would likely get a dose of IV meds, possibly even admitted for observation overnight...

 

I discussed with patient/parent the pros/cons to outpatient oral antibiotics versus going to the emergency room.  They were both adamant they would prefer to avoid ED/Hospitalization.  Gave the very detailed instructions of worsening infection, and advised to go to the ED with increase/change in symptoms.  

 

I put the patient on Bactrim DS BID x 10 days.  (Allergic to Cipro).  The next morning sure enough they went to the ED.  ED gave dose of IV antibiotics and fluids.  Offered admission, and again patient declined and went home.  ED physician wrote Bactrim DS BID x 10 days good regimen and to continue.

Next day patient returned to the ED basically septic.  Was admitted to the hospital and given broad spectrum IV abx. Culture results came back and bacteria was resistant to Bactrim DS.

 

Obviously I felt terribly about the situation.  Could it have been prevented?  Should the patient have been pushed to the ED day one?  Who knows...

[Cideous]

26 minutes ago, UVAPAC said:

I think it is difficult to determine who should go to the emergency room and who shouldn't.  (Obviously you try to use your best clinical judgement, and there are some which are slam dunk cases, but there are also borderline cases.)  

 

For instance, I will present a case that I recently had...

Healthy 17 y/o F in college, no medical problems.  Came to urgent care (accompanied by a parent that drove several hours to attend appointment)... chief complaint of UTI symptoms x 1 week.  Why treatment was delayed so long, who knows... U/A showed roaring UTI.  Clinically had pyelonephritis (CVA tenderness, low grade temperature hovering around 100.0, other vital signs stable.  Was tolerating PO, no vomiting reported.

 

Do you send to the ED or not?  Obviously if this patient went to the emergency room they would likely get a dose of IV meds, possibly even admitted for observation overnight...

 

I discussed with patient/parent the pros/cons to outpatient oral antibiotics versus going to the emergency room.  They were both adamant they would prefer to avoid ED/Hospitalization.  Gave the very detailed instructions of worsening infection, and advised to go to the ED with increase/change in symptoms.  

 

I put the patient on Bactrim DS BID x 10 days.  (Allergic to Cipro).  The next morning sure enough they went to the ED.  ED gave dose of IV antibiotics and fluids.  Offered admission, and again patient declined and went home.  ED physician wrote Bactrim DS BID x 10 days good regimen and to continue.

Next day patient returned to the ED basically septic.  Was admitted to the hospital and given broad spectrum IV abx. Culture results came back and bacteria was resistant to Bactrim DS.

 

Obviously I felt terribly about the situation.  Could it have been prevented?  Should the patient have been pushed to the ED day one?  Who knows...

You guys have

Rocephin inj in clinic?

BTW, I am getting almost 50% resistance to Bactrim now on my urine C&S's....just nuts.  Macrobid seems to be the only PO antibiotic I see very little resistance to.

[ventana]

Just now, Cideous said:

You guys have

Rocephin inj in clinic?

BTW, I am getting almost 50% resistance to Bactrim now on my urine C&S's....just nuts.  Macrobid seems to be the only PO antibiotic I see very little resistance to.

and that doesn't work in the old or renal disease

[Guest ral]

^^^

Nothing wrong with OP treatment of pyelo, if patient doesn't look bad, and is able to tolerate po (not vomiting).  In such cases, I will document pros/cons of admit discussed with patient, and their understanding that OP tx is not always successful, so not necessarily an AMA.  Another thing to keep in mind is, remember the difference between antibiotics that are bacteriostatic vs batericidal.  If you are truly worried about a possible failed outpatient treatment, give a big dose of Rocephin, which theoretically gives you 24 hours of bactericidal coverage (and this is coming from a guy who hates ordering shots).  I recall an older version of 5-minute ER Consult stating a rule of 2's for pyelo: 2 liters of fluid, 2 grams of Rocephin, and 2 Tylenol ES to get things rolling.  Averting the progression to "really sick" is the goal.

Finally, outpatient treatment for pyleo really should last for  a full 14 days. 

[sk732]

UVAPAC - Had something similar occur last year when I was doing some of my Army Reserve days at a Base Clinic...luckily, the kid came back as soon as things progressed, got the IV ABx/fluids going and fired them off to hospital.  Clinical judgement is important and I've had that pyelo discussion many times, both in the ED and in clinic - some people do well if they've come early enough, others not so much.  My guess is that the kid showed up late because  (a) they didn't understand what was happening because (b) Mummy always did all the talking for them in the past and is still a helicopter parent even though the kid's in university.

Agree with ral - I usually treat pyelo for 10-14 days.

Cideous - I'd say at least 1/3 of the E coli we get where I am is resistant to at least one agent.  One place I used to work in, it was nitrofurantoin only po, ceftriaxone or Pip/Taz IV, and as Vent notes, you can't really use nitro in pyelo or in old folks.

SK

[Cideous]

1 hour ago, sk732 said:

UVAPAC - Had something similar occur last year when I was doing some of my Army Reserve days at a Base Clinic...luckily, the kid came back as soon as things progressed, got the IV ABx/fluids going and fired them off to hospital.  Clinical judgement is important and I've had that pyelo discussion many times, both in the ED and in clinic - some people do well if they've come early enough, others not so much.  My guess is that the kid showed up late because  (a) they didn't understand what was happening because (b) Mummy always did all the talking for them in the past and is still a helicopter parent even though the kid's in university.

Agree with ral - I usually treat pyelo for 10-14 days.

Cideous - I'd say at least 1/3 of the E coli we get where I am is resistant to at least one agent.  One place I used to work in, it was nitrofurantoin only po, ceftriaxone or Pip/Taz IV, and as Vent notes, you can't really use nitro in pyelo or in old folks.

SK

Of course, but the case in question was a 17 year old.  Not an old person with renal disease.  I would absolutely have no problem starting this girl on Macrobid given the condition she came in with as described by the original poster.  I would of given her a gm of Rocephin IM as well and called her the next morning.

If they were old, or had renal issues, I would of sent them to the ER.  No question.

[dchampigny]

If you can't come up with a definitive diagnosis and there is question about supplemental information (labs, imaging, procedures) to be done to help clinch the diagnosis, they need to go to the ED. 

Things I've sent in the past four shifts:

two appys (fever, nausea, vomiting, hunched over), both were slam dunks.

Syncope of undetermined origin  (Hx of a. fib, heart disease etc)

90 something year old with "heart thumping".

80 something year old with rattly chest, confusion, decreased PO intake 

 

All  were admitted.

 

My general concern is that if I can't come up definitively what is going on, they need a higher level of care. If there is high suspicion for something (pneumonia, pyelo, etc) but I'm not sure they will do well with oral antibiotics, they will go. 

I'm a firm believer that complicated lacerations and dislocations should go. I'm not about to make something worse by trying to put it back in place if I can't control pain and have a risk of making things worse. I'm also not going to spend 1 hour on a laceration that needs sedation etc. 

 

The gut feeling is important. Clinical gestalt is something that comes. Another good thought is that if the thought crosses your mind of them needing a higher level of care, you've got your answer. I learned this from a podcast a long time ago. Another good thought is that if you feel like you'll go home and lose sleep about them, they should go (I.e., I wonder what the white count was, I wonder if they are able to keep their doxycycline down). 

 

One thing that I'm trying to be better about is that if the patient is leaving personal vehicle reminding them of the Monopoly saying "Do not stop at go. Do not collect $200". I notice a lag time between when I send them and when they arrive, sometimes a couple hours. Our ER is at most a 5-10 min drive. I always try to remember patients who might need surgery to ask them not to stop at Chik Fil A, etc prior to ED trip. 

[medic25]

3 hours ago, ventana said:

and that doesn't work in the old or renal disease

Always important to remember that nitrofurantoin should never be used if pyelonephritis is suspected.  It has very poor penetration into the renal parenchyma; you'll never reach therapeutic levels if it's anything more than a simple cystitis.

[d2305]

Might want to cover chlamydia. 

[Guest UVAPAC]

38 minutes ago, medic25 said:

Always important to remember that nitrofurantoin should never be used if pyelonephritis is suspected.  It has very poor penetration into the renal parenchyma; you'll never reach therapeutic levels if it's anything more than a simple cystitis.

I was thinking the same thing... Was confused by previous posts.

[MCHAD]

On 12/28/2017 at 6:24 PM, SCPA said:

great stuff in this post. I sometimes struggle (FP) deciding to send via personal vehicle or EMS. Obviously unstable is a no brainer EMS ride or helicopter.. But those patient who are stable but need to be r/o ... but conceivably could not be fine on way to ER in the worst case scenario that you are trying to R/o ( and you can't r/o b/c you're fp and the closest thing you have to troponins or CT head is a rapid strep test .... ugh some days)...

In my situation, It also takes approx 45 minutes for EMS get to us (RURAL fp) and it's 30 mins to nearest ED, which adds more weight to the decision since I'm tying up an ambulance 60-90 minutes minimum each call.. 

We struggle with this where I work too, volunteer ambulance crew is awesome but can take time to get to us.  I’m pretty cautious and send people via ambulance (air or ground) more often than I would have at other facilities because of geography.  

I tell every patient/family we provide care for its worth the $60 a year (per household) to sign up for the flight service membership plans.  They bill insurance and whatever isn’t covered is written off by the flight company so the patient doesn’t end up holding the bag for a $20-40k flight. 

[lkth487]

[Peds]

 

It's always interesting to me what comes through from the non pediatric EDs and urgent care centers.  It's so variable and I can't make any sense of why people decided to send a child to our children's hospital.  I'd say 75% of the transfers are kind of ????, but I'm a resident and I've never worked in a place without dedicated children's services, so I understand that the pressures are different when you don't have every child subspecialty services available on hand.

For the people who work in general urgent cares and general EDs - how much experience/how comfortable are you guys with sick/potentially sick children and babies?  It seems to me that it's extremely variable.

[EmmaMarie]

I've been working UC for the last 1.5 years. I completely agree with previous posters regarding, "if you think it, do it" and having a low threshold to send to the ED. Fortunately (or unfortunately) my UC is next to a very busy ER. When their wait times are extra long, we get their overflow (CP, head injuries, hand lacs that require surgical consult, etc). I have no problem telling people to go to the ER. If someone needs a level of evaluation or care I can't provide they are gone. It's what is best for them and for me.

In regards to OP pyelo; we manage pyelo OP all the time. We have IM/IV Rocephin. They get that plus cipro. Follow up in a day for monitoring. We can also do CBC/BMP, so I can follow that as well. Agreed that macrobid is wonderful for UTI, but should not be used for pyelo. And obviously if super sick, send to the ER. Or if I suspect they wont be compliant with meds/follow up, they get sent too.

If I send someone to the ER, I NEVER treat them. For example, if my recommendation is for you to go to the ER for your hypertensive emergency and you don't want to go, I will not refill your lisinopril/HCTZ. I feel like to do so basically guarantees the patient will not get the emergent care they need plus it opens me up to a heap of liability.

For children and babies (at least in my area), mostly what we get is strep/OM, ortho injuries, and anxious parents. The same principles apply. If I can't diagnose/fix them, I send them.

[houston2321]

I was doing some shadowing in the ED and I saw several patients that were sent over from urgent care. One of them was a splinter in the hand. Yes a splinter. Don't be that person. 

[camoman1234]

23 minutes ago, houston2321 said:

I was doing some shadowing in the ED and I saw several patients that were sent over from urgent care. One of them was a splinter in the hand. Yes a splinter. Don't be that person. 

Does this count? :)

[EMEDPA]

actually have removed things like that before in urgent care. looks like it is just in the subq. image it, numb him up, remove, irrigate, loosely approximate, abx, td. doable in UC if you have some self confidence.