This chapter was reproduced from the Emergency Medicine Clerkship Primer, 2008, Chapter 13, with the permission of the Editor, for ease of viewing on mobile devices.
Disposition (admission vs. discharge) is, of course, the ultimate endpoint for all emergency department visits. However, this does not mean you should begin to think about it toward the end of the patient encounter. On the contrary, a good clinician thinks about patient disposition from the moment he or she enters the room. Imagine you pick up the chart of a 64yearold male patient with a history of diabetes and hypercholesterolemia who presents to the emergency department with chest pain and shortness of breath. Even before you walk into the patient’s room, you should start to think about the differential diagnosis, diagnostic workup, therapeutic management, and of course disposition.
|A good clinician thinks about patient disposition from the moment he or she enters the room|
By reviewing the “stopgaps” in the admission process, the concept of timely disposition can be placed in better context. In a typical ambulatory presentation to the emergency department, a patient undergoes a triage assessment, usually by a nurse, followed by a brief interview by a registrar to obtain medical insurance and other demographic information. These steps may at times take 30 minutes or more.
Next, depending on the availability of a treatment room, the presentation of unexpected emergencies, and staffing resources, a patient may still wait in the waiting room for some time before being brought back to the emergency department for an evaluation. After a patient is brought back into the treatment area, he or she is often reevaluated by a nurse before being evaluated by a physician. Add to this the time it takes to perform a H&PE, obtain a chest radiograph, draw blood, wait for test results, and more, you could easily add 2 or 3 or additional hours to the patient’s stay before disposition is addressed. Assuming all of these steps are performed in series, you can easily see how a patient presenting with what initially appeared to be a non-urgent complaint can spend many hours in the emergency department. This timeline does not take into account the time that some patients must then endure as they wait in the emergency department for an inpatient bed to become available. If some of these steps are performed in parallel—that is, bedside registration, nursing standing orders for selected clinical presentations, early disposition for the straightforward admission—many hours could easily be taken off the back end, and a patient could be expedited through the system with much more efficiency.
|By addressing the disposition early during a patient’s evaluation, you can easily save many hours on the back end, thus reducing a patient’s stay in the emergency department and improving patient satisfaction and patient flow.|
The case study on the next page gives an example of planning for disposition early. By addressing the disposition early during a patient’s evaluation, you can easily save many hours on the back end, thus reducing a patient’s stay in the emergency department and improving patient satisfaction and patient flow. Of course, the best disposition for a patient is not always clear cut. Some patients will be admitted without a clear diagnosis, whereas others require admission because of social or other contributing factors. A number of these issues and contributing factors need to be considered that may affect the ultimate disposition of a patient:
- Access to follow-up health care
- Ability to fill medication prescriptions
- Level of functional independence or ability to ambulate
- Ability of the patient to care for himself or herself at home (e.g., activities of daily living, dressing, bathing)
- Family and social support network
- Suspicion of child or elder abuse
Once you have decided to admit a patient to the hospital, the next step will be to determine which service he or she should be admitted to. In many cases, this will be obvious—a patient with acute appendicitis should be admitted to the surgery service, a patient with chest pain who requires a cardiac rule-out should be admitted to the medicine service. But sometimes this will not be clear.
When these situations arise, you will need to be your patient’s advocate to avoid or minimize conflict as to who will care for the patient. For example, an elderly patient suffers a hip fracture after a fall. Should this patient be admitted to the orthopedic service with an internal medicine consult to manage her hypertension and diabetes? Or would she be better served by being admitted to the medicine service to manage her comorbidities and have the orthopedic consultant manage the hip fracture? It may prove helpful at times to involve the patient’s primary care physician. He or she would certainly want to be updated on the patient’s condition and may have a preferred referral pattern that can help mitigate these potential disposition conflicts.
Finally, you will have to decide what type of hospital bed a patient will need, that is, a medical–surgical floor bed, telemetry monitoring, stepdown bed, or an intensive care unit (ICU) bed. This decision is often based on the stability of the patient; the expected course of the acute illness; and the need for cardiac monitoring, intensive nursing care, and the like. Some of the nuances of an ICU bed versus a stepdown bed or a stepdown bed versus a telemetry bed may be institution dependent and should always be determined on a case-by-case basis. In addition, consider in selected circumstances the need for contact or respiratory precautions or the need for reverse isolation precautions.
Imagine you pick up the chart of a 64 year-old male patient with a history of diabetes and hypercholesterolemia who presents to the emergency department with chest pain and shortness of breath. Even before you walk into the patient’s room, you should start to think about the differential diagnosis, diagnostic workup, therapeutic management, and of course disposition. A patient such as this should be immediately brought back to the treatment area. The initial nursing assessment and registration could be performed at the bedside. In a high-functioning emergency department, this patient should have an ECG performed, be connected to a cardiac monitor, and often have IV access initiated before a formal evaluation by a physician. In this type of case, the eventual disposition can be made early on in his evaluation. In many institutions, a preliminary admission order can be made before obtaining the results of all diagnostic studies.
A special situation arises when you believe a patient should be admitted, but he or she refuses to stay and wants to leave against medical advice (AMA). As a patient care advocate, we need to ensure that a patient fully understands the benefit of hospitalization and appropriate treatment and the risk of leaving AMA. By doing so, the patient can make an informed decision. To make this decision, we must ensure to the best of our ability that the patient has medical decisionmaking capacity. All reasonable efforts should be used to help resolve issues surrounding the patient leaving AMA. At times, a patient may just be frustrated or hungry, concerned about the hospital bill, or perhaps concerned about missing work. Some of these issues may be able to be resolved, others cannot. If a patient is going to leave AMA, it is best to develop an alternative treatment plan that the patient can adhere to, including the need for close outpatient follow-up or return to the emergency department for reevaluation. Written documentation in the medical record should detail the conversation that the physician and patient had regarding the risks of leaving and the benefits of hospitalization. If you encounter a patient who wants to leave AMA, always alert your supervisor.
|As a patient care advocate, we need to ensure that a patient fully understands the benefit of hospitalization and appropriate treatment and the risk of leaving AMA . . . If you encounter a patient who wants to leave AMA, always alert you supervisor.|
In summary, keep the disposition of the patient in mind early in the course of the evaluation. If expedited in a timely fashion, proper disposition may lead to improved patient care and satisfaction with the emergency department evaluation.