Get out Front! by Shari Welch, M.D.

Shari Welch, M.D.Yesterday while working in an ultra high volume ED (300 patients a day) I witnessed the perfect example of why our currently practiced intake model is all wrong. A 21 year old Hispanic woman presented with a history of two months of progressive chest pain and shortness of breath. The greeter nurse saw a young woman, who ambulated into the department and made her a non-urgent case and placed her in the waiting room.

Over one hour later she was placed in a room using a slow motion triage and this is what I saw: A young woman who was grossly cyanotic, plethoric, with enlarged pulsating neck veins sitting up and leaning forward, and with the most amazing clubbing I have ever seen. I knew this from the doorway. You would have recognized this too. Let me come back in a moment and tell you about her diagnosis. But let’s make the case for putting the physician at the front of an ED encounter, instead of at the back of it.

There is much data to support the placement of physicians at intake. The most compelling argument is that they are particularly good at recognizing ill patients. Paramedics correctly predict whether or not patients will need to be admitted from the ED 62% of the time. (Email me if you want all these references). Other studies report how reliably the nurse can predict a patient’s disposition; with about 78% reliability. On the other hand, there is a growing body of evidence in the literature that demonstrates that physicians’ assessments of outcome and disposition are highly reliable, with 85% to 95% accuracy. Mind you this is one of the most reliable processes in medicine, the physician’s initial assessment.

Dedicating a physician to the intake process has a number of advantages. Studies have shown that placing a physician in triage decreases the length of stay (LOS) and walkaways, and increases staff satisfaction. Studies also show that upwards of one third of patients can be rapidly discharged using few or no resources.

Back to the young woman with the chest pain: At the end of her work-up this woman was found to have Ebstein’s Anomaly, a type of congenital cyanotic heart disease that can result in thrombus formation and stroke, PSVT, endocarditis etd. She had never been diagnosed until she came to the ED. Her hematocrit was 75 and her O2 saturations were 75. She had a big atrial clot, and runs of tachycardia and was about to decompensate on a number of fronts. She was one of the sickest patients in the department and my nursing colleagues failed to recognize that. Rather than blame any individual, let’s recognize that physicians have more training, knowledge and experience than our nurse colleagues and we are better at it than they are. With that understanding I urge you to GET OUT FRONT!

Comments

[omega]

Chanel handbags
Movado Store
I have been keeping track of your site for a long time I read these articles, this is an interesting reading I will continue to pay attention to it more

Your article is one of the most classical style, when I read once, I have been deeply in love with them, you look forward to more perfect work.