Dear Director: After some recent events nationally, our hospital administration has told us not to “push” patients out the door by using security or the police. I’m concerned that we’ll end up being a shelter and just have patients who won’t leave after they’re discharged. What can I do?
In a prior life, I worked as a bouncer in a beach bar after college. If you know me now, and didn’t know that fact, you’re probably laughing. Back then, it was an easy job and a chance to live at the beach. The job involved taking out more trash than people, but plenty of people were escorted out of the bar. Usually, it was for fighting, but sometimes the bartender would wave us down and tell us someone had to leave, and our job was to show them out. If you’ve been in emergency medicine long enough, I have no doubt that you’ve also had security or police escort someone out of the ED. But, we work in a hospital, not a bar, and have an obligation to care for our patients. We also have an obligation to make sure our ED is safe, and for violent, aggressive, or dangerous patients, I recommend calling the police. However, for the sake of discussion, this article will focus on the patient who believes they are too sick to leave without being a threat to staff.
I spent most of my career working in urban emergency departments. I often felt that our psych area was a shelter—say you’re suicidal and you could typically get a couple days of ED turkey sandwiches while you waited for a bed and slept before contracting for safety and leaving. On the other hand, occasionally, patients came in for medical issues and then refused to leave once they had been fully evaluated. Security would typically be called. We got into our jobs because we liked emergency medicine and no one wants to think their ED has become a shelter. As I’ve talked to colleagues who still work in this environment, security and police escorting someone off hospital property occurs regularly.
However, a quick Google search will show you that bad outcomes afterwards is not an uncommon occurrence—patients have died or had significant morbidity after being escorted out of the ED after the patient didn’t leave initially because they felt they were too sick and required more care. These are certainly challenging situations and need to be considered on a case by case basis. It’s unrealistic to think that police or security would never be needed to escort patients from the hospital, but below are what I consider to be best-case scenarios for preventing future bad outcomes in this scenario and minimizing the need to have patients physically removed by police or hospital security.
Get the Medicine Right
While this seems inherently obvious, we still make mistakes. For starters, consider the history, the differential diagnosis, how much testing have you done, and how certain are you of your diagnosis. Do you know this patient or not? Are they a super utilizer and never want to leave the ED? I’d be more concerned if this is a dramatic change from their behavior (i.e. they usually leave after some meds, food, or sleeping and now they won’t) or if this is the first presentation of a patient to our ED. I had a great attending when I was a resident. He would say, “Ask another question and order one less test.” That’s great advice that has served me well but for these patients, I would say, ask a few more questions and then consider if you need more testing. These patients are not the ones to take a minimalist approach on and not do labs or a CT. I’m not advocating for needless tests, but if the patient has abdominal pain and you haven’t done any testing and they’re refusing to leave, I might reconsider my work up. Personally, I feel much better having police escort someone out with normal labs and a negative CT than if I simply decided they don’t have a surgical emergency because I didn’t appreciate any rebound or guarding on my exam. We see lots of back pain patients but most get better after some meds and are agreeable to discharge. I feel like I am only allowed so many MRIs a year and I hold on to these chits closely. However, I’ve also been surprised to find significant abnormalities on patients who refused to leave and pressured me into getting an MRI (in my mind, I’m doing it to prove nothing is wrong with them so they will leave).
Vital signs are vital. Part of getting the medicine right means clearly addressing abnormal vital signs. By now, everyone has seen the literature that shows the relationship of unanticipated post ED discharge death to abnormal vital signs. Vitals are the first thing I look at when I review a case from a quality perspective. Experience tells us that abnormal vitals are frequently seen in patients who are discharged and have bad outcomes. Patients can certainly be discharged with abnormal vitals, but these should be explained, or explainable, in the chart.
Phone a Friend
If a patient won’t leave, now’s the chance to get more history or elicit help. Take the opportunity to have them call friends or family to pick them up. If the family is present, ask them to clarify history. Find out what else is going on. If it’s not a medical issue, what is the underlying problem? Get case management involved. Maybe a shelter bed, a cab voucher, or a couple days of a prescription is all they need. However, if it’s not a psychiatric issue or social circumstances, and family is saying the patient appears more ill than usual, then reconsider your diagnosis. Of course, you can also call a colleague. If you have double coverage, take a minute to discuss the case with a colleague for an unofficial consult. We don’t do this too often, but these discussions can provide a fresh perspective on a case. Maybe you need a hospitalist consult. Again, you probably don’t do this very often, but for the handful of times a year where patients won’t leave an ED and require a security escort, this work won’t overwhelm your hospitalists.
Don’t Let Their Personality Impact Your Judgment
This is easier said than done since no one really wants to go out of his or her way to take care of a rude, obnoxious, ungrateful, uncooperative, cursing patient. Certainly, we can quickly be swayed when the nurse comes over and encourages us to discharge someone who’s not pleasant for them to take care of. For these patients, take a few deep breaths, and always make sure you’re making your decisions based on the medicine and not on the patient’s personality.
Document, Document, Document
Now that you’re sure the medicine is right and you’re making the appropriate discharge decision, before you contact security, take the time to do one more review of the chart. Start with the EMS and nursing notes. Is there information that may impact your decision-making and have you addressed all of the issues noted? Now is also the time to document your conversations with the patient, family, patient representatives or nurse supervisors who become involved, and case management.
Be sure to include what has been offered to the patient. Finally, just like you thoroughly document a chart when a patient leaves AMA, now is the time to make sure your medical decision-making is clearly spelled out. Include your differential diagnosis and why you think your diagnosis is correct and hospitalization is not required. Often, these are the cases where the diagnosis is an atypical presentation of an unusual diagnosis; so keep an open mind on your differential diagnosis. Document thoroughly because just like an AMA patient, if there’s a bad outcome, your documentation will be the key to supporting your decision-making.
The ED is not a shelter, and from time to time, patients will refuse to leave the ED. Before calling security or the police, be very confident of your diagnosis. This involves a thorough work up and if available, collaboration with family and case management. Rarely does a patient’s refusal to leave require the police or hospital security to physically remove them. In these cases, take the extra few minutes to thoroughly review the care provided, other social issues that may be impacting the disposition, the documentation in the medical record with a section for your own medical decision making, and consider any other options that may exist prior to the police being involved.