Last shift a woman returned because the day prior she was seen for abdominal pain and her doc said to come back to the ER for a recheck in 24 hours. She had no pain. Zero. New ER visit and bill.
Later a patient called me, Pre-R, to evaluate his surgical wound a few days post-op. He said his surgeon recommended he do a wound recheck with someone. No fevers, pus, pain, redness. Wound looked great. Bright guy just following orders.
You probably think this all sounds appropriate, but these two patients got me thinking about discharge instructions and the patient ping pong experience. Back in my attending days at UNM I used to teach residents and med students to hit four points on their discharge instructions:
- “Return if… fevers, vomiting, pain, etc.”
- “Follow up with… your doctor in 10 days for suture removal.”
- Med recs… “Ibuprofen with food, Zofran for nausea, and Benadryl for rash, but don’t take while driving.”
- Lifestyle changes… “Stop smoking. Your alcohol intake may kill you. Avoid fatty/spicy foods.”
Today I still try to cover these for each patient I see in ERs, but point number 2 is the one I’ve changed most. With Pre-R I’m in a much better position now to say: “Give me a call if you’re in a bind.”
When I first started doing this, many nurses thought I was nuts. “You’re giving out your cell phone number? Are you crazy?!” But it’s just remarkably rare that any of my ER patients call, and even less so that I get abused. Worst case scenario I can always block the number, but it hasn’t yet happened. Plus I’ll admit that this is not for every patient. It’s for those who don’t have easy follow up and for those with problems where we’re on the fence, and frankly, for those I think I can help. College kids with neck pain and colds, who don’t want spinal taps, or patients traveling through town with no PCPs are a couple examples.
Since starting this, I really go home feeling far more comfortable that I’ll hear first if anything turns south. It feels like better care, and at the same time I think it may help to dampen the amplifier that is US healthcare.
We, ER doctors, consistently ask patients to “Follow up with your primary care physician.” Never mind that many patients have no PCPs or they struggle to get appointments at California Health Clinics.
“CHCs,” nurse hotlines and answering services outside the ER do the same thing in reverse. “If you are having an emergency, then call 911.” ERs routinely receive patients around 5pm for further workups, IV hydration, simple blood tests, and X-rays that just don’t fit well into business hours.
Pre-R is a healthcare short circuit. From the ER, I can have patients follow up with… me. And if someone struggling at home needs a little extra assessment or treatment, often we can knock it down during odd hours or at least come up with a plan. Usually just a little conversation and reassurance gets folks through the night though.