Safe Discharge for Undifferentiated Abdominal Pain

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    Safe Discharge for Undifferentiated Abdominal Pain

    Abdominal pain is the most common chief complaint in the emergency room, yet up to 40% of these patients are discharged without a definitive diagnosis. In cases of nonspecific abdominal pain, it is crucial to have a meaningful discussion about discharge with the patient and document a robust discharge assessment. A safe discharge for nonspecific abdominal pain should include ALL of the following:
    1. Successful PO challenge with sips of water.
    2. Non-concerning repeat abdominal exam just prior to discharge. Justify any abnormal findings, or document the absence of concerning findings. Reconsider discharging patients with worsening or new abdominal exam findings.
    3. Document that symptoms have been addressed. They don’t need to be completely resolved, but they do need to have improved or no long require active inpatient intervention.
    4. Review ALL vital signs, lab values, and imaging results obtained during ED visit. All abnormal findings should be noted and addressed/justified. Nursing, provider, and consult notes should also be reviewed for discrepancies (triage complaint doesn’t match chief complaint), notable findings (acute pain or vomiting episodes noted by nursing or other staff), and additional follow-up instructions (recommendations from consults upon discharge).
    5. Arrange robust follow-up. Simple “PMD f/u” is not enough. You should specify a time frame, contact info, and patient’s acknowledgement of instructions. For nonspecific abdominal pain, close follow-up within 48 hours is often reasonable. Make sure your patient can reliably contact the outpatient provider or specialist and understands the importance and urgency of the follow-up visit.
    6. Give strict return precautions. The patient should know to return to the ED immediately for progression of symptoms, new symptoms, or any other concerns. For some higher risk but reliable patients, it may even be reasonable to have the patient return for a repeat abdominal exam even in the absence of symptom progression.
    7. Communicate with your team. Make sure that your attending, resident, and nurse are all on the same page and agree with the discharge plan.
    8. Communicate with your patient. Make sure your patient understands the entirety of your discharge instructions and indications for follow-up and return.
     Here’s a sample discharge note template:
     
     “At time of discharge, the patient is stable, comfortable, and in no acute distress. She is PO tolerant, alert, and at her baseline functional status. Her [pain, nausea, or other symptoms] have improved significantly after [PO pain meds, fluids, etc]. Her vital signs are within normal range and there are no concerning findings on labs or imaging during this ED visit. In discussion with my ED team and based on our workup today, I have determined that the patient is at low risk for emergent conditions including, but not limited to, appendicitis, acute cholecystitis, ovarian torsion, PID, and bowel obstruction at this time. She does not require inpatient admission and can be safely discharged home. She is reliable and has agreed to visit her PMD [Dr. Smith at 212-344-1919] in the next 48 hours for close outpatient follow-up. She has also agreed to return to the ED immediately in case of progressive or persistent abdominal pain, nausea/vomiting, PO intolerance, or any other concerns.”

     

    Jean Sun

    Jean Sun

    PGY2 Resident

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