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.