confessions of call night accountability

I did something last night I cannot remember doing in all of my 30 plus years of taking phone calls from referring physicians requesting hospital admission of a patient. Instead of following my usual policy of "just say yes" to a request for transport and admission of a young child, I spent ten minutes on the phone reviewing the case, and then explaining to the physician in a rural Southwest Virginia emergency department why the patient would not benefit from the admission.

And then I couldn't get back to sleep. It would have been easier for me to follow my usual policy, and accept the child. This would have relieved the referring physician of any further responsibility for a child with a problem s/he may not have been comfortable dealing with, and it may have reassured the family of the toddler to get direct input from our pediatric experts about the diagnosis and prognosis of the problem. I have risked antagonizing the referring physician, as well as the child's primary care physician, and I have risked this family potentially thinking that the Carilion Clinic Children's Hospital was uncaring, or did not want to be bothered. I also "lost" the potential income this admission would have generated in hospital charges and physician fees. Sound like I may have acted inappropriately?

Well, here is my reasoning. This child had suffered from a condition that has been well-studied and reported in the literature. It is known that, given the referring physician shared with me all important information available, I would not have been able to add ANYTHING SUBSTANTIAL to the care of this child, except to increase cost and risk.

The child did not require any additional tests, did not need to be seen by a subspecialist, and would most likely have been admitted over night ( the call came in around midnight) to be sent home the next morning. There would have been cost to the family and the health insurer (I did not ask for any insurance information, so I have no idea who the payer was), and there would have been material risk to the child because of the  2  hour transport that would have been required. Ambulance travel is not without risk. In addition, as we have mentioned over the last few posts, patients are sometimes harmed in hospitals, although that would have been extremely unlikely in this particular situation.

So, I recommended a few hours of observation in the emergency department, and offered additional consultation by phone if further questions arouse (without charge), and encouraged the physician to call back if anything changed that would make hospital admission necessary. I did not receive any further calls about this child.

As an accountable care organization, it is the responsibility of all of us to act in concert with "evidence based medicine" and above all to do what is right for the patient without doing anything unnecessary. Knowing that the admission was not indicated, I therefore chose this path. But this is uncomfortable for me. As a tertiary pediatric institution, we often can provide the expertise and experience that doesn't exist in the community, and we have a significant role to play in reassuring families, primary doctors and emergency physicians that children are receiving the "right" care.

I would love to hear from the readers of this post if you think I did the right thing. I tossed and turned all night considering how I would have felt if I were that child's parents.

Comments

Absolutely the correct thing! Cheers!

As a parent of 3 children, I would have been more upset if I travelled 2 hrs away, locating sitters for the other 2 children, paying my deductible, only to discover that the receiving hospital did "nothing but watch my child", something the ED can do. It's also very reassuring that conversations are open between physicians of both hospitals to make the critical decisions necessary and provide guidance as needed.

I feel your pain! In my former position, when I was on call, all outside requests for admission to our children's hospital came through me. I generally stuck with the policy of accept all patients for the same reasons you site--relationship with the referring facility, desire to reassure the family everything is being done, fear that the child is sicker than the impression the referring facility is relaying to me. There were many admissions that went home the next day without any further testing, invasive monitoring or subspecialty consult. I struggle with the bigger, public health question of what cost and risk am I adding to the health care system by transferring, admitting and billing these children. I pondered if the families were relieved or annoyed by spending a few hours in our children's hospital with as much as 6 hour transports. On the rare occassion I took the route you did last night, I too worried the rest of the night as to whether I had done the right thing. I wanted to, but never had the nerve, to check the next day and see if the referring hospital called another pediatric center to transfer the patient or followed my instruction. If I attempted to not accept the patient and the referring facility protested, I was fairly fast to back down, not wanting to alienate the referring center.
Most of our transports were helicopter without specialized pediatric teams which worried me that I could cause more harm in accepting them. This was balanced against many of the rural ERs being staffed by midlevels with little pediatric experience. I always was trying to balance the risk of the transfer againt the posibility that the referring care provider was not clearly describing the patient to me.
In summery, I think you did the correct thing, but surprisingly to those who have never been in your position, the more difficult thing!

I think you did the right thing. I have been able to talk ED physicians out of admissions when I can evaluate the patient myself. It is much more difficult to do over the phone for the various reasons mentioned. Often we accept patients where the child is either more or less ill than the impression we get from the phone call.

I agree that you did the right thing. An important question from my perspective is were the parents part of the conversation and did they understand. As you point out, patients deserve to know what decisions are being made and why, particularly when they might not appear to be in line with what they might reasonably expect.

Pat
Thanks for your comments. As I was on the other end of the phone, I have no idea what the parents were told, or not by the ED physician. I tried to share the information available with the physician, and I hope he shared it appropriately, but I have no idea whether my ten minute conversation was translated into: "Dr. Ackerman is refusing to accept your child" or "Dr. Ackerman has advised us that this problem is self-limited, and given how much we have already done here, will not need to do any additional testing, and will likely be sending your child home in a few hours."
I agree that the parents need to be part of the conversation, and in fact, after I got off the phone, almost called back to offer to speak with them directly on the phone. This is one area where telemedicine can help us, and once we have a reliable web-based telemedicine product that would have allowed me to converse with them "face-to-face" from my home to explain the evidence behind my recommendation. I suppose I could have just used skype--but most emergency rooms would not have a web cam available in the middle of the night.

I also think you made the correct call, Alice. As a pediatrician on the other end of the phone, I appreciate a consultant who is willing to listen to my concerns, offer real, practical advice, and be available if I need more help! Sometimes that means accepting care of the patient from me, but other times the situation calls for treatment advice and reassurance. As long as we all keep the best interests of our children in mind and strive to provide the best quality care that we can, we will do the right thing for our patients!

Dr.Ackerman, having known you and received my training from you, I am not surprised that you did the right thing even though it was the more difficult option. What makes the situaton even more difficult unlike the bigger cities along the coasts is that the ED's do not have uniform capabilities or the same level of personnel and that is where the 10 minutes you spent on the phone coupled with your experience comes in handy. If I have not told you before, you are my ideal pediatric critical care physician.Cheers!

Alice,

There is no question that you did what was most appropriate for all parties potentially effected by the decision. The way this is handled with the refering facility is the key. Too often there is not enough thought, consideration and honest analysis given to these type of scenarios. The "least path of resistance" is always to say, " Sure, transfer" to CCCH or whatever tertiary center and this is not the best decision for many of the reasons you outlined. If there is no benefit to the patient, then why transfer.
Over the past two decades the chronically ill pediatric population has significantly increased which has put this issue in the forefront.
We all need to better appreciate the incredible resources involved transfering such patients, not to mention the impact on the families.
We do have a professional responsibility to educate our outlying ED facilities and to support them as local triage centers so that we can make the best decisions for the patients and their families in like scenarios.
Our Pediatric Transport Outreach Program here at CCCH does just that and over years has had an impact. Trust between the tertiary center and the local/regional ED's is paramount.
I sleep better when I make decisions that I am confident are in the best interest of the patient and family.

I agree that you did the right thing, albeit it undoubtedly wasn't the easy thing to do. I feel we have to ask not only the right medical questions (which you undoubtedly did), but also need to realize the threshold of anxiety of the transferring physician. we have two "clients" in these cases; the patient and their physician. In this case you addressed both with resolving the anxiety of the physician and helping the patient; thus a true win/win. As you said, it meant that we didn't receive the money from the transfer; but doing the "right thing" at the "right time" is reward in itself.

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