CONCEPTS, COMPONENTS, AND CONFIGURATIONS
Basic Decisions in Emergency Department Cases: A Logical Approach Barry W. Wolcott, MD Fort Sam Houston, Texas
In the emergency department teaching program at Brooke Army Medical Center, housestaff rotating through the emergency department are given an algorithm for use in making basic diagnostic decisions. Housestaff frequently believe that the result of their contact with a patient should be establishment of the correct pathophysiological etiology of the patient's chief complaint followed by definitive therapy and feel anything less is unacceptable. The algorithm, which had been in use for nine months at the time of this report, was formulated in an attempt to deal with the problems such views may create, such as inappropriate management of patients who obviously require admission, second-best care, and delays for patients requiring emergency department evaluation. The algorithm has been successful in changing housestaff attitudes and actions and will continue to be used. Wolcott BW: Basic decisions in emergency department cases: a logical approach. JACEP 7:149151, April, 1978.
protocol, emergency department, diagnosis; diagnosis, protocol, emergency department.
INTRODUCTION
When house officers arrive for their emergency department experience, they have an image of the role of a physician that is the product of their own personality, medical school experience, and postgraduate training. Most believe the result of a physician's contact with a patient should be the establishment of the correct pathophysiological etiology of the patient's chief complaint followed by definitive therapy. They view anything less than this diagnostic and therapeutic precision as an ~inco~aplete evaluation" done only by ~'LMDs", ~'GPs", and ~lazy physicians." Since the nature of the complaints and the time available in the emergency department preclude such precision, house officers frequently dislike emergency department rotations. At Brooke Army Medical Center, all categorical and flexible interns participate in a two-month teaching experience in the emergency department. In addition, all medical residents during their two-year residency spend one month in the major medicine section of the emergency department from 0700 to 1800 hours and three nights per month from 1800 to 0700 hours. During a two-month period the interns provide care for approximately 2,400 patients while the residents will evaluate approximately 1,100 patients during their formal rotation and night coverage. From the Ambulatory Care Research Unit, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas. Presented at the University Association for Emergency Medicine Annual Meeting in Kansas City, Missouri, May, 1977. Address for reprints: Barry W. Wolcott, MD, Ambulatory Care Research Unit, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas 78234.
7:4 (Apr) 1978
JACEP
149/41
Housestaff Attitudes in ED
Diagnosis: Resuscitate
T h r e e y e a r s ' e x p e r i e n c e w i t h conf r o n t i n g t h e s e h o u s e s t a f f v i e w s reg a r d i n g t h e p h y s i c i a n ' s role i n t h e e m e r g e n c y d e p a r t m e n t a n d m y professional communication with other e d u c a t o r s l e a d m e to b e l i e v e t h a t t h e s e v i e w s e x i s t u n i v e r s a l l y . I h a v e c o m e to r e c o g n i z e t h a t t h e s e t e n e t s c a u s e significant and often dangerous problems in treating patients in an emergency d e p a r t m e n t , s u c h as: 1) P r o l o n g e d p a t i e n t e v a l u a t i o n s t h a t i n c r e a s e w a i t i n g t i m e for o t h e r p a t i e n t s a w a i t i n g e v a l u a t i o n of p o t e n tially life-threatening complaints. 2) P h y s i c i a n f i x a t i o n o n a s i n g l e patient's problem in a treatment area w h e r e p h y s i c i a n p r i o r i t i e s s h o u l d be reassessed with each new patient. 3) P r o l o n g e d e m e r g e n c y d e p a r t m e n t e v a l u a t i o n p r i o r to h o s p i t a l adm i s s i o n to a v o i d " d u m p i n g p a t i e n t s " i n t o t h e h o s p i t a l for e v a l u a t i o n b y h o u s e s t a f f p e e r s c r i t i c a l of a ~ s w i n g i n g door" i n t h e e m e r g e n c y d e p a r t m e n t . 4) P r e m a t u r e assignment of pathophysiological diagnoses that preclude later diagnostic efforts either because "the diagnosis was made in t h e e m e r g e n c y d e p a r t m e n t " or because therapy instituted in the emerg e n c y d e p a r t m e n t , b a s e d on p r e m a ture diagnoses, interferes with diagnostic efforts required later. 5) L a c k of follow-up to d e t e c t failu r e of specific t r e a t m e n t r e g i m e n s . 6) R e l u c t a n c e to u s e t i m e as a d i a g n o s t i c tool to e l i m i n a t e t h e m y r i a d of n o n l i f e - t h r e a t e n i n g c o m p l a i n t s not diagnosable at the index visit but which resolve spontaneously with nonspecific therapy. Instead, " t i n c t u r e of t i m e " is r e p l a c e d b y expensive diagnostic tests. 7) P h y s i c i a n i d e n t i f i c a t i o n of patients with undiagnosable complaints as e m e r g e n c y d e p a r t m e n t " a b u s e r s , " " t u r k e y s , " "crocks," etc, w i t h t h e hostility, c o m p l a i n t s , a n d p o o r care t h e s e labels often engender. To a l l e v i a t e t h e s e p r o b l e m s , w h i l e r e t a i n i n g t h e c o n c e p t of " d i a g n o s i s " as a p r i m a r y p h y s i c i a n goal, we h a v e c r e a t e d a n a l g o r i t h m ( F i g u r e ) for o u r h o u s e s t a f f o u t l i n i n g b a s i c decis i o n s i n e m e r g e n c y m e d i c i n e . I present that algorithm here as we present i t to e a c h n e w g r o u p of h o u s e officers.
A p h y s i c i a n in a n e m e r g e n c y dep a r t m e n t makes diagnostic decisions t h a t are different from those made on inpatient services. The initial diagnosis t h a t must be e n t e r t a i n e d as a patient enters the emergency t r e a t m e n t area is: " t h i s p a t i e n t does (or does not) r e q u i r e immediate resuscitation." If he does, further diagnostic efforts will have to await successful resuscitation. Failure to e n t e r t a i n this diagnosis as the patient arrives can result in a patient deteriorating or even dying while a physician, a few feet away, delivers less emergent care to another patient. A l w a y s look up as a n e w p a t i e n t is b r o u g h t in, so t h a t t h i s d i a g n o s t i c possibility c a n be c o n s i d e r e d .
INSTRUCTIONS TO HOUSE OFFICERS IN ED The emergency d e p a r t m e n t will require physician skills you m a y not yet possess. During your full-time rotation a n d scheduled n i g h t s on call you will learn those skills from the teaching staff of the emergency department.
42/150
Diagnosis: Admit Next, t h e diagnosis, " t h i s p a t i e n t clearly will be admitted regardless of any information I gather or actions I take," should be entertained. It is not necessary to have a specific etiological reason for the admission, to prove admission necessity beyond a shadow of a doubt, or to have the p a t i e n t ' s problem completely evaluated, in order to m a k e this diagnosis. As you will see, m a n a g e m e n t of pat i e n t with this diagnosis will differ subs t a n t i a l l y from p a t i e n t in w h o m it is excluded. Failure to properly make this d i a g n o s i s will r e s u l t in i n a p p r o p r i a t e physician actions. The m a n a g e m e n t of patients carrying the diagnosis "obviously needs admission" is straight forward - - admit them. The only diagnostic and t h e r a p e u t i c actions t h a t should be t a k e n in the emergency department are those necessary to safely transport the patient to his ward: lidocaine, b i c a r b o n a t e , volume e x p a n s i o n , anticonvulsants, chest tubes, oxygen, etc. Holding the patient in the emergency dep a r t m e n t for additional therapy or tests .prior to admission h a s several unfortunate effects: !) The patients arrive on the ward as inpatients late in the day or in the early morning hours which may interfere with t h e i r proper evaluation by the ward staff. 2) P a t i e n t s w i t h serious or potentially serious illnesses are kept from definitive, well-monitored i n p a t i e n t care. In the emergency department, a sudden emergency arrival can "use up" all the paramedical help available, leaving ser i o u s l y ill p a t i e n t s u n w a t c h e d . Since emergency department personnel m a y not be as e x p e r i e n c e d in m o n i t o r i n g a n d therapy of inpatients as the critical care area personnel, p a t i e n t s "held" in t h e emergency d e p a r t m e n t are not g e t t i n g the best care available in the hospital. 3) Emergency d e p a r t m e n t resources are directed at patients who no longer require them, and are thus unavailable to patients who do. "Holding" patients delays timely evaluation of all other emergency department patients - - the emergency department's first responsibility. Thus, inappropriate m a n a g e m e n t of p a t i e n t s obviously r e q u i r i n g admission interferes with ward physician evalua-
JACEP
tion, provides only second-best care for t h a t patient, and delays evaluation of subsequent patients. O n c e a p a t i e n t is an o b v i o u s adm i s s i o n , get h i m p h y s i c a l l y into the hospital i m m e d i a t e l y . The w a r d staff c a n " w o r k h i m up."
Diagnosis: Perform Further Diagnostic Evaluation Patients not diagnosed as requiring r e s u s c i t a t i o n or obvious a d m i s s i o n require a f u r t h e r diagnostic e v a l u a t i o n . Again, specific etiological diagnoses are not the primary goal - - the three appropriate diagnostic categories required are: 1) definitive t r e a t m e n t in the emergency department. 2) additional o u t p a t i e n t evaluation and/or follow-up. 3) admission. The emergency physician's job is to arrive at one of these diagnoses as rapidly as possible and take appropriate actions. P a t i e n t s placed in t h e t h i r d diagnostic category are managed identically to those identified earlier as requiring admission. P a t i e n t s whose c o n d i t i o n s c a n be definitively treated in the emergency dep a r t m e n t (ie, no follow-up r e q u i r e d ) should be so treated at time of diagnosis and discharged home. By definition, they require no follow-up arrangements. Patients may require additional outpatient follow-up because: 1) An etiological diagnosis was not made and p a t i e n t needs further diagnostic studies before definitive t h e r a p y is possible. In these cases, the emergency physician must make certain the appropriate follow-up is scheduled and t h a t any symptomatic therapy initiated will not obscure a definitive diagnostic effort later. 2) An etiological diagnosis was made, but the therapy needs to be monitored for appropriateness and effectiveness. Examples are p a t i e n t s w i t h p n e u m o n i a and urinary tract infections started on antibiotics before culture results were available. Again, arranging proper follow-up is the responsibility of the emergency physician. 3) A n etiological diagnosis was not made and the patient will require further evaluation if spontaneous resolution does not occur. The emergency physician must arrange with the p a t i e n t when and where the patient will present for care and what specific i n d i c a t i o n s s h o u l d p r o m p t reevaluation. You do not need to have an etiological diagnosis established to discharge a patient from the emergency department. However, you are obliged to h a v e arranged any indicated follow-up and explain the requirements and mechanics of follow-up to the patient. If you view each patient in the emergency d e p a r t m e n t w i t h this diagnostic approach, you will improve the care offered to all patients seen in t h a t facility.
Algorithm in Use We have now used this algorithm as a teaching tool in our emergency department for nine
7"4 (Ap r) 1978
BASIC DECISIONS IN EMERGENCY MEDICINE Patient Arrives in Maj Med/Maj Surg
Does this patient require resuscitation?
Will this patient obviously be admitted regardless of any actions I take?
NO YES
Perform any therapy essential to allow safe transport to ward
YES NO
1
PERFORM RESUSCITATION
EVALUATION- Hx, PE, Lab
ADMIT AND TRANSPORT TO WARD
This patient has a process a. Allowing definitive ED therapy. b. Requiring additional outpatient evaluation c. Requiring admission
Carry out appropriate therapy
Schedule appropriate follow -up Begin symptomatic RX that does not interfere with follow-up.
DISCHARGE
DISCHARGE
months. Daily c h a r t review and ~ase presentations in the e m e r g e n c y dep a r t m e n t c e n t e r on t h i s basic logic pattern. A t these sessions, house ofricers are asked to discuss with the staff the c r i t e r i a t h e y use for diagn o s i n g '~obvious a d m i s s i o n s , " how they diagnose a problem t h a t allows them to send a p a t i e n t home to ret u r n to the e m e r g e n c y d e p a r t m e n t only if unimproved, or w h y t h e y felt specific l a b o r a t o r y a i d s w o u l d or would not assist in m a k i n g a decision. The housestaff is counseled t h a t t h e i r f r e q u e n t i n a b i l i t y to m a k e definitive p a t h o p h y s i o l o g i c a l diagnoses is a sign of diagnostic maturity, not professional failure. They are encouraged to tell t h e i r p a t i e n t s that, while m a n y serious causes of t h e i r
7"4 (Ap r) 1978
1
complaints have been eliminated, u n o e r t a i n t y as to specific cause rem a i n s , a n d f u r t h e r e v a l u a t i o n or ~:watchful w a i t i n g a r e a p p r o p r i a t e ' ~ o u r s e s of action. A p p r o p r i a t e l y arr a n g e d follow-up is given the h i g h e s t praise by a t t e n d i n g staff.
CONCLUSION We find t h a t most of our house officers change t h e i r o p e r a t i o n a l philosophy after about four weeks of exp o s u r e to t h i s logic p a t t e r n r e i n forcement. A f t e r t h r e e weeks in the e m e r g e n c y d e p a r t m e n t , m o s t new house officers lose the h o s t i l i t y t h e y i n i t i a l l y displayed t o w a r d s m a n y of t h e i r p a t i e n t s , a n d r e p l a c e it w i t h u n d e r s t a n d i n g , if not acceptance, of the reason for the p a t i e n t ' s presenta-
JACEP
Perform any therapy necessary to allow safe transport to ward
1
ADMIT AND TRANSPORT TO WARD
tion. Their c h a r t s d o c u m e n t t h e i r increased a w a r e n e s s of the importance of and i m p r o v e m e n t in t h e i r a b i l i t y to p r o v i d e a p p r o p r i a t e follow-up. Clinical a s s e s s m e n t s recorded on the clinical record cease s t r e t c h i n g the clinical evidence and o v e r s t a t i n g the t r u e level of d i a g n o s t i c sophistication. House officers begin to a d m i t p a t i e n t s e x p e d i t i o u s l y to the w a r d s "because he was obviously coming in and I didn't w a n t to hold him here." Finally, the housestaff become able to verbalize t h e i r a t t i t u d e changes - m o s t c o m m e n t i n g f a v o r a b l y on it. Our experience using this technique h a s been successful enough to continue it n e x t y e a r as the philosophical basis of o u r e m e r g e n c y d e p a r t m e n t t e a c h i n g program.
151/43
Basic Decisions in Emergency Department Cases: A Logical Approach Barry W. Wolcott, MD Fort Sam Houston, Texas
In the emergency department teaching program at Brooke Army Medical Center, housestaff rotating through the emergency department are given an algorithm for use in making basic diagnostic decisions. Housestaff frequently believe that the result of their contact with a patient should be establishment of the correct pathophysiological etiology of the patient's chief complaint followed by definitive therapy and feel anything less is unacceptable. The algorithm, which had been in use for nine months at the time of this report, was formulated in an attempt to deal with the problems such views may create, such as inappropriate management of patients who obviously require admission, second-best care, and delays for patients requiring emergency department evaluation. The algorithm has been successful in changing housestaff attitudes and actions and will continue to be used. Wolcott BW: Basic decisions in emergency department cases: a logical approach. JACEP 7:149151, April, 1978.
protocol, emergency department, diagnosis; diagnosis, protocol, emergency department.
INTRODUCTION
When house officers arrive for their emergency department experience, they have an image of the role of a physician that is the product of their own personality, medical school experience, and postgraduate training. Most believe the result of a physician's contact with a patient should be the establishment of the correct pathophysiological etiology of the patient's chief complaint followed by definitive therapy. They view anything less than this diagnostic and therapeutic precision as an ~inco~aplete evaluation" done only by ~'LMDs", ~'GPs", and ~lazy physicians." Since the nature of the complaints and the time available in the emergency department preclude such precision, house officers frequently dislike emergency department rotations. At Brooke Army Medical Center, all categorical and flexible interns participate in a two-month teaching experience in the emergency department. In addition, all medical residents during their two-year residency spend one month in the major medicine section of the emergency department from 0700 to 1800 hours and three nights per month from 1800 to 0700 hours. During a two-month period the interns provide care for approximately 2,400 patients while the residents will evaluate approximately 1,100 patients during their formal rotation and night coverage. From the Ambulatory Care Research Unit, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas. Presented at the University Association for Emergency Medicine Annual Meeting in Kansas City, Missouri, May, 1977. Address for reprints: Barry W. Wolcott, MD, Ambulatory Care Research Unit, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas 78234.
7:4 (Apr) 1978
JACEP
149/41
Housestaff Attitudes in ED
Diagnosis: Resuscitate
T h r e e y e a r s ' e x p e r i e n c e w i t h conf r o n t i n g t h e s e h o u s e s t a f f v i e w s reg a r d i n g t h e p h y s i c i a n ' s role i n t h e e m e r g e n c y d e p a r t m e n t a n d m y professional communication with other e d u c a t o r s l e a d m e to b e l i e v e t h a t t h e s e v i e w s e x i s t u n i v e r s a l l y . I h a v e c o m e to r e c o g n i z e t h a t t h e s e t e n e t s c a u s e significant and often dangerous problems in treating patients in an emergency d e p a r t m e n t , s u c h as: 1) P r o l o n g e d p a t i e n t e v a l u a t i o n s t h a t i n c r e a s e w a i t i n g t i m e for o t h e r p a t i e n t s a w a i t i n g e v a l u a t i o n of p o t e n tially life-threatening complaints. 2) P h y s i c i a n f i x a t i o n o n a s i n g l e patient's problem in a treatment area w h e r e p h y s i c i a n p r i o r i t i e s s h o u l d be reassessed with each new patient. 3) P r o l o n g e d e m e r g e n c y d e p a r t m e n t e v a l u a t i o n p r i o r to h o s p i t a l adm i s s i o n to a v o i d " d u m p i n g p a t i e n t s " i n t o t h e h o s p i t a l for e v a l u a t i o n b y h o u s e s t a f f p e e r s c r i t i c a l of a ~ s w i n g i n g door" i n t h e e m e r g e n c y d e p a r t m e n t . 4) P r e m a t u r e assignment of pathophysiological diagnoses that preclude later diagnostic efforts either because "the diagnosis was made in t h e e m e r g e n c y d e p a r t m e n t " or because therapy instituted in the emerg e n c y d e p a r t m e n t , b a s e d on p r e m a ture diagnoses, interferes with diagnostic efforts required later. 5) L a c k of follow-up to d e t e c t failu r e of specific t r e a t m e n t r e g i m e n s . 6) R e l u c t a n c e to u s e t i m e as a d i a g n o s t i c tool to e l i m i n a t e t h e m y r i a d of n o n l i f e - t h r e a t e n i n g c o m p l a i n t s not diagnosable at the index visit but which resolve spontaneously with nonspecific therapy. Instead, " t i n c t u r e of t i m e " is r e p l a c e d b y expensive diagnostic tests. 7) P h y s i c i a n i d e n t i f i c a t i o n of patients with undiagnosable complaints as e m e r g e n c y d e p a r t m e n t " a b u s e r s , " " t u r k e y s , " "crocks," etc, w i t h t h e hostility, c o m p l a i n t s , a n d p o o r care t h e s e labels often engender. To a l l e v i a t e t h e s e p r o b l e m s , w h i l e r e t a i n i n g t h e c o n c e p t of " d i a g n o s i s " as a p r i m a r y p h y s i c i a n goal, we h a v e c r e a t e d a n a l g o r i t h m ( F i g u r e ) for o u r h o u s e s t a f f o u t l i n i n g b a s i c decis i o n s i n e m e r g e n c y m e d i c i n e . I present that algorithm here as we present i t to e a c h n e w g r o u p of h o u s e officers.
A p h y s i c i a n in a n e m e r g e n c y dep a r t m e n t makes diagnostic decisions t h a t are different from those made on inpatient services. The initial diagnosis t h a t must be e n t e r t a i n e d as a patient enters the emergency t r e a t m e n t area is: " t h i s p a t i e n t does (or does not) r e q u i r e immediate resuscitation." If he does, further diagnostic efforts will have to await successful resuscitation. Failure to e n t e r t a i n this diagnosis as the patient arrives can result in a patient deteriorating or even dying while a physician, a few feet away, delivers less emergent care to another patient. A l w a y s look up as a n e w p a t i e n t is b r o u g h t in, so t h a t t h i s d i a g n o s t i c possibility c a n be c o n s i d e r e d .
INSTRUCTIONS TO HOUSE OFFICERS IN ED The emergency d e p a r t m e n t will require physician skills you m a y not yet possess. During your full-time rotation a n d scheduled n i g h t s on call you will learn those skills from the teaching staff of the emergency department.
42/150
Diagnosis: Admit Next, t h e diagnosis, " t h i s p a t i e n t clearly will be admitted regardless of any information I gather or actions I take," should be entertained. It is not necessary to have a specific etiological reason for the admission, to prove admission necessity beyond a shadow of a doubt, or to have the p a t i e n t ' s problem completely evaluated, in order to m a k e this diagnosis. As you will see, m a n a g e m e n t of pat i e n t with this diagnosis will differ subs t a n t i a l l y from p a t i e n t in w h o m it is excluded. Failure to properly make this d i a g n o s i s will r e s u l t in i n a p p r o p r i a t e physician actions. The m a n a g e m e n t of patients carrying the diagnosis "obviously needs admission" is straight forward - - admit them. The only diagnostic and t h e r a p e u t i c actions t h a t should be t a k e n in the emergency department are those necessary to safely transport the patient to his ward: lidocaine, b i c a r b o n a t e , volume e x p a n s i o n , anticonvulsants, chest tubes, oxygen, etc. Holding the patient in the emergency dep a r t m e n t for additional therapy or tests .prior to admission h a s several unfortunate effects: !) The patients arrive on the ward as inpatients late in the day or in the early morning hours which may interfere with t h e i r proper evaluation by the ward staff. 2) P a t i e n t s w i t h serious or potentially serious illnesses are kept from definitive, well-monitored i n p a t i e n t care. In the emergency department, a sudden emergency arrival can "use up" all the paramedical help available, leaving ser i o u s l y ill p a t i e n t s u n w a t c h e d . Since emergency department personnel m a y not be as e x p e r i e n c e d in m o n i t o r i n g a n d therapy of inpatients as the critical care area personnel, p a t i e n t s "held" in t h e emergency d e p a r t m e n t are not g e t t i n g the best care available in the hospital. 3) Emergency d e p a r t m e n t resources are directed at patients who no longer require them, and are thus unavailable to patients who do. "Holding" patients delays timely evaluation of all other emergency department patients - - the emergency department's first responsibility. Thus, inappropriate m a n a g e m e n t of p a t i e n t s obviously r e q u i r i n g admission interferes with ward physician evalua-
JACEP
tion, provides only second-best care for t h a t patient, and delays evaluation of subsequent patients. O n c e a p a t i e n t is an o b v i o u s adm i s s i o n , get h i m p h y s i c a l l y into the hospital i m m e d i a t e l y . The w a r d staff c a n " w o r k h i m up."
Diagnosis: Perform Further Diagnostic Evaluation Patients not diagnosed as requiring r e s u s c i t a t i o n or obvious a d m i s s i o n require a f u r t h e r diagnostic e v a l u a t i o n . Again, specific etiological diagnoses are not the primary goal - - the three appropriate diagnostic categories required are: 1) definitive t r e a t m e n t in the emergency department. 2) additional o u t p a t i e n t evaluation and/or follow-up. 3) admission. The emergency physician's job is to arrive at one of these diagnoses as rapidly as possible and take appropriate actions. P a t i e n t s placed in t h e t h i r d diagnostic category are managed identically to those identified earlier as requiring admission. P a t i e n t s whose c o n d i t i o n s c a n be definitively treated in the emergency dep a r t m e n t (ie, no follow-up r e q u i r e d ) should be so treated at time of diagnosis and discharged home. By definition, they require no follow-up arrangements. Patients may require additional outpatient follow-up because: 1) An etiological diagnosis was not made and p a t i e n t needs further diagnostic studies before definitive t h e r a p y is possible. In these cases, the emergency physician must make certain the appropriate follow-up is scheduled and t h a t any symptomatic therapy initiated will not obscure a definitive diagnostic effort later. 2) An etiological diagnosis was made, but the therapy needs to be monitored for appropriateness and effectiveness. Examples are p a t i e n t s w i t h p n e u m o n i a and urinary tract infections started on antibiotics before culture results were available. Again, arranging proper follow-up is the responsibility of the emergency physician. 3) A n etiological diagnosis was not made and the patient will require further evaluation if spontaneous resolution does not occur. The emergency physician must arrange with the p a t i e n t when and where the patient will present for care and what specific i n d i c a t i o n s s h o u l d p r o m p t reevaluation. You do not need to have an etiological diagnosis established to discharge a patient from the emergency department. However, you are obliged to h a v e arranged any indicated follow-up and explain the requirements and mechanics of follow-up to the patient. If you view each patient in the emergency d e p a r t m e n t w i t h this diagnostic approach, you will improve the care offered to all patients seen in t h a t facility.
Algorithm in Use We have now used this algorithm as a teaching tool in our emergency department for nine
7"4 (Ap r) 1978
BASIC DECISIONS IN EMERGENCY MEDICINE Patient Arrives in Maj Med/Maj Surg
Does this patient require resuscitation?
Will this patient obviously be admitted regardless of any actions I take?
NO YES
Perform any therapy essential to allow safe transport to ward
YES NO
1
PERFORM RESUSCITATION
EVALUATION- Hx, PE, Lab
ADMIT AND TRANSPORT TO WARD
This patient has a process a. Allowing definitive ED therapy. b. Requiring additional outpatient evaluation c. Requiring admission
Carry out appropriate therapy
Schedule appropriate follow -up Begin symptomatic RX that does not interfere with follow-up.
DISCHARGE
DISCHARGE
months. Daily c h a r t review and ~ase presentations in the e m e r g e n c y dep a r t m e n t c e n t e r on t h i s basic logic pattern. A t these sessions, house ofricers are asked to discuss with the staff the c r i t e r i a t h e y use for diagn o s i n g '~obvious a d m i s s i o n s , " how they diagnose a problem t h a t allows them to send a p a t i e n t home to ret u r n to the e m e r g e n c y d e p a r t m e n t only if unimproved, or w h y t h e y felt specific l a b o r a t o r y a i d s w o u l d or would not assist in m a k i n g a decision. The housestaff is counseled t h a t t h e i r f r e q u e n t i n a b i l i t y to m a k e definitive p a t h o p h y s i o l o g i c a l diagnoses is a sign of diagnostic maturity, not professional failure. They are encouraged to tell t h e i r p a t i e n t s that, while m a n y serious causes of t h e i r
7"4 (Ap r) 1978
1
complaints have been eliminated, u n o e r t a i n t y as to specific cause rem a i n s , a n d f u r t h e r e v a l u a t i o n or ~:watchful w a i t i n g a r e a p p r o p r i a t e ' ~ o u r s e s of action. A p p r o p r i a t e l y arr a n g e d follow-up is given the h i g h e s t praise by a t t e n d i n g staff.
CONCLUSION We find t h a t most of our house officers change t h e i r o p e r a t i o n a l philosophy after about four weeks of exp o s u r e to t h i s logic p a t t e r n r e i n forcement. A f t e r t h r e e weeks in the e m e r g e n c y d e p a r t m e n t , m o s t new house officers lose the h o s t i l i t y t h e y i n i t i a l l y displayed t o w a r d s m a n y of t h e i r p a t i e n t s , a n d r e p l a c e it w i t h u n d e r s t a n d i n g , if not acceptance, of the reason for the p a t i e n t ' s presenta-
JACEP
Perform any therapy necessary to allow safe transport to ward
1
ADMIT AND TRANSPORT TO WARD
tion. Their c h a r t s d o c u m e n t t h e i r increased a w a r e n e s s of the importance of and i m p r o v e m e n t in t h e i r a b i l i t y to p r o v i d e a p p r o p r i a t e follow-up. Clinical a s s e s s m e n t s recorded on the clinical record cease s t r e t c h i n g the clinical evidence and o v e r s t a t i n g the t r u e level of d i a g n o s t i c sophistication. House officers begin to a d m i t p a t i e n t s e x p e d i t i o u s l y to the w a r d s "because he was obviously coming in and I didn't w a n t to hold him here." Finally, the housestaff become able to verbalize t h e i r a t t i t u d e changes - m o s t c o m m e n t i n g f a v o r a b l y on it. Our experience using this technique h a s been successful enough to continue it n e x t y e a r as the philosophical basis of o u r e m e r g e n c y d e p a r t m e n t t e a c h i n g program.
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