After the Acute Care Visit:  NOW WHAT?

May I share a few common scenarios that I see at work?

1. 18 month old, otherwise healthy female has had 4 days of high spiking fevers and some cold symptoms. She is fully immunized and has no obvious infection on exam. She’s hydrating herself adequately but not at her baseline. We test her urine looking for a bladder infection and the initial urinalysis is negative. She has an ice pop and is discharged with the instructions to continue the fever reducer medicines, lots of hydration, and follow up with her regular doctor within 48 hours, sooner if things get worse.
2. 6 year old male with wrist fracture after falling on the playground. The fracture line is only minimally displaced, thankfully, and his pain is under control. We can easily splint this fracture until he is seen by pediatric orthopedic surgery.
3. 12 year old male with known asthma comes in sounding very tight with significant difficulty breathing. After many nebulizer treatments, oral steroids, and observation, he is better with improved aeration and respiratory rate. He can go home but will need to be observed closely.

These are all fairly different medical problems, right? Yet what do they have in common?

…Each of these patients needs FOLLOW UP. It would be fantastic if all acute health issues could be completely solved at one urgent or emergency visit. And sometimes that’s true. Some straightforward medical problems or simple lacerations can be contained in one visit. But in the 3 situations I describe above, there are ongoing care needs that will must be addressed to ensure an optimal medical outcome. Honestly I’m surprised at the number of people who don’t bother to follow up, like it’s not really a big deal, and in many cases that decision doesn’t serve them well.

So I want to talk about follow up today. And send out a big collegial hug to my partners in primary care. We really are a team.

In many cases, follow up care is as important as the initial urgent visit. Whether it’s ongoing therapy or lab follow up or a simple “closing of the loop” on communication between primary and acute care, this component deserves attention. When I’m at work, it’s often a key factor in deciding which treatment path I’ll choose if there are potentially a few different courses of action to take. I’ve admitted children to the hospital in certain situations when I’ve felt uncomfortable about the follow up plan.

First, follow up can be critical for ongoing care and medical decision making.

In all of the situations above, another clinical evaluation is needed for the 3 kids described. The child with the fever needs a reassessment for dehydration and to make sure that the illness hasn’t evolved or taken a wrong clinical direction. The boy with the broken wrist needs to see a pediatric orthopedic surgeon to make sure that fracture heals correctly. The asthmatic needs more immediate follow up the VERY NEXT DAY for a respiratory check. In this situation, many parents have quite good experience with recurring wheezing attacks, but even then it’s just smart medicine to have another set of eyes weigh in on the course of illness. What I’ve seen in my practice if follow up DOESN’T happen is: the child with the fever could end up with a pneumonia and significant dehydration; the fracture doesn’t heal well because the child got the splint wet accidentally and stopped wearing it, and the asthmatic boy goes out in the pollen filled playground the next day and worsens rapidly, ultimately requiring an intensive care stay. Some of these outcomes are unavoidable and simply can be traced to unfortunate progression of illness, but I often feel that had a child with an acute medical issue been evaluated earlier, that chapter in the health story might have been rewritten. I also understand that sometimes it can be difficult to access follow up in a timely manner, but truthfully I believe that the overwhelming majority of pediatrician offices are quite good about scheduling follow up after urgent/emergency care, and I regularly encourage people who are having trouble accessing needed specialty care to follow up with their pediatrician first to enlist that staff in assisting acquiring the specific follow up.

Lab and/or radiology results are another reason why follow up is important, because they always come with the “So what now” question.

Most good clinicians don’t send tests if they aren’t searching for an actionable answer, so having some kind of connection about the plan after results are in is crucial. This can happen with just a phone call in many cases, but it’s a ball that shouldn’t get dropped. Simple as that.

Finally, and perhaps paramount, is keeping the continuum of care between acute and primary care as smooth as possible.

Those of us on the acute care side do our best to make that happen by transmitting the clinical documentation of the visit to our primary care partners and will frequently have a clinician to clinician conversation at the time of care if the gravity of the situations demands it- that way everyone is on the same page immediately and can make sure that the care plan gets executed. It also simplifies the next visit because there’s not much “fill in the blank” that needs to be done to bring the primary care provider up to speed on the issue at hand. Sometimes I’ll hear that it costs money and doesn’t make sense to go to a follow up visit “for nothing” or just to hear that everything is ok. But I have always felt that I’d rather hear a thousand “everything was OK’s” over one single missed deteriorating condition or gap in treatment. In the end that will be more expensive, more resource intensive, and more of a time thrash than handling the matter early and attentively. I’ve seen it many times.

Alright! My one take home message today is:

Make sure you follow up as directed after an acute care visit.

The health of you and your child may really depend on it.

At PM Pediatrics, we instruct all patients to follow up with their primary care provider. So important, we say it twice!