Traditionally, many EPs did not know what happened to patients after they were discharged from the ED.
“Emergency medicine was a specialty that really had no follow-up on patients. It really kind of took medical care out of context, by caring for patients in a vacuum,” says Shamai A. Grossman, MD, MS, associate professor of medicine and emergency medicine at Harvard Medical School.
Grossman and colleagues developed a tool to track outcomes of ED patients. The tool is integrated into the EMR systems at six hospitals within the Beth Israel Lahey Health system. The tool automatically creates a list of each patient a physician sees in the ED, along with the room number.
“One might not remember the patient’s name, but might remember where they were in the ED,” explains Grossman, an attending EP at Beth Israel Deaconess Medical Center.
EPs can access the patient’s record quickly; the full online record if the patient was seen at the hospital or affiliated clinics; a list of all residents, attendings, advanced practice providers who were involved in the patient’s care; the ED diagnosis; disposition; length of hospital stay (if the patient was admitted); and notifications if the patient returned the ED.
“For us as clinicians, that opened up an incredible opportunity,” Grossman shares. “We can look at whether what we did was right. If what we are doing is right, we need to disseminate the information. If it’s wrong, we need to fix it and make our care better.”
The idea is to help not only individual EPs next time they see a similar patient, but also EDs everywhere. Of 111 EPs practicing at the six hospitals, 98% reported tracking their former patients through the EMR.1 This suggests that for virtually all EPs, the old model is no longer acceptable. “The truth is that’s not the way people want to practice in emergency medicine. Given the opportunity, we really want to find out what happens to people,” Grossman asserts.
Most commonly, EPs wanted to find out what happened to a patient because it was an unusual or complex case, or because the diagnosis was uncertain at the time the patient left. Forty-eight percent of EPs said they had tracked a patient specifically because of concern about a potential error. Most EPs wanted to know the hospital discharge summary or test results after the patient’s ED visit, or any new diagnoses added since the visit.
If the EP sees anything concerning, the EP can flag the case for departmental review. This generates an automatic email to leadership. One EP flagged a case involving a radiology over-read. During the first ED visit, the EP was concerned about a possible tear in the lung lining. The patient underwent a chest X-ray, and was discharged. When the patient returned to the ED, staff ordered a CT scan, which revealed a pneumothorax.
The provider who flagged the case asked these questions: Could the pneumothorax have been seen on the initial chest X-ray? Should the first ED team who sent the patient home have ordered a CT scan before considering discharge? “We often will contact the person who flagged the case to give us added insight to the issue,” Grossman says.
Notably, 86% of EPs said knowledge they gained by tracking patients’ outcomes changed the way they practice in some way. Ninety-eight percent agreed or strongly agreed patient tracking helps EPs avoid future mistakes.
One EP admitted a patient to a cardiac care unit on a heparin drip for intractable chest pain the EP assumed was cardiac. It turns out the patient actually had cholecystitis. Another EP missed cellulitis in a patient who was admitted, and acknowledged future patients should undergo more careful physical exams.
In other cases, EPs discovered their initial approach was confirmed. An EP admitted a patient for suspected COPD and saw the patient was subsequently transferred to another hospital after elevated cardiac troponin levels, because inpatient providers suspected congestive heart failure. The EP saw the patient was diagnosed with COPD with demand ischemia.
In another case, the EP was pressured to discharge a patient, but pushed for the patient to be admitted. The EP found the patient ended up hospitalized for a week with complicated issues. Another EP saw a patient with severe abdominal pain who had undergone an CT, ultrasound, D-dimer, and stool guaiac test; all were negative. The patient’s pain seemed out of proportion to these findings and the exam, but the EP decided to discharge the patient instead of putting the patient in observation status. The EP followed up via text, learning the patient subsequently had diarrhea and then improved. This confirmed the EP’s suspicion of gastroenteritis.
Grossman notes EPs are legally obligated to follow up with patients on any test results pending that were ordered in the ED. This includes incidental findings (e.g., a nodule found on a chest X-ray). In cases like that, “if you see a patient as an emergency physician, you need to make sure they follow up with a doctor. Otherwise, you could end up being responsible,” Grossman cautions.
The hospital maintains a full-time follow-up office where nurses look at every abnormal result from labs and imaging studies to make sure follow-up happens. EPs are using a newly developed electronic tool to communicate with outpatient providers. Instead of phone calls, abnormal results are posted on an electronic board. The outpatient provider is alerted to the abnormal results, and the EP can see where the situation stands regarding follow-up. “We began trialing the tool this year, with one of our largest primary care provider groups, with the hope to expand it to all of our affiliated providers,” Grossman reports.
Overall, the tools and practices facilitating follow-up with ED patients serve to expand the scope of the EP’s relationship with the patient. “It takes us out of the mindset that we are working only within the four walls of the ED,” Grossman says.
REFERENCE
- Villalba C, Burke RC, Gurley K, et al. Electronic health record-based patient tracking by emergency medicine physicians. AEM Educ Train 2022;6:e10732.
Emergency physicians must follow up with patients on any test results pending that were ordered in the ED, especially if said test reveals something troubling, like a lung nodule via X-ray.
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