How do you handle patients sent in for needless tests?

[daveyjwin]

We're all familiar with the patient who was sent to the hospital by the PCP or random specialist to get a test, say, an MRI, CTA or something. How do you deal with these situations when you a) don't agree with the need for testing or b) think it's testing that should be done outpatient, or non-emergent (as most MRIs are).

For instance, at my facility after hours, we have to call in MRI/US if needed, and if a patient came from a PCPs for one of these, with no clear clinical indication, what would you do? Where do you draw the line?

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[Old_Mil]

MRI, I explain to the patient that EPS are only allowed to order this test under some very limited circumstances. The rest, I just order and dispo. It's just not worth fighting the battle.

 

[Perrin]

I generally err on the side of doing the test. MRI's are the exception. They'll tie up the radiologist for a bit and are rarely indicated in the ED.

I agree with old mil that its not worth the fight. Also, say you refuse to do the test and there is a bad outcome. On one hand you have the PMD who thought a test was needed and on the other you have the EP who thought it wasn't indicated, but was 'wrong'. You probably won't win in front of a jury by explaining how your clinical acumen and criteria did not indicate an MRI, CT, and serum porcelain level when another doc sent them to the ED for it, regardless if the doc only sent them b/c the office was closing in 15 min.

Redux: Lazy or whatever reason Doc 1 sends pt for test. Doc 2 says not indicated. Pt has bad outcome. Test may or may not have changed outcome. Who is right and who wins are not the same.

 

[daveyjwin]

How far do you take it? How invasive?

I ask because I recently had a patient who was sent in for multiple compartment pressures, to evaluate for "chronic exertional compartment syndrome" and had NO SIGNS of compartment syndrome, I didn't do it, and the referring Dr threw a fit a week later when the patient had his FU appt, called my director and everything. His leg didn't fall off or anything, obviously not an emergency, and frankly, not an EM diagnosis or anything requiring emergent treatment. Chronic.

Would anyone here have done it?

 

[diphenyl]

How far do you take it? How invasive?

I ask because I recently had a patient who was sent in for multiple compartment pressures, to evaluate for "chronic exertional compartment syndrome" and had NO SIGNS of compartment syndrome, I didn't do it, and the referring Dr threw a fit a week later when the patient had his FU appt, called my director and everything. His leg didn't fall off or anything, obviously not an emergency, and frankly, not an EM diagnosis or anything requiring emergent treatment. Chronic.

Would anyone here have done it?

I def would not have done it. Answer is in the name of the disease. CHRONIC. No emergent condition exists, follow up with your primary care provider. End of story. I would also add that there are many EP's who don't measure compartment pressures on a regular basis or ever. I would see more liability doing a procedure you're not familiar/ comfortable with then sending the guy home. If I were in a good mood I would refer them to PM&R since the PMD managing this has his head lodged up his rectum.

 

[WilcoWorld]

How far do you take it? How invasive?

I ask because I recently had a patient who was sent in for multiple compartment pressures, to evaluate for "chronic exertional compartment syndrome" and had NO SIGNS of compartment syndrome, I didn't do it, and the referring Dr threw a fit a week later when the patient had his FU appt, called my director and everything. His leg didn't fall off or anything, obviously not an emergency, and frankly, not an EM diagnosis or anything requiring emergent treatment. Chronic.

Would anyone here have done it?

Agree with diphenyl - multiple compartment pressures for diagnosis of chronic compartment syndrome is not in the purview of the EP. If I sent a belly pain to a Cardiologist none would fault her for deciding not to take out the appendix. You shouldn't be faulted for not doing this procedure. How did your director handle it?

 

[WilcoWorld]

To the OP - I don't always order the test, but I need to stand on very firm ground to refuse. If there's more than a sliver of grey area, and it's not harmful to the patient, I'll usually order the test. I work at a referral center and often get patients transferred >2 hours for non-indicated testing. My usual tack, on clearly non-indicated testing is to convince the patient that the test is not in his or her best interest. Last week I had a kid transferred for an LP, but he very clearly had mononucleosis, and he had a supple neck, normal neuro exam, etc. However, I did not flat out refuse to do the test. Rather, I explained my thought process to the parents, explained the risks & benefits, and the parents agreed to not having the LP done. Admittedly, this approach almost never works for people sent to me to have an MRI for their back pain.

 

[Groove]

I usually don't get too worked up about it though I'll call the PCP and make them feel like an idiot on occasion. If it's a quick study and they really want their pt stuck with an ER bill, so be it. I don't get non emergent MRIs but I haven't had any PCPs send any to the ED for a routine MRI. If they did, I'd call them up and tell them to set it up as an outpatient study.

 

[Birdstrike]

Balance customer service with throughput and efficiency. A very difficult task indeed.

 

[GeneralVeers]

If it's a non-invasive, non time-consuming test then I just go ahead and order it. MRIs, LPs, echocardiograms, joint aspirations are all things I refuse. Simple US, X-ray or CT? Sure why not!

 

[emd123]

Do the test.

 

[Birdstrike]

If it's a non-invasive, non time-consuming test then I just go ahead and order it. MRIs, LPs, echocardiograms, joint aspirations are all things I refuse. Simple US, X-ray or CT? Sure why not!

Why wouldn't you tap a non-emergent knee, especially a non-emergent knee with almost no liability whatsoever? You must not be payed by rvu's or on productivity. Tapping a knee is the easiest extra $60 (Medicare allowable for CPT 20610) you'll ever make. You should be able to do this in an extra 5 minutes, start to finish, in addition to your level 3 you're already going to bill (plus modifier -25) and document $60/0.83hr =

$722/hr

 

[VA Hopeful Dr]

As a PCP, threads like this always make me sad - I'm sure I've sent some things that probably could have waited, but I always call the ED and give a heads up and explain why I'm sending someone.

Some of the stuff you guys/gals see that my brethren have sent in are just sad.

 

[Daiphon]

Easy, low risk, won't mess with throughput? Do it & d/c home. As noted above, easy money.

Time consuming or risky? Admit obs to the PCPs service for inpatient workup. If they refuse, I ask them to come & d/c their own patient to their face & explain why... funny, noone ever takes me up on this.

-d

 

[kat82]

I will do most tests even if I disagree because
1. I don't want to create a distrustful relationship between the patient and their PMD
2. Unless I can speak to the PMD (which usually the pt shows up at night and the PMD is long gone) I may be missing something in the history that the patient isn't telling me and maybe the test is reasonable
3. It sucks to be the patient in the scenario where you refuse to do the test and they have to get punted back to their PMD and then to some outpatient testing center. Its not the patients fault

But I would never do an MRI thats not indicated b/c I'd have to basically lie to the radiologist to get it done and call in a tech from home and that is wrong on so many levels. Then I call the PMD and give them an earful

 

[GeneralVeers]

Why wouldn't you tap a non-emergent knee, especially a non-emergent knee with almost no liability whatsoever? You must not be payed by rvu's or on productivity. Tapping a knee is the easiest extra $60 (Medicare allowable for CPT 20610) you'll ever make. You should be able to do this in an extra 5 minutes, start to finish, in addition to your level 3 you're already going to bill (plus modifier -25) and document $60/0.83hr =

$722/hr

At the moment I'm not, but in my old RVU shop it was a huge pain to put the patient in a proper room, do a sterile field, tap it and then sit on the patient for an hour for results. All for something that isn't an urgency, much less an emergency.

 

[Groove]

I tap any joint that needs it. It's so quick, easy and billable. GV, it sounds like your old shop had efficiency issues so that makes sense. I don't have to put the pt anywhere. Quick prep, stick, aspirate, send down, results are back in about 30 mins-40 mins. Done and done.

I feel the same way about celestone/depomedrol trigger point / joint injections. Easy and excellent pt satisfaction.

 

[Old_Mil]

Not going to measure compartment pressures. If there is concern for that a surgeon needs to see the limb and do the compartment pressures.

The thing about procedures is they tie you up. Time you are tied up is time you aren't seeing new patients. I loved them in residency and hate them now.

I started at 7am yesterday and was single coverage for two hours before the MLP showed up. In that time, we had five ambulances show up, two were SOB, one was hypertensive AMS, had HBO send over another with sats in the 50s plus the usual walk up stuff. There simply isn't time to tie yourself up doing procedures that aren't emergently indicated.

If it is some blood test, xray, or CT I can order and forget about I am happy to oblige.

 

[GeneralVeers]

I agree. I hate procedures. Yes you can bill for them, but for every 30-minute lac repair I do, I know that when I'm done the department will be in chaos and I'll have to rush to see 4-5 patients who have built up.