Being able to think patients through to their final disposition can be a challenging skill at the clerkship level. However, a good clinician should start thinking about a patient’s disposition as soon as they pick up the chart. Before you take a patient’s history, look at the triage note and start to think through your differential diagnosis, diagnostic workup, therapeutic management, and disposition plan. What are the “most common” and “cannot miss” diagnoses that you should ensure are covered? How does your management and disposition plan change based on this differential list? What aspects of the patient’s history and physical exam make it more or less likely for them to be admitted to hospital or sent home?
When it comes time to present the patient to your staff, your case presentation should be an organized rationale for a management and disposition plan. This can be difficult when your knowledge and experience are at their infancy. However, the 3-minute clinical presentation and the RAPID approach to ED patients (resuscitation, analgesia & assessment, patient needs, interventions, and disposition) are two frameworks that you can use to help remain organized and efficient with your presentations1,2.
Diagnostic Tests and Imaging:
Most patients seen in the ED will require some sort of diagnostic test to gain insight into their presenting complaint and help you develop a final management plan. It is important to think about why you are ordering each test, and how each result plays into your final decision regarding diagnosis and disposition. For cognitive load, it is best to get your patients down to a fairly binary decision-making process. For example: low risk chest pain with normal ECGs and no significant change in their 2-hour troponin = going home, whereas elevated troponin = call Cardiology. Additionally, you must also consider how long each test takes to be reported. Most lab tests take approximately one hour once they are collected. Urine testing is notoriously forgotten, difficult to obtain, or lost. Make sure you check in if your tests have not returned in a timely fashion. There are many reasons for tests to be delayed, but the worst ones are if you forgot to order them or the orders were missed and you only realize 3 hours later!
Similar to lab results, imaging studies are usually reported fairly quickly; however, this can vary based on your site and the number of patients that require these investigations. It is also important to think about how time of day might affect this: does your hospital have access to ultrasound overnight? If not, is the patient stable enough to go home and return in the morning for an appointment, or are they sick and need to stay in the ER overnight?
Patient Response to Treatment:
This is also the time to consider how the patient’s clinical response to initial treatments, if any, will alter your differential diagnosis and thus your disposition plan. For example, a patient with chest pain and a moderate HEART score whose symptoms improve with a GI cocktail will still need a referral to Cardiology even though your clinical suspicion for a cardiac event has decreased due to their response to treatment. Additionally, a patient with RLQ abdominal pain with normal labs, complete resolution of pain after analgesia, and an ultrasound where the appendix could not be seen could likely be sent home with ‘expectant management’ with instructions to return if their symptoms return/worsen as the suspicion for appendicitis has now decreased.
Consider the Consult:
Additionally, getting a sense of how long it will take for a consultant to arrive can help you plan your patient’s disposition and give an effective handover to your colleague at the end of shift. Consultant response times vary by specialty, location, the presence/absence of residents, and their patient load, among other factors. If you know a patient will be waiting awhile for a consult, consider leaving ‘holding orders’ for diet, pain control, nausea, and fluids so that nurses can treat their patients without having to interrupt you while you are completing other tasks.
Use Your Social History:
It is also important to note that the best disposition plan for a patient may not always be clear cut. At times, you may not be able to reach a final diagnosis before admitting a patient to hospital. Other times, there are social factors that greatly alter a patient’s disposition that must be taken into consideration. This includes their current living situation, level of functional independence, and social supports. Do they have a home? How do they function in their home? Is there a caregiver that is available to help with an increased burden of illness? Knowing this early in a patient’s presentation can help you coordinate outpatient resources (i.e. shelter beds, home care supports, outpatient referrals, addictions counseling). Examples include:
- A stable 25 year old patient with no fixed address presents with an upper GI bleed, likely from varices and alcohol abuse. Regardless of their hemoglobin level they will likely need to be admitted as they will be unable to coordinate outpatient follow-up independently.
- An 80 year old patient presents with weakness likely secondary to pneumonia, and does not require oxygen. Their spouse helps to transfer them in and out of bed, as well as to and from the toilet. Given this patient’s current living situation and supports, they will either require additional home supports to manage their illness or an admission to hospital if this cannot be arranged in a timely manner.
Final Disposition Decisions:
Once you’ve made a decision regarding whether the patient is able to go home or should be admitted to hospital, there are still more factors to consider! If the patient requires an admission, what service should they be admitted under? There may be some debate regarding this decision if the patient’s presentation is complex or if they have multiple concerns that need to be addressed. If that is the case, consider admitting the patient under the service that can address their most pressing issue(s) while requesting consults from the other services to ensure all of the patient’s needs are met. Alternatively, if you think that a patient should ultimately be sent home, what signs or symptoms would warrant a return to hospital? What prescriptions would you like to send them home with? Is there any follow up required? If you learn about outpatient resources that exist in your community, you can ensure appropriate follow-up for your patients.
Putting it All Together: Practice Case
Now it’s time to put it all together and present the patient’s case to your attending. Here is a sample case for you to practice creating an effective disposition plan:
A 37 year old male presents to the ED with 2 hours of upper abdominal pain and vomiting. He is a smoker, on medication for hypertension, and drinks heavily on weekends. After your assessment, you suspect that biliary colic and gastritis are the most likely differential diagnoses, but you want to rule out ACS, GI bleed, esophageal perforation, and pancreatitis.[bg_faq_start]
- What tests will you order to rule in or out the above conditions?
- How long will it take to get these results?
- How are you going to manage your patient’s symptoms?
- Under what combination of lab tests and clinical change would they be admitted or sent home? What barriers to discharge home do you anticipate?
- If you are considering the above conditions, you should order lab work (CBC, lytes, urea, creat, gluc, liver enzymes, lipase, serial troponins), a CXR, and serial ECGs.
- The first set of labs should take 1-2 hours, but your serial set of troponins should be spaced out – duration depends on which assay you have (high sensitivity or not) and what your institutional practice is.
- For upper abdominal pain, you can try a GI cocktail, along with opioids, anti-emetics, fluids, and even intravenous proton pump inhibitors. If you are chasing ACS, you should give your patient ASA.
- This patient has many possible dispositions:
- Elevated liver enzymes and/or pain that does not settle = U/S to look for biliary pathology. If cholecystitis: ABX and surgical consult. If biliary colic: outpatient referral to Surgery and pain management in ED until settled.
- Elevated Troponin or abnormal/dynamic ECGs = ACS. Get Cardio consult.
- New drop in Hb = GI bleed, ?peptic ulcer. Consider PPI Rx and inpatient or outpatient referral for endoscopy depending on social factors and degree of anemia.
- Mediastinal air on CXR = pneumomediastinum. Consider ABX and surgical consult.
- Elevated lipase = pancreatitis. Consider continued pain management, possible admission, further imaging as inpatient or outpatient, and GP follow-up.
- If everything is normal = likely gastritis. Consider H2 antagonist or PPI or expectant management. They would have a low risk HEART score, so further risk stratification for ACS will add little for the patient.
- Tests or imaging studies you would like to order to rule in or out any differential diagnoses on your list
- Interventions or therapies you would like to start (remember to reassess your patient to assess for any clinical change)
- Social factors that would require an admission even if their clinical diagnosis alone would allow the patient to go home
- If you are sending a patient home, what do they need to go home with, for what reasons should they return to hospital, and what follow-up do they need?
- If you believe a patient needs to be admitted to hospital, what service should they be admitted to and with what requirements for their care?
- 1.Davenport C, Honigman B, Druck J. The 3-Minute Emergency Medicine Medical Student Presentation: A Variation on a Theme. Academic Emergency Medicine. July 2008:683-687. doi:10.1111/j.1553-2712.2008.00145.x
- 2.Woods RA, Trinder K, D’Eon M, McAleer S. Teaching the RAPID approach at the start of emergency medicine clerkship: an evaluation. CJEM. July 2014:273-280. doi:10.2310/8000.2013.131034
Reviewing with the Staff
Disposition is a more advanced level objective as it can be challenging to know institutional practice. As someone who works in both academic & community EDs you quickly realize how context specific your disposition can be. Do you have rapid outpatient access to further testing? What happens overnight? How do you get advice from your consultant colleagues?
For junior trainees, focus on answering the big question - is the patient safe to go home? Ie. Is there an immediate need for them to stay in hospital. Do they need oxygen? Is there a real chance of imminent worsening prognosis? Is their treatment a procedure only available in hospital? This will get you the group of people who obviously should stay.
Next category are the ones who can obviously go home: minimal or stable disease, few comorbidities and stable housing and ability to follow up as outpatients.
For the more nuanced patients I always ask myself, do they already meet my discharge criteria? If I\'m going to tell them to come back if they are short of breath, and they already can\'t make it from their room to the bathroom, then sending them home is likely an exercise in futility. Then I think about if they would be safe and succeed in their home environment. This is where the social history you took can be handy. Finally if you\'re not sure, don\'t be afraid to \"test\" their ability by an ambulation trial (with or without oxygen saturation monitoring) a Po fluid challenge or get further help from \"admission avoidance\" teams if available (they have some combination of OT/PT/geriatric/outpatient community supports).