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Welcome to ERCast, a focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

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Oct 30, 2017

What is your real motivation when making medical decisions? Is it 'what's in the patient's best interest' or is it 'what will keep me from getting sued'? The reflexive answer is, of course,  the former, but if you really do some soul-searching, there's probably a bit of the latter as well. In this episode, Mike Weinstock, author of Bouncebacks, and Bouncebacks Pediatrics, discusses why we sometimes have our priorities misaligned with the patient's and how that doesn't need to be the case.


Along with Amal Mattu and Erik Hess, Mike has recently published an article titled How Do We Balance the Long-Term Health of a Patient With the Short-Term Risk to the Physician? (link). The study's conclusion is this:  A test/intervention should be done if the risk of a missed diagnosis or adverse outcome is greater that the risk of the test/intervention. Involving the patient in the decision-making process may help to shift the management balance from the physician’s short-term concern of their own risk to the patient’s long term health. 

An example of where this sort of thinking comes into play is with the evaluation of patients with chest pain. Should they be admitted to the hospital? Are they safe to go home? Before we can answer either of those questions, we first need to address the elephant in the room...


What is an acceptable miss rate for chest pain?

Than, M., et al. "What is an acceptable risk of major adverse cardiac event in chest pain patients soon after discharge from the Emergency Department?: a clinical survey." International journal of cardiology 166.3 (2013): 752. PMID:23084108

  • Survey of 1029 emergency department clinicians.
    • 395 comfortable with a 1-2% miss rate
    • 267 comfortable with < 1%
    • 331 only comfortable w < 0.1%

Putting that last number in perspective, that's admitting 1000 patients to find one with cardiac disease. Is that a good return on investment or wise stewardship of health care resources? I think the answer is no. There are several reasons for this. The first is that being admitted to the hospital is not a benign event.


What is the chance that a patient will be harmed by hospitalization?

James, John T. "A new, evidence-based estimate of patient harms associated with hospital care." Journal of patient safety 9.3 (2013): 122-128. PMID: 23860193

  • Estimates a lower limit of over 200,000 deaths per year related to the deleterious effects of hospitalization


It's no secret that hospitalization can be dangerous, but it can also be extremely helpful in the properly patient. So in a patient with chest pain who has two negative troponins and a non ischemic EKG, what is the short term risk of clinically relevant adverse cardiac event (CRACE)? In other words, if we hospitalize patients with these factors (negative EKG and enzymes) what is the likelihood that something bad will happen in the next few days that could be mitigated by hospitalization?

Weinstock, Michael B., et al. "Risk for clinically relevant adverse cardiac events in patients with chest pain at hospital admission." JAMA internal medicine 175.7 (2015): 1207-1212. PMID:25985100

  • This study sought to determine the risk of life-threatening arrhythmia, inpatient ST-segment elevation myocardial infarction, cardiac or respiratory arrest, or death during hospitalization in patients with negative serial troponin, non concerning initial ED vital signs, and nonischemic, interpretable EKG.
  • Over 7,000 chest pain patients admitted (non ischemic EKG, negative serial troponin)
  • 0.06% incidence of CRACE during the hospitalization
  • So over the few days that a patient with non corning EKG and negative enzymes is in the hospital, there was a 6 in 10,000 chance of a catastrophic outcome
  • This is different than what's being asked by the HEART score. HEART is looking for the risk of major adverse cardiac event (MACE) in 6 weeks.


Taking all of this into account, how does Dr. Weinstock approach shared decision making?

  • If the ED workup shows a non-ischemic EKG and there are two negative serial troponins, he presents the option of an outpatient workup. A caveat to this is that access to rapid outpatient evaluation must be readily available
  • He advises the patient that the possibility of a CRACE is one in several thousand and, while being hospitalized may seem like the safest course of action, hospitalization itself is not without risk
  • The Weinstock Credo: Don't practice defensive medicine. Document "defensibly"


Also mentioned in this episode

  • Brown, Terrence W., et al. "An epidemiologic study of closed emergency department malpractice claims in a national database of physician malpractice insurers." Academic Emergency Medicine17.5 (2010): 553-560. Full article link
  • Have a good time, all the time


Editors note: Show notes are meant to complement the podcast and do not represent a complete synopsis of what is contained in the audio.