POTD: "I'm not leaving doctor"- Part 2

In our previous PODT we started a discussion regarding how to handle patients that refuse discharge. We will continue our tips on the management of these situations.

Tip 2:

Call on others

• Speak to the patient’s family/ household members/ friends to get more collateral and history. Ask them if the patient looks more sick than usual

• Get case management/ social work involved if you feel like there is an  underlying social issue at play that’s causing the patient to resist discharge

• Discussing the case with another colleague can be very helpful. It never hurts to have a fresh set of eyes evaluate a case without any prior bias

Tip 3:

Document

So you’ve come to the point where there is very little more you can offer the patient in terms of diagnostic workup in the ED. Do one more chart review starting with your EMS and nursing notes and make sure you can make sense of any abnormal vital signs.

If you’ve gotten to this point, now is the time to document your conversations. Make sure you explain your MDM well and document your conversation with the patient extensively. Document any collateral you obtained and any consult recommendations including case management recommendations. Document the plan and outpatient follow-up plan and any conversations you may have had with the PMD.

Summary

Remember the primary purpose of the ED is not a shelter. Sometimes you will have situations where it will get to the point where you have to call security to escort a patient out of the ED. Be extra careful with those patients who still say that they feel sick and have a low threshold to broaden your workup. Make sure to involve others, including family, case management, and colleagues who may be able to shed more light on the care. Phoning a friend for a second option never hurts. Document well. Bad outcomes unfortunately sometimes do happen in this segment of the patients so be carful not to blindly dismiss someone's complaint. EM is a game of balance and with time, diligence, and practice we will perfect our skills. 

Stay well,

TR Adam

POTD: "I'm not leaving doctor"

Let's say you have a patient who comes in with chest pain and you do an extensive workup including CTs, serial troponins, Echos, stress test, PMD discussions. However, despite a thoroughly negative workup the patient still feels sick and refuses to leave. Would you call security on this patient to leave?

Chances are you’ve had to bring security or police in to escort a patient out of the ED before. Some cases are pretty straight forward- if a patient is violent, aggressive, or  dangerous, then they should be removed from the ER once they are medically cleared.

However, other times it’s not so clear who we should call security on to escort them out of the ED. Especially if the patient is not a threat to staff and the patient believes that they are too sick to leave. These decisions are very case by case dependent and sometimes you will end up having to call security.

But keep in mind that patients have had significant negative outcomes including death after being escorted out of the ED when they initially did not want to leave because they felt like they were too sick.

Over the next few days, we will discuss a few tips to prevent bad outcomes when it comes to these difficult patients/ scenarios.

Tip 1:

Re-consider your workup

Ask yourself:

How sure are you of your diagnosis?

Is this a high utilizer who normally leaves in the morning after a good night’s rest and food?

We all make mistakes and we all may miss something. If you have come to a roadblock with a patient who you feel you have worked up thoroughly but still feels so sick they won’t leave, take a step back. Go back and expound upon your history and physical. Ask questions to the patient you didn’t ask the first time. Rethink your differential.

These patients are often not good candidates for a minimalist workup. One of our responsibilities as ED doctors, is to rule out dangerous morbidity and mortality- affecting conditions. Yes, we as ED doctors have to judiciously order tests but in general, we should have a lower threshold for these patients.

For example, you have a patient with abdominal pain who you haven’t done any labs or imaging because their belly is soft without rebound and guarding. The patient states they still feel unwell and are not comfortable leaving. In this situation, you should reconsider your workup. You have much more justification on calling security for exit escort on a patient with abdominal pain who you did labs and CT on than no workup at all. It gives you as well as the patient more reassurance.

Address any abnormal vital sign prior to discharge and use as a general sign of ‘badness.’

To sum up:

Err on the side of caution and order more tests if you have to. Reconsider your differential and workup.

Made it this far? Ready for tip 2?! Tune in next time for part two!

Stay well,

TR Adam