Using Risk Factors and Red Flags to Rapidly Identify Potential Serious Disease Processes

Identifying high risk patients from common chief complaints is an endeavor that needs to be cultivated and will significantly enhance one’s clinical acumen.

High Risk Patients can present with very subtle findings. An acute MI with ST elevation becomes readily apparent but the patient with the dissection can easily be misdiagnosed. High risk also includes illnesses that need to be treated in a specific time frame and bad outcomes leads to high liability.

Risk Factors are a combination of historical associations through family history, social history, genetics and red flags are positive responses to goal directed questions and physical exam findings that can lead to a higher suspicion of serious illness. Risk factors that are historical have been determined by longitudinal clinical studies over many years. They are a helpful guide but do not exclude serious illness in an individual patient.

The converse is also true. The majority of back pain chief complaints are musculoskeletal. How does one rapidly identify the patient that needs a more extensive evaluation?

The #1 Risk Factor is abnormal vital signs. Each abnormal sign must be addressed. If cannot be explained, further evaluation or monitoring is required.

See index below for some examples of risk factors and red flags associated with the following chief complaints. They are not all inclusive.

Chief Complaint:

        i.           Chest Pain
      ii.            Shortness of Breath
    iii.            Ob-Gyn
    iv.            Back Pain
      v.            Headache
    vi.            Syncope
  vii.            Allergic reaction
viii.            Abdominal Pain
     ix.            Testicle pain

This list is extensive, however evaluating the patient with knowledge of these risk factors and red flags will limit your liability and allow benign processes (tincture of time) to heal most patients without extensive cost , radiation, side effects of unnecessary treatments.  When artificial intelligence is fully developed and placed in EHRs, these items will be sent to the provider in real time to enhance their clinical decision making.

More details available upon request.

Index:

i.                    Chest Pain

         Risk Factors for Acute Coronary Syndromes:

o   Past Hx of CAD

o   Family Hx of CAD

o   Age: Male >33 Female >40

o   Diabetes

o   Hypertension

o   Smoking

o   Increased Lipids

o   Sedentary lifestyle

o   Obesity

o   Postmenopausal

o   Drug use- cocaine

Risk Factors for Pulmonary embolism (PE):

o   Prolonged immobilization

o   Surgery >30 days 3 months

o   Prior DVT or PE

o   Pregnancy

o   Lower extremity trauma

o   Oral contraceptives

o   Smoking

o   CHF

o   Chronic obstructive pulmonary disease

o   Obesity

o   PMH or FH Hypercoagulability

Risk Factors for Aortic Dissection:

o   Hypertension

o   Congenital disease of the aorta or aortic value

o   Inflammatory aortic disease

o   Connective tissue disease

o   Pregnancy

o   Arteriosclerosis

o   Smoking

ii.                  Shortness of Breath

                          Risk factors for Acute Coronary Syndromes:

           o See list above

                        Risk factors for Pulmonary embolism (PE):

o   See list above

 Risk factors for Pneumothorax:

o   Hx Pneumothorax

o   Valsalva maneuver

o   Chronic lung disease

o   Smoking

iii.                Ob-Gyn

             Risk Factors for Ectopic Pregnancy:

o   Abdominal pain

o   Abnormal tenderness

o   Positive hCG test

 Ovarian Torsion

o   Pregnancy

o   ovarian cysts

o   ovarison hyper stimulation syndrome

o   tumors

Pelvic Inflammatory Disease

o   STD exposure

o   Abdominal pain

o   Fever

o   Vaginal discharge

o   Pelvic pain

o   Multiple sex partners

iv.                Back Pain

          Risk Factors for Abdominal Aortic Aneurysm:

o   Abdominal pain

o   Back pain

o   Age >50

  Red flags:

o   Numbness

o   Dizziness

o   Motor Weakness

o   Syncope

o   Paresthesias

o   Fever

o   urinary retention

v.                  Headache

          Red flags:

o   Syncope

o   Loss of Consciousness

o   Mental State

o   Speech Difficulty

o   Seizure disorder

o   Focal weakness

o   Dizziness

o   Gait Abnormal

o   Numbness

o   Paresthesias

o   Fever

o   Polycystic kidneys

o   Osteopathic manipulative treatment

vi.                Syncope

            Risk Factors for ACS:

o   See above

Risk Factors for Pulmonary Embolism (PE):

o   See above

Risk Factors for Abdominal Aortic Aneurysm:

o   See below

Risk Factors for Drug Syncope:

o   Drug use

o   Polypharmacy

o   Drug interactions

Risk Factors for Ectopic Pregnancy:

o   See above

Family History of Sudden Death

CHF (Congestive Heart Failure)

vii.              Allergic Reactions

          Red flags:

o   Allergic to ace inhibitors

o   Allergen exposure

o   Allergic to bee stings

o   Bug bites / stings

o   Allergic to shellfish

o   Allergic to soap/detergent

o   Allergic to pets

viii.            Abdominal Pain

         Risk Factors for Ectopic Pregnancy:

o   See above

Red Flags for Abdominal Aortic Aneurysm:

o   Abdominal pain

o   Back pain

o   Age >50

 Risk Factors for Mesenteric Ischemia and Ischemic Bowel Disease:

o   Age >55

o   Hx Cardio Vascular Disease (CV)

o   Hx Congestive heart failure (CHF)

o   post-myocardial infarction mural thrombi

o   Congestive heart failure (CHF)

o   Shock

o   hypercoagulable state

o   pain is out of proportion

o   coagulable state

o   arrhythmias

o   Sleeping impairment

Risk Factors for Acute Coronary Syndromes:

o   Past Hx of CAD

 Red Flags for Acute Appendicitis:

o   Anorexia

o   Right lower quadrant pain

o   Fever

ix.                 Testicle Pain

             Age <40

The 5-Minute Focused History and Physical Exam

Speediness has become a necessary virtue in EDs and urgent care settings, where providers, without exception, are expected to provide accurate, efficient, cost-effective care quickly.  While it may often feel that such expectations are not realistic, it is still nevertheless true that perceptions of promptness and efficiency are major factors in determining patient satisfaction.

Therefore, achieving a balance between speed, quality of care, safety, and efficiency, requires that each provider refine and polish a personal approach that facilitates rapid, complete, assessment in a minimum amount of time, using whatever tools are at hand.  In most cases--even in complex presentations--this can be accomplished in 5 minutes, or less, and is facilitated when using an EHR with the capacity to present information succinctly.

TIMELINE:

MINUTE 1:  45 seconds- review pertinent data; 15 seconds- establish common ground, put patient at ease.

MINUTE 2:  30-60 seconds- Allow the patient to speak. Listen.

MINUTE 3:  15-30 seconds - Discover the patient’s motivation (reason) for the visit. You will have already gotten the main clues, but make sure you also understand the driving forces behind the decision to come to the ED… Did the family drag them in? Are they worried about a stroke? Etc.

MINUTE 4:  30- 60 seconds - Ask very specific chief complaint driven high risk questions to identify the seriousness of the problem

MINUTE 5:  30- 60 seconds - Perform a goal directed physical while simultaneously restating the patient’s story. This reaffirms confidence in you as the provider, gives an opportunity to correct any overlooked concerns, and gets the key physical elements examined.

If you have an electronic order entry system at the bedside, you may be concurrently clicking off initial orders while gathering information during minutes 4 and 5. 

This system is very effective.  It allows you to keep with the patient flow and concentrate on treatment plans and dispositions (creating space for the next encounter. Additionally Patients immediately perceive that you are concerned about them, engaged, and “on their team” concerning their medical issues.

The next blog will be on how to “close the deal”.

The Role of the Provider in Triage

The proposed addition of a physician’s assistant or nurse practitioner at triage adds a new wrinkle in the fabric of patient processing. The political and administrative motivation to do so is usually an external demand to achieve “door to provider” times of less than 30 minutes. If claimed by a hospital, usually in the form of “see the doctor within 15 min or less,” it is a powerful advertising tool.

The clinical benefits of adding a high-level provider at triage include immediate reliable assessment, pre-ordering of tests, and direct, speedy, discharge of minor problems.  The upside to these is the potential to create often needed space in the ED and/or waiting room. The downside is that these results provide no guarantee that average patient LOS will be any shorter than if triage were performed by a qualified nurse or other non-physician staff.

Q&A

Q: What kind of provider is necessary out in triage? 

A:  At minimum, triage requires a highly skilled physician’s assistant or nurse practitioner, with extensive experience, who understands the clinical needs and operational characteristics of the particular ED in question. Since an associated goal is to also improve the patient experience and ultimately his/her satisfaction, the personality characteristics of the triage provider are essential. Optimal personalities do not “grow on trees,” yet even if uncommon, one would look for those who exhibit a “gentle touch,” a welcoming, understanding manner, and an ability to skillfully handle the stresses of triage.

Q: Can a physician do this job?

A: Yes, but it is expensive and some, perhaps most, physicians are better suited to encounter (conscious) patients after other staff has done the initial meet, greet, & initiate functions.

Q: How much of a work-up is needed from triage?

A: As usual it depends on the presentation and context.  If space is an issue, the proper ordering of tests can lead to prompt disposition (admit or discharge) shortly after the treating provider arrives to see the patient (1 stop-shop). This works in even complex patients, if an excellent triage provider orders the appropriate tests and initiates key treatments. Whether one test or multiple tests are needed, the treating provider can often make a final disposition (“close the deal”) if results are back and response to treatment can be assessed at the first physician encounter.

Q: What about flow?

A: A good working relationship between the triage provider, and the charge nurse can significantly benefit patient flow through an ED.  Communication between triage and the unit are key to quickly identifying patients at high risk and making appropriate and efficient bed assignments.  While the standard use of 5-level triage has some value, it is not subtle enough to make distinctions between those in the middle, who are often gray-zoned until results come back. That is, not all 3’s are equal; after the dust settles and tests are back, many middle tier patients can be sent to Fast Track or discharged without even being placed in a bed.

Q: What’s the bottom line?

A: The triage provider needs to be an exceptional, dynamic, individual, one with extensive clinical experience, who can not only multi-task but is also able to function as an ED Flow expert.