This RMD Review comes from patient feedback regarding transferring care to the emergency room. Many of our patients feel the provider who sent them to the ER did not listen to them, evaluate them, or care about them as people or patients.
When it comes to CRH Healthcare clinics, there are two distinct categories of patients who need emergency evaluation.
The first category is the patient who simply needs more testing to definitively rule in or rule out an emergent condition. This patient’s risk is typically lower, but it is not negligible. The condition must be further evaluated due to the medical risk to the patient. The second category is the patient who is in an obvious emergency, such as a crushing substernal chest pain or facial drooping.
This article mainly pertains to the first category of patients. The second category of patients should receive expedited triage by calling EMS while the provider evaluates the patient’s safety and stability.
As healthcare providers, we understand that certain conditions cannot be fully treated in an urgent care facility. We know that a 70-year-old with a head injury needs a head CT; however, our patients often do not share this same level of knowledge or understanding. One of our responsibilities is to educate these patients so they understand the necessity of emergency workup and treatment.
The first point of this approach is to treat the patient as you would any other. Follow the AIDET guidelines. Take a complete history. Perform a complete physical examination. Perform any point-of-care testing. Then, present the treatment plan to the patient. This treatment plan may include a referral to an ER.
When you have a complete assessment, patients are more likely to feel heard and adequately cared for, which helps establish strong medical reasoning for ER referral.
A 42-year-old female with a past medical history of GERD and obesity presented to the clinic on Saturday at 8 a.m.
The patient reported abdominal pain that had been intermittent for two to three months. The pain previously lasted a few hours at a time. Now, the pain has become persistent for the past three to four days. Vital signs are within normal limits and stable.
The patient’s exam reveals tenderness to palpation of the epigastric and right upper quadrants. Murphy sign is further positive. Due to a complaint of abdominal pain in a woman of childbearing years, a UA and UPT were completed as a standing order. Both were negative.
The treatment plan was presented to the patient with an ER recommendation for a presumed diagnosis of gallbladder irritation, which was likely caused by a gallstone that had been popping in and out of the exit of the gallbladder for the past months causing the patient pain but was now likely stuck causing the buildup and irritation in the gallbladder.
It was further explained to the patient that the process of the condition could lead to infection and even death or that a gallstone can progress further into the shared tubes and lead to liver or pancreas backup and damage to the organs. The issue is that we don’t know what stage the patient is in the process, and the only way to learn for sure on a Saturday morning was with an ER evaluation.
The patient asked for other options, including outpatient evaluation and workup with in-house blood work and imaging, which would likely not be until Monday morning at the earliest. It was reiterated that there was a risk to this choice as the level and severity of the disease state are not known and could progress or worsen before that time.
The visit punctuated what the expected ER workup might involve, with a disclaimer that the ER will work it up as they see medically fit. There was also the addition that there was hope the ER workup was negative and the patient went home from the ER with a clean bill of health or the known diagnosis of GERD, as this would be the best-case outcome of an ER visit.
After being thoroughly informed and involved in the decision-making process, the patient opted to go to the ER for further evaluation. That evening, the patient underwent a cholecystectomy.
Do not delay a truly emergent visit, such as crushing chest pain or facial drooping, to provide this level of care.
If the example patient had opted for an outpatient workup, the appropriate response would have been to reiterate this decision goes against medical advice. The provider would have them sign the AMA form and treat them as best as possible within the bounds they have set with their patient autonomy.
In the example case, labs, an immediate right upper quadrant (RUQ) ultrasound, and a surgical consult as soon as possible would be needed. The patient may have been persuaded to visit the ER with a RUQ ultrasound, which demonstrated cholecystitis.
Don’t be afraid to tell a patient:
As a healthcare provider, I don’t ever want to miss something. The ER can do a more complete workup than I can do here in an urgent care setting. I would rather you go, and they find that your gallbladder is fine, than to miss a more serious problem. If they say everything is ok, then you have the best possible outcome. However, we don’t know for sure unless you go to the ER.
Our patients want to be heard, validated, examined, and cared for, as we all desire. When they enter our clinics, some of them know they likely should have gone to the ER, and they are scared.
We often see people on what may be the worst day of their lives, so remember to listen carefully, evaluate thoroughly, and treat them with the kindness and professionalism you’d want to be shown to yourself or a family member—even when you know they require a higher level of care.
Daniel Ralston, MD
Regional Medical Director
Peachtree Immediate Care
E-mail: dralston@peachtreemed.com
