If You Leave


“Admission Denial”

Use in Emergency

Not really words that as an E.D. doc we used to have to think about.   Of course, these words are taking on a whole new meaning for us when we try to readmit that CHF’er who decided they really needed a smoke to go home to “take care of business,”  and we then get push-back from the admitting service or Utilization Review nurse.

It’s not our fault the patient decided that they didn’t like the food. Or that they felt they would get more frequent narcotic administration by absconding from the hospital ward and coming down to the E.D.   I get that patients become bored on the floor and feel like no one is paying attention to them when rounds are just once a day.  I understand that patients sometimes feel like “the doctor wasn’t doing anything anyways just sending me off for a bunch of tests.”  I’m sorry if they left last time;  however, their lung cancer, GI bleed, cardiac disease, end-stage renal disease is a reality, and they really do need to be in the hospital.

Somehow, though, I don’t quite get the patient who was stabbed in the shoulder, had a tension pneumothorax we needle decompressed and who we then admitted with a chest tube, who didn’t want to “wait around the hospital” and so absconded with their chest tube in place and carrying their Pleuravac. To their credit, they did show up back in the E.D. two days later saying that’s when he was originally told he was going to have his chest tube removed and was back to have it taken out.

I also had another patient who developed chest pain and walked to their closest fire department where they proceeded to collapse on the steps. The firemen performed CPR and defibrillated the patient getting back a pulse when EMS arrived. The STEMI was evident on the pre-arrival EKG, and we got the patient to the cath lab within 30 minutes. He, of course, absconded just after his angioplasty because, “he’d been on his way to do something, and couldn’t be sitting around the hospital doing nothing.” He shows up from time to time with anginal pains. Probably because a proper discharge would have included medications which he didn’t get that would have helped with those pesky clogged arteries.

Don’t even get me started on why he hasn’t filled his scripts yet….

  1. #1 by Dr. J - August 22nd, 2010 at 12:14

    I think the trick here is that we have sort of been conned into ‘admitting the patient’ in the first place. What we are actually doing is consulting the inpatient service because the patient requires admission.

    Yes I am well aware that it is now normative to write a full order set that can last at least 24 hours until the admitting team gets around to seeing the patient. That’s how it works in my shop too. Here’s the catch; only someone who has actually seen and evaluated the patient can decide if they do or do not require admission. There is no telephone denial of admission, I am consulting an inpatient service because in my opinion as the physician who has seen the patient I think they need to come in. If the inpatient service wishes, and as a convenience to them I can write holding orders, but if they do not want to admit the patient they can come and do an actual consult and decide what they want to do after that.

    Finally I will note that I see a lot of these where patients are admitted and denied a day pass because the inpatient team thinks they might smoke, drink or do drugs. The patient goes out for a few hours anyways and come back to the ward to find themselves signed out AMA and so they come back to emerg. For anyone who is in this practice I would caution them that in most circumstances the medical team cannot legally restrict mobility of person. Patients who are mentally incapacitated, mentally ill, or demented can in some jurisdictions be detained against their will. The majority of people who want to go smoke, drink or drug do not meet the criteria for involuntary detention and preventing them from exercising freedom of person is, in some cases, a criminal offense.

  2. #2 by Ronald A. Hellstern, MD - August 28th, 2010 at 20:04

    1 in 5 chronic disease readmissions within 30 days of discharge are a national scandal and for the most part preventable. The transition from inpatient to outpatient is poorly coordinated if at all. Patients headed off track have no where to go to be seen and receive intensive outpatient therapy in a timely manner to avoid further deterioration. EM needs to be a part of the solution to this, probably through involvement in observation units.

  3. #3 by Jane - September 13th, 2010 at 21:31

    I think that people are conditioned by television, the Internet and the media to think that things should happen quickly. They don’t understand that assessment, diagnosis and observation take time; whether they are in the ED or on the floor. We had a guy that split last night because he said he’d been there 6 hrs (4.5 was the real LOS) and was pissed off. Perhaps Dancing with the Stars was on. I don’t know. Patients don’t have patience. I’m new to the medical field and one thing I’ve learned is that yes, we want them out as fast as they want to be out, but it just doesn’t always work that way. Pts need to be educated that if you are going to come to the ED, it isn’t like the drive through window and if you’re going to go to the floor, it isn’t the Plaza Hotel and after Medicare says bye bye (3 days) you’re outa there. I hear that some institutions’ ED MDs will try to admit a pt needing such, and the case manager can veto that if the diagnosis isn’t to their liking. You can’t win!

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