Chest pain in Urgent Care

[kadiah]

So I'm looking for advice here. I work for a health system in their "Urgent Cares" . Honestly, we're glorified walk ins, we don't even have x-ray on staff 24/7, we're usually solo providers unless it's a busy clinic then there's 2 providers, always a PA/NP, never a physician. Most of our clinics have 2-3 rooms max, the biggest has 5 rooms. Support staff is generally LPNs and MAs, and sometimes it's just you and 1 support, who rooms and checks in. 

Well, we have monthly provider calls and on today's call, our medical director said he visited another urgent care (that is staffed by physicians and RNs) that has a protocol for chest pain, where if it's not a STEMI and they're stable, they send them acutely to cardiology same day, not the ER. He didn't really give us specifics, but we have zero ability to get STAT troponins unless we call a STAT courier. And obviously not all chest pain is an ACS - but how do I rule out a spontaneous pneumo if I don't have x-ray. And d-dimers for PEs has the same problem with STAT labs, and I don't want to think about the prior auth I might need to get a STAT chest CT for pe. 

I'm just floored that they want to do this. Honestly, when it comes down to it, I will 100% send them to the ER if I have concerns. I sent an email with my concerns and what I think it would take to make this work and be safe, just in hope that he sees how ridiculous and how much work it would be to implement. 

[Cideous]

If I had a dollar for all the bat shit crazy ideas that I have seen come and go in Urgent Care I would have already retired.  Pre-op release physicals (certifying they are released to go under anesthesia on a patient I have NEVER SEEN and with NO medical records to review, New medical/Medicine trials given to patients for the first time IN URGENT CARE, screenings for psychological health and approval sending people into a war zone, on and on and on.......Obviously it's a terrible idea, which you already know, but there is a bigger discussion here that should be mentioned and that is protecting yourself and your license.

 

One of the "realizations" that I have come to know as gospel over my years in Urgent Care is this:  No one will look out for your license, your career (malpractice), and your well being but you.  No one.  Not medical directors, not co-workers and certainly not admins.  You are a revenue stream in UC and they will come up with all sorts of hair brained ideas to make money off of you and your license.  And when it goes bad...and it will....they wipe their hands free, stick their heads in the sand and quietly whisper behind your back..."wow I can't believe we got him/her to actually do that??? They should of known better! Hahahahaha "....

Protect yourself, your career because no one else will.

[kadiah]

Our system is big on "taking burden from the ER." 

We can open up all the Urgent cares in the world, and some patient is still going to go to the ER because they stubbed their toe. 

I already have high acuity in my UC. just last week I sent out a lady having a stroke and a patient with a heart rate in the 180s (apparently she was hyperthyroid for years and it finally became a problem).  I don't need to trend troponins for 6 hours. The PAs in our ER only see level 3s and below. 

[GetMeOuttaThisMess]

If I had a dollar for all the bat shit crazy ideas that I have seen come and go in Urgent Care I would have already retired.  Pre-op release physicals (certifying they are released to go under anesthesia on a patient I have NEVER SEEN and with NO medical records to review, New medical/Medicine trials given to patients for the first time IN URGENT CARE, screenings for psychological health and approval sending people into a war zone, on and on and on.......Obviously it's a terrible idea, which you already know, but there is a bigger discussion here that should be mentioned and that is protecting yourself and your license.
 
One of the "realizations" that I have come to know as gospel over my years in Urgent Care is this:  No one will look out for your license, your career (malpractice), and your well being but you.  No one.  Not medical directors, not co-workers and certainly not admins.  You are a revenue stream in UC and they will come up with all sorts of hair brained ideas to make money off of you and your license.  And when it goes bad...and it will....they wipe their hands free, stick their heads in the sand and quietly whisper behind your back..."wow I can't believe we got him/her to actually do that??? They should of known better! Hahahahaha "....
Protect yourself, your career because no one else will.

This is not allowed (retirement) before you serve your time in our clinic when I retire. It is mandated.

[Cideous]

LOL after reading my vent posts on these boardsI don't think anyone would ever hire me

 

Funny enough though, my patient satisfaction and P.Gainey scores are some of the highest in the entire district.  Smile there, vent when I get off.  We all need to find outlets to blow off steam from time to time I guess.

 

Edited July 9, 2019 by Cideous

[ohiovolffemtp]

@Kadiah,

Reading between the lines it sounds like you can get an EKG in your UC - so you can see if there is a STEMI.  However, the overall chest pain workup includes a chest xray - which you say you can't get during all of the hours you're open, stat blood work, including serial: initial, 3, and 9 hour troponins to revaluate for non-STEMI's, plus possible CT's for PE or dissection, etc.  You aren't going to keep a pt in the UC for even 3 hours and you don't have all the tools needed to do the workup.  So, if you think the chest pain may be cardiac, they need to be sent right away to the ED.

[kadiah]

Oh yeah I'm 100% aware of the work up for cardiac chest pain. This post is 99% venting that my medical director even finds it mildly appropriate to suggest we attempt a work up. I mostly made this to reorient myself to reality, that indeed, cardiac chest pain belongs in the ED. 

[rpackelly]

Some one said bat shit crazy and I agree.   

 

[thinkertdm]

Wait- are you saying you can’t work up chest pain in an office setting?  And deliver a baby in the next room?  And do it with a shit eating grin on your face to get the press-ganey at a “10”?  What a bunch of n00bs.  That administrator should get an award!

Hell, if you can’t do it right, just do it fast.  Most of the time, no one can tell the difference.

[CAdamsPAC]

Do good medicine, exercise your brain, apply the skills that you have and "screw The Suits" and their lackey physicians.  Sitting on a CP pt  in UC for however long it takes to get troponin results is just not dumb it's wrong. UC is not the setting to R/O MI, send them out when your gut says they might be having a cardiac event; as the plaintiff lawyer will ask you just what you thought holding  them in the clinic  would accomplish!

[GetMeOuttaThisMess]

Let me take it a step further.  If the lab comes back positive what are you going to do?  Send them to the ED.  If the labs come back negative have you truly excluded an MI or other life-threatening maladies (initial series only since I wouldn't sit on one in the clinic who could be having a NSTEMI, or what us old folks in wheelchairs and canes first called non-Q wave, or non-transmural MI's) and with Monday morning quarterbacks having months to second guess you how are you going to defend your decision?  No, you're still concerned, so you send them to the ED.  Bottom line, where do they end up?  Remember that for every fifty CP patients that you see one will have the real deal which you will miss regardless of how extensive a work up you did excluding cath, and even then you can miss a Prinzmetal's.

[YoungH89]

Devils advocate. How many chest pain patients are you truly concerned about spontaneous pneumo on ? That dx aside if the chest pain story is weak and PERC negative with heart score of 3 or less with non ischemic ECG I wouldn’t of mind having access to troponin and /or ability to send to cards when I worked urgent care. I wouldn’t send a dimer from urgent care as you said that gets messy. Chest pain radiating to back , goodACS story, abnormal ecg, concern for PE, or chest pain with neuro sx yeh that has to be evaluated in ER. But what if the story is weak in a low risk patient who is currently asx with normal ecg and vitals. You wouldn’t be comfortable sending that to cards for eval ? Obviously your CVA and thyrotoxicosis needs to be in the ER. I just think there are some patients who reflexively get sent to the ER that can be taken care of as an outpatient. Forget chest pain. Are you guys comfortable ordering RUQ US and DVT studies from urgent care in an insured patient. If not why not?

[CAdamsPAC]

1 hour ago, YoungH89 said:

Devils advocate. How many chest pain patients are you truly concerned about spontaneous pneumo on ? That dx aside if the chest pain story is weak and PERC negative with heart score of 3 or less with non ischemic ECG I wouldn’t of mind having access to troponin and /or ability to send to cards when I worked urgent care. I wouldn’t send a dimer from urgent care as you said that gets messy. Chest pain radiating to back , goodACS story, abnormal ecg, concern for PE, or chest pain with neuro sx yeh that has to be evaluated in ER. But what if the story is weak in a low risk patient who is currently asx with normal ecg and vitals. You wouldn’t be comfortable sending that to cards for eval ? Obviously your CVA and thyrotoxicosis needs to be in the ER. I just think there are some patients who reflexively get sent to the ER that can be taken care of as an outpatient. Forget chest pain. Are you guys comfortable ordering RUQ US and DVT studies from urgent care in an insured patient. If not why not?

In my mind, those studies that could lead to a surgical or medical admission are not UC cases. If  my DDX includes serious badness they are ED bound as it's cut to the chase as far as I'm concerned.

[Cideous]

1 hour ago, YoungH89 said:

 Forget chest pain. Are you guys comfortable ordering RUQ US and DVT studies from urgent care in an insured patient. If not why not?

Hell no.

 

It only takes one going bad to ruin your day....and theirs.  Remember, providers are sued all the time not just for missing something, but for a delay in diagnosis.   Ordering US's from UC for acute symptoms?  lol just no.

[MedicinePower]

I'd love to know their protocol for referring acutely to cardiology and not the ED. Are they able to go directly from UC to a cardiologist who has labs and imaging at their immediate disposal? If so then I can see the argument if the story is vague CP with no ST segment changes on EKG and otherwise unconcerning story for same day referral to cardiology.

 

I doubt, however, that any cardiologist would appreciate someone with tearing chest pain radiating to their back calling to make a same-day outpatient appointment.

[LT_Oneal_PAC]

As an ED resident (almost done YAY!) and prior family medicine, I would say if you are really thinking ACS, then send to ED. Never order troponins from clinic. If you have that high of a suspicion, send them on. This does not mean every chest pain needs to come to the ED. 

I think DVT rule out, without signs and symptoms of PE, can be done in the urgent care setting if the patient meets outpatient criteria for treatment. I'm not doing anything extra than an ultrasound and sending them home on lovenox or DOAC. I'm doing a history and physical, a formal ultrasound, and sending these people on their way. I do tons of DVT r/o myself with POCUS. One could possibly do this with PE meeting HESTIA and PESI criteria, but no one would have the balls to do that. 

RUQ US studies, I don't see why not. Did them all the time in FM. If you are concerned because the patient is hemodynamically unstable, jaundice, or fever with RUQ pain, then obviously no. Send people you are concerned about for obstructing stone, portal thrombus, ascending cholangitis. Again, I do a lot of these by POCUS when it appears to be simple cholelithiasis and if I'm really concerned because of the previously listed, I'm usually either getting the CT or the formal RUQ US. 

[kadiah]

9 hours ago, YoungH89 said:

Devils advocate. How many chest pain patients are you truly concerned about spontaneous pneumo on ? That dx aside if the chest pain story is weak and PERC negative with heart score of 3 or less with non ischemic ECG I wouldn’t of mind having access to troponin and /or ability to send to cards when I worked urgent care. I wouldn’t send a dimer from urgent care as you said that gets messy. Chest pain radiating to back , goodACS story, abnormal ecg, concern for PE, or chest pain with neuro sx yeh that has to be evaluated in ER. But what if the story is weak in a low risk patient who is currently asx with normal ecg and vitals. You wouldn’t be comfortable sending that to cards for eval ? Obviously your CVA and thyrotoxicosis needs to be in the ER. I just think there are some patients who reflexively get sent to the ER that can be taken care of as an outpatient. Forget chest pain. Are you guys comfortable ordering RUQ US and DVT studies from urgent care in an insured patient. If not why not?

Well since I saw one in a 16 year old female with completely normal vital signs and no trauma history who's complaint was chest pain - yeah. I think about it. I had convinced myself it was costochondritis, as she had referred breath sounds, but did the x-ray anyway to CYA, and I'm glad I did. 

And if the chest pain ISN'T concerning for ACS, and I truly think it's GERD and they have no risk factors, then I don't refer to the ED, I get them a close f/u with their PCP. 

Any yes, I order DVT r/o all the time, and my UC clinic actually has a protocol for acute abdominal pain where our hospital is required to get them in and whatever imaging we order read in under 2 hours. Actually, sometimes we find the appys sooner than the ED would. 

I truly DO try to keep as much out of the ER as possible - I just think that just because the ECG doesn't show a stemi, that should mean we can be all happy. 

4 hours ago, MedicinePower said:

I'd love to know their protocol for referring acutely to cardiology and not the ED. Are they able to go directly from UC to a cardiologist who has labs and imaging at their immediate disposal? If so then I can see the argument if the story is vague CP with no ST segment changes on EKG and otherwise unconcerning story for same day referral to cardiology.

 

I doubt, however, that any cardiologist would appreciate someone with tearing chest pain radiating to their back calling to make a same-day outpatient appointment.

Yeah, that's why I pray our cardiology group will kick this in the bucket. It doesn't even make sense to me. 

[sas5814]

We have a simple protocol. Any chest pain that does not have a clear non-emergent cause goes to the ER. The only variable is POV or ambulance and we generally prefer ambulance. I have been in this particular UC for 2.5 years. I average 1-2 MIs a week (Non-STEMI). I have had 2 pneumos since I have been here and more PEs than I can remember.

This is a bad policy and it will bring harm to a patient and, concurrently, the provider's whose names appear in the chart.

I wrote a blog piece about holding administrative people legally responsible for bad policy that brings harm to a patient or provider. I think if 1 administrator gets personally sued by a provider (after relieving the administrator of the protective umbrells of their organization) it would be national news and alter corporate medicine in this country forever.

BTW you remove them from the protection of their organization by claiming they acted recklessly and beyond their mandate.

Edited July 11, 2019 by sas5814

[Cideous]

^^^^^^^^    Cheer!