Controversy: Should PID patients be admitted?
A controversy exists as to whether patients with pelvic inflammatory disease (PID) should be admitted to the ED. "This is an edgy situation, particularly in today's managed care era," reports William Mallon, MD, FACEP, associate professor of emergency medicine at University of Southern California Medical Center in Los Angeles. "The HMOs feel everything should be managed on an outpatient basis, whereas some clinicians insist that any woman of reproductive age should be managed as an inpatient. But that's a difficult thing to get done in a managed care environment."
Managing PID on an outpatient basis may endanger some patients, says Mallon.
"A long time frame that elapses before the ultimate devastating complications you are fearing, such as ectopic pregnancy infertility, from the initial inspection," he explains.
There is no definitive literature on the subject. "There is no good, long-term outcome data to say that women with PID do just as well managed as outpatients," notes Mallon. "They all get better, but do they have the same rates of infertility? No one has compared the two groups of inpatients versus patients aggressively managed with antibiotics. But that doesn't justify the conclusion that it is acceptable to treat these patients on an outpatient basis."
Know criteria for admission. Many EDs no longer admit all PID patients. "When I was in training at a children's hospital, we admitted all patients with the diagnosis of PID," recalls Terry Adirim, MD, MPH, assistant professor of pediatrics and emergency medicine at George Washington University School of Medicine. "This was because PID is a risk for infertility."
As inpatients, the young girls could get education regarding sexually transmitted diseases, birth control and disease prevention, Adirim explains. "Also, since adolescents are notoriously non-compliant with medication and follow-up, admission assured that the girl would get IV antibiotics and treatment for at least a few days," she says.
Today, the pressures of managed care may affect which patients get admitted. "It is possible that as managed care has limited admissions, physicians have felt pressured to treat this as an outpatient disease," says Adirim. "Also, many girls may be treated in general EDs where the practice is generally not to admit uncomplicated PID patients."
The criteria for admission of adolescents and women with PID varies from institution to institution and from practitioner to practitioner, notes Adirim. "I have noted that in the field of pediatrics at the hospitals where I have worked, that the threshold for admission has changed," she says. "We are now less likely to admit a patient with PID than in years past."
General criteria for admission includes the following: (see CDC guidelines, excerpted in this issue) 1) if the diagnosis is uncertain or a surgical emergency such as an ectopic pregnancy or appendicitis cannot be excluded; 2) a pelvic abscess is suspected; 3) the patient is pregnant; 4) the patient is an adolescent; 5) the patient has HI;, 6) the patient is severely ill, such as with nausea and vomiting that cannot be managed as an outpatient; 7) failed outpatient therapy; and 8) clinical follow-up within 72 hours cannot be arranged.
However, not all adolescent patients with PID are admitted, notes Adirim. "Institutions may have other criteria. Personally, in my practice, I admit adolescents if they are very young (under 15), if I suspect a tuboovarian abscess, if it is unclear this is not an appendicitis, if the patient failed outpatient therapy or if the patient appears very ill or cannot keep fluids down," she says. "I transfer any pregnant patient to an adult facility."
Patients not managed for pain. When PID patients are discharged from the ED, they often leave without being managed for pain, says Mallon. "One study found that many women with PID who were outpatient managed weren't given any pain management whatsoever," he says. "This is a very painful condition which definitely warrants medication. Undertreatment of pain in PID is rampant."
A possible reason for this is that the majority of physicians are male, says Mallon.
"You'll find physicians who have had fractures will be much more liberal with pain medication than those who haven't. Obviously, male physicians have never had PID," he says. "Even though the chief complaint of these patients is frequently pain, they leave without pain medication, which is not right. Nurses should prompt physicians to give pain medication."
Know signs of PID
"Nurses should look for signs of PID in adolescents complaining of abdominal pain," stresses Adirim. Here are some signs and symptoms to watch for:
Abdominal pain. "PID should always be suspected in teenage girls with abdominal pain," Adirim says. "The patient may also have vomiting, vaginal discharge, and/or fever."
Fever. "Asking about fever and vaginal discharge is important. Fever may make the physician/practitioner more suspicious of tuboovarian abscess," says Adirim.
Last menstrual period. "Asking about the last menstrual period is important for two reasons: typically PID manifests after the period, and when suspecting pregnancy," says Adirim.
Sexual partners. "Asking about sexual partners is very important because they need to be treated also or the girl risks reinfection," says Adirim. "The ED nurse may also be more able to assess the adolescent's social situation and likelihood of compliance with medication and follow-up."
Pelvic exam. "Girls commonly deny sexual activity so it is still important to rule out this diagnosis by performing a pelvic exam," Adirim notes.
Test for STDs. "Any girl with PID should be tested for not only Gonorrhea and Chlamydia by culture, but also should have a RPR for syphilis," Adirim advises. "The girl should be encouraged to have an HIV test, though not in the ED. She should be counseled as to the health risks of sexually transmitted diseases and she should be made aware that there is a risk of infertility which increases significantly with subsequent episodes of PID."
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