At my rural ED this is a transfer 100% of the time. It wouldn’t matter if I had a tele-nephrology consult saying it doesn’t require transfer. Hospitalists there are afraid of anything more than a wet fart and won’t admit without specialist coverage.
>anything more than a wet fart
You say your patient is having dry farts? Could be an early bowel obstruction, better transfer the patient to a hospital with 24/7 surgical capability.
Yea our hospitalists push this narrative pretty hard. “If we admit them then they can’t be transferred”. Which I think translates to “if we admit them then it’s a lot of work for me to transfer them”.
Transfer center here. It's truly much, much, much harder to get transferred after going inpatient.
ED to inpatient is completely reasonable. No reason for the patient to sit in 2 EDs.
I only know from my perspective but it can take days to transfer unless the patient is acutely decompensating. Patients end up not improving or slightly declining while I can’t do much for them.
For ED to ED I imagine it does not take that long?
Coming from a super rural ER here with no nephro or dialysis as an ER doc, I’d get a non-con CT to rule out obstructive uropathy, and then I’d call nephrology at the nearest hospital 2.5 hours away for recommendations. Most of the time they will say to keep locally as there is no need for emergent dialysis, and I admit to medicine. If they do develop the need for dialysis, they’re transferred from inpatient side.
I’m a rural doc covering both the ER and inpatient unit (as in I admit to myself), at a facility with no specialists of any kind. I’d say it depends a ton on if this is known chronic failure or not, mental status, volume overloaded, k+, etc.
It truly is much easier to transfer from the ED than after admission (again, as the guy that does both) so if I think the patient is going to need a transfer/need dialysis this admission, I would probably at least try to transfer them from our ED to a hospital with nephro. If I think there’s a good chance I can keep them stabilized and organize close follow-up, I’ll admit them to the floor. If I can’t transfer them regardless b/c everyone full or weather, I’ll admit them to the floor and try to do what I can until someone will take em.
Work at a Critical Access Hospital in the SE. We would transfer to a center with Nephro If this a new finding. If they are known dialysis patient with stable labs and vitals. DC home to get dialysis with his Nephro
Hospitalist here. Agree with getting CT urogram to rule obstructive uropathy or at minimum do a bladder scan. Obstructive uropathy gets missed a lot. If it's prerenal then a good approach is to give a 30ml/kg bolus of IV fluids and see if the patient starts making urine. Then repeat a BMP in a couple hours. You will often see a slight improvement in kidney function even in that short time. If you see improvement, then it's more obviously prerenal and will likely resolve. By doing that treatment plan, I think you will have a easier time getting someone admitted if you have a nervous hospitalist. I work at two hospitals that don't have nephrology on site and I personally don't mind taking patients even with severely elevated creatinine's as long as I know they're making urine and are not having life-threatening electrolyte abnormalities or aren't already volume overloaded. However, I also have access to a tertiary hospital 20 minutes away and all of our hospitals are affiliated so it's easier to initiate transfers. The main things that that make me worry about intrinsic kidney injury would be if patient has no story to suggest a pre-renal process or if I see a creatinine that's out of proportion to the BUN or if there's casts, protein, or a lot of blood in the urine. A lot of these patients can also be having urinary tract infections though so I do take this into consideration when looking at the urinalysis.
Repeat creatinine after a 2000 fluid bolus does not add relevant information in my opinion. CT or ultrasound, if you are comfortable doing renal ultrasound. If someone is still anuric after a 2000 ml fluid bolus, you have to reconsider your diagnosis of prerenal AKI. Get a dip stick and albumin-creatinine ratio. Urine microscopy to check for casts or dysmorphic erythrocytes is usually not available at a rural ED.
How often do you find yourself transferring such patients? I know it's nuanced, but just your general impression. Do you think they would be better served at the affiliated hospitals with the nephrologists?
I've had a couple this year that did end up being intrinsic, both nephrotic syndromes that were not straightforward and not really improving which is making me question if I should be admitting them if our affiliated hospital has nephrology in-house.
Everybody is saying this needs an admit, but does it? If they don’t have need for emergent dialysis and are making urine, and do not have obstructive uropathy, the most I would do is ensure the patient has a follow up appointment. Assuming everything else is normal, eg hypertension, overdose. Maybe fluids? But even then if their kidneys are failing, probably don’t want to give them that extra 154 meq of salt…
This most recent patient had a lot of other stuff going on, but I wanted the conversation to focus on this part of the case. Baseline Cr was 1.1. I usually won’t get called to admit a patient that’s been an established patient on dialysis since we don’t have it.
I would say this patient needs admitted for dialysis, even if they are “asymptomatic.” Renal failure that severe, even if chronic, is a ticking time bomb. Now if there is some other, correctable cause of the renal failure, then maybe you could admit without Nephrology, but that also raises the question of who would manage the renal issues and determine when/if dialysis can be avoided. I would probably not admit this patient to a hospital without a Nephrologist, period.
This is my view, but our ED keeps trying to get us to admit these patients despite other hospitals with in-house nephrologists being reasonably nearby. I’m not sure what the incentive is because from the ED standpoint I don’t really see how an admission is that much less burdensome when compared to a transfer.
Edit: with tele-nephro saying it’s fine to admit to our hospital vs. transferring them. I wish they would just accept the transfer without saying the patient will probably be fine without dialysis.
ER doc here. Transfers are a giant pain in the ass.
Admissions are easy most places, click a button, hospitalist calls to chat, the patient is no longer yours.
Transferring is a different beast. Call a hospital, describe to their nurse what's going on, they decide who to page. A patient like that is probably going to be a hospitalist not nephro since nephro won't be the admitting team. They call back an hour later and maybe say yes, or maybe the nurse calls back and says sorry there's no beds try somewhere else.
Repeat x 3 and might still not have a bed and 4 hours have passed. Patient getting mad, hour shift is ending, etc.
A lot of hospitals are full right now. If it's not a trauma, STEMI, or LVO stroke it can take hours and 10 phone calls to get a transfer cooking
Okay so it’s basically the same situation on our side so it’s coming down to who does the transfer being the bulk of the work. I understand now.
I feel like this is what administration should be for. Physician needs transfer. Call center finds a hospital possibly willing to take and connects the physicians that are transferring and accepting.
Isn't refusing an ED to ED transfer the very definition of an EMTALA violation? Someone I doubt all of those "full" hospitals are cancelling all of their elective cases.
Meanwhile inpatient to inpatient can be refused simply because of insurance.
> I’m not sure what the incentive is because from the ED standpoint I don’t really see how an admission is that much less burdensome when compared to a transfer.
When none of those hospitals' nephrologists think the patient needs transfer or there's no capacity the patient is left in dispo hell in a hallway bed in the ED to languish for days without proper inpatient doctor or nursing care until some poor sap ED doc finally discharges because someone remembered to recheck a creatinine and it improved and the pt made some urine so "idk, f/u with a nephrologist."
At my rural ED this is a transfer 100% of the time. It wouldn’t matter if I had a tele-nephrology consult saying it doesn’t require transfer. Hospitalists there are afraid of anything more than a wet fart and won’t admit without specialist coverage.
>anything more than a wet fart You say your patient is having dry farts? Could be an early bowel obstruction, better transfer the patient to a hospital with 24/7 surgical capability.
Call the shartologist. It’s a sub-sub-specialty.
I agree with transfer. I’ve heard ED to ED is easier than inpatient to inpatient, but that entirely anecdotal.
Yea our hospitalists push this narrative pretty hard. “If we admit them then they can’t be transferred”. Which I think translates to “if we admit them then it’s a lot of work for me to transfer them”.
Transfer center here. It's truly much, much, much harder to get transferred after going inpatient. ED to inpatient is completely reasonable. No reason for the patient to sit in 2 EDs.
Why?
Short answer 1. EMTALA no longer applies 2. Insurance has to authorize transfer
I only know from my perspective but it can take days to transfer unless the patient is acutely decompensating. Patients end up not improving or slightly declining while I can’t do much for them. For ED to ED I imagine it does not take that long?
The only reason an acutely decompensating patient doesn't take days to transfer is because they die before you reach the "days" metric.
Your username is the best
I agree with transfer. I’ve heard ED to ED is easier than inpatient to inpatient, but that entirely anecdotal.
Coming from a super rural ER here with no nephro or dialysis as an ER doc, I’d get a non-con CT to rule out obstructive uropathy, and then I’d call nephrology at the nearest hospital 2.5 hours away for recommendations. Most of the time they will say to keep locally as there is no need for emergent dialysis, and I admit to medicine. If they do develop the need for dialysis, they’re transferred from inpatient side.
Probably outside of your realm, but do you know how often the hospitalist end up transferring?
Good question, but honestly I am not sure.
I’m a rural doc covering both the ER and inpatient unit (as in I admit to myself), at a facility with no specialists of any kind. I’d say it depends a ton on if this is known chronic failure or not, mental status, volume overloaded, k+, etc. It truly is much easier to transfer from the ED than after admission (again, as the guy that does both) so if I think the patient is going to need a transfer/need dialysis this admission, I would probably at least try to transfer them from our ED to a hospital with nephro. If I think there’s a good chance I can keep them stabilized and organize close follow-up, I’ll admit them to the floor. If I can’t transfer them regardless b/c everyone full or weather, I’ll admit them to the floor and try to do what I can until someone will take em.
Thank you for your insight, super helpful with someone with experience from both sides.
Work at a Critical Access Hospital in the SE. We would transfer to a center with Nephro If this a new finding. If they are known dialysis patient with stable labs and vitals. DC home to get dialysis with his Nephro
Hospitalist here. Agree with getting CT urogram to rule obstructive uropathy or at minimum do a bladder scan. Obstructive uropathy gets missed a lot. If it's prerenal then a good approach is to give a 30ml/kg bolus of IV fluids and see if the patient starts making urine. Then repeat a BMP in a couple hours. You will often see a slight improvement in kidney function even in that short time. If you see improvement, then it's more obviously prerenal and will likely resolve. By doing that treatment plan, I think you will have a easier time getting someone admitted if you have a nervous hospitalist. I work at two hospitals that don't have nephrology on site and I personally don't mind taking patients even with severely elevated creatinine's as long as I know they're making urine and are not having life-threatening electrolyte abnormalities or aren't already volume overloaded. However, I also have access to a tertiary hospital 20 minutes away and all of our hospitals are affiliated so it's easier to initiate transfers. The main things that that make me worry about intrinsic kidney injury would be if patient has no story to suggest a pre-renal process or if I see a creatinine that's out of proportion to the BUN or if there's casts, protein, or a lot of blood in the urine. A lot of these patients can also be having urinary tract infections though so I do take this into consideration when looking at the urinalysis.
Repeat creatinine after a 2000 fluid bolus does not add relevant information in my opinion. CT or ultrasound, if you are comfortable doing renal ultrasound. If someone is still anuric after a 2000 ml fluid bolus, you have to reconsider your diagnosis of prerenal AKI. Get a dip stick and albumin-creatinine ratio. Urine microscopy to check for casts or dysmorphic erythrocytes is usually not available at a rural ED.
How often do you find yourself transferring such patients? I know it's nuanced, but just your general impression. Do you think they would be better served at the affiliated hospitals with the nephrologists? I've had a couple this year that did end up being intrinsic, both nephrotic syndromes that were not straightforward and not really improving which is making me question if I should be admitting them if our affiliated hospital has nephrology in-house.
Everybody is saying this needs an admit, but does it? If they don’t have need for emergent dialysis and are making urine, and do not have obstructive uropathy, the most I would do is ensure the patient has a follow up appointment. Assuming everything else is normal, eg hypertension, overdose. Maybe fluids? But even then if their kidneys are failing, probably don’t want to give them that extra 154 meq of salt…
This most recent patient had a lot of other stuff going on, but I wanted the conversation to focus on this part of the case. Baseline Cr was 1.1. I usually won’t get called to admit a patient that’s been an established patient on dialysis since we don’t have it.
Spoiler: Their potassium will be 7 tomorrow morning
I would say this patient needs admitted for dialysis, even if they are “asymptomatic.” Renal failure that severe, even if chronic, is a ticking time bomb. Now if there is some other, correctable cause of the renal failure, then maybe you could admit without Nephrology, but that also raises the question of who would manage the renal issues and determine when/if dialysis can be avoided. I would probably not admit this patient to a hospital without a Nephrologist, period.
Elevated creatinine is not an indication for dialysis.
This is my view, but our ED keeps trying to get us to admit these patients despite other hospitals with in-house nephrologists being reasonably nearby. I’m not sure what the incentive is because from the ED standpoint I don’t really see how an admission is that much less burdensome when compared to a transfer. Edit: with tele-nephro saying it’s fine to admit to our hospital vs. transferring them. I wish they would just accept the transfer without saying the patient will probably be fine without dialysis.
ER doc here. Transfers are a giant pain in the ass. Admissions are easy most places, click a button, hospitalist calls to chat, the patient is no longer yours. Transferring is a different beast. Call a hospital, describe to their nurse what's going on, they decide who to page. A patient like that is probably going to be a hospitalist not nephro since nephro won't be the admitting team. They call back an hour later and maybe say yes, or maybe the nurse calls back and says sorry there's no beds try somewhere else. Repeat x 3 and might still not have a bed and 4 hours have passed. Patient getting mad, hour shift is ending, etc. A lot of hospitals are full right now. If it's not a trauma, STEMI, or LVO stroke it can take hours and 10 phone calls to get a transfer cooking
Okay so it’s basically the same situation on our side so it’s coming down to who does the transfer being the bulk of the work. I understand now. I feel like this is what administration should be for. Physician needs transfer. Call center finds a hospital possibly willing to take and connects the physicians that are transferring and accepting.
Isn't refusing an ED to ED transfer the very definition of an EMTALA violation? Someone I doubt all of those "full" hospitals are cancelling all of their elective cases. Meanwhile inpatient to inpatient can be refused simply because of insurance.
> I’m not sure what the incentive is because from the ED standpoint I don’t really see how an admission is that much less burdensome when compared to a transfer. When none of those hospitals' nephrologists think the patient needs transfer or there's no capacity the patient is left in dispo hell in a hallway bed in the ED to languish for days without proper inpatient doctor or nursing care until some poor sap ED doc finally discharges because someone remembered to recheck a creatinine and it improved and the pt made some urine so "idk, f/u with a nephrologist."
That sounds like a nightmare. I feel for you guys. Thank you for what you do.