The Effect of Removing Fecal Occult Blood Testing from the ER

[docB]

This article in Annals notes that when you make it harder to get tests done we do fewer tests. Many of us (including me) have seen their hospitals take fecal occult blood testing out of the ED and move it to the lab for various regulatory and financial reasons. The result: we're not doing as many rectal exams. In a lot of instances this is bad for patients.

The article concludes that when regulatory bodies start dreaming up new hoops for us to jump through they should at least try to consider what unintended consequences they will cause.

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[xaelia]

Well, fewer rectals* isn't hurting our patients anyway, but, sure, it's a fine line to walk once you start passive-aggressively constraining supply of a diagnostic test.

* 8th edition of ATLS has taken the DRE out of the trauma workup excepting pelvic trauma, penetrating abdominal injury, and suspected cord injury.

"Utility of the digital rectal examination in the evaluation of undifferentiated abdominal pain." PMID: 19931762 states the DRE was useless in 92% of their cohort, and the 8% where it affected management it misled their management as often as it helped them.

 

[docB]

I agree that it's probably not useful in trauma unless you have suspicion of a specific injury. But for all the gastritis, anemia, ?able GI Bleeds, etc. It needs to be done. Since they took away the test I only do it to look for gross blood. If the admitting doc wants a guiac they have to either do it themselves or (more likely) order the nurse to scoop the poop.

 

[southerndoc]

I agree that it's probably not useful in trauma unless you have suspicion of a specific injury. But for all the gastritis, anemia, ?able GI Bleeds, etc. It needs to be done. Since they took away the test I only do it to look for gross blood. If the admitting doc wants a guiac they have to either do it themselves or (more likely) order the nurse to scoop the poop.

I still guaiac every stroke patient that I TPA. Get someone who's brightly heme positive and give them TPA and watch your neurologists scatter.

 

[willow18]

This article in Annals notes that when you make it harder to get tests done we do fewer tests. Many of us (including me) have seen their hospitals take fecal occult blood testing out of the ED and move it to the lab for various regulatory and financial reasons. The result: we're not doing as many rectal exams. In a lot of instances this is bad for patients.

The article concludes that when regulatory bodies start dreaming up new hoops for us to jump through they should at least try to consider what unintended consequences they will cause.

The article in where?

Ah, how I miss elementary school humor.

 

[docB]

The article in where?

Ah, how I miss elementary school humor.

It's so early I had to go make sure I spelled it right.

 

[deleted109597]

I still guaiac every stroke patient that I TPA. Get someone who's brightly heme positive and give them TPA and watch your neurologists scatter.

How often are you giving tPA?

Here at our shop, everyone on a heparin drip automatically gets every stool tested by nursing (on the floor anyway).

How often does a positive guaiac change management of any other patient population? Did I miss a recent study where it was sensitive or specific for anything?

 

[southerndoc]

How often are you giving tPA?

How often does a positive guaiac change management of any other patient population? Did I miss a recent study where it was sensitive or specific for anything?

I give TPA about once every two months (personally). We average about 1 TPA candidate per week.

If it's weakly heme positive with brown stool, then we give TPA. If it's brightly heme positive with brown stool, then we have a risk/benefit discussion with the family but go ahead and give TPA the majority of times (just document the extra risk in the consent form). If it's melenic and heme positive, then no TPA.

 

[MLT2MT2DO]

This article in Annals notes that when you make it harder to get tests done we do fewer tests. Many of us (including me) have seen their hospitals take fecal occult blood testing out of the ED and move it to the lab for various regulatory and financial reasons. The result: we're not doing as many rectal exams. In a lot of instances this is bad for patients.

The article concludes that when regulatory bodies start dreaming up new hoops for us to jump through they should at least try to consider what unintended consequences they will cause.

Can't you still just smear it on the card and then have a tech or volunteer run it down to the lab. The TAT should still be no longer than 5-10 minutes.

 

[EMDoc0411]

We still keep contraband developer in the physician's desk drawer. Just gotta make sure we don't get any poop smears on the handle.

 

[DrWBD]

How often does a positive guaiac change management of any other patient population? Did I miss a recent study where it was sensitive or specific for anything?

It does change management, but mostly unnecessarily. Hemoccult testing, by my observation, is horrendously misused, especially in the ER.

If it's weakly heme positive with brown stool, then we give TPA. If it's brightly heme positive with brown stool, then we have a risk/benefit discussion with the family but go ahead and give TPA the majority of times (just document the extra risk in the consent form). If it's melenic and heme positive, then no TPA.

There is no such thing as "weakly" or "strongly" heme positive. Either you are positive or you aren't. The distinction based on the degree of color change has zero clinical relevance. Indeed, it's more likely that when you guys jam a finger up the rectum and rupture a hemorrhoid or cause trauma, you'll have a "strong" reaction, whereas a colon cancer that bleeds intermittently could give a "weak" reaction.

 

[docB]

We still keep contraband developer in the physician's desk drawer. Just gotta make sure we don't get any poop smears on the handle.

We have vultures... er, helpful administrative assistants who review charts. If you document a guiac and it wasn't done by the lab you're busted.

 

[southerndoc]

There is no such thing as "weakly" or "strongly" heme positive. Either you are positive or you aren't. The distinction based on the degree of color change has zero clinical relevance. Indeed, it's more likely that when you guys jam a finger up the rectum and rupture a hemorrhoid or cause trauma, you'll have a "strong" reaction, whereas a colon cancer that bleeds intermittently could give a "weak" reaction.

Some turn very blue, others only a faint blue. That's weakly and strongly heme positive.

 

[DrWBD]

Some turn very blue, others only a faint blue. That's weakly and strongly heme positive.

Right, but that is a distinction that has absolutely zero clinical relevance, as I mentioned. Unfortunately it is a medical myth that persists.

 

[corpsmanUP]

I confiscated a box of developer before they changed our policy to similar one. I do 2 of them. One goes to the lab and one for me to make a real decision with acutely. If there is ever a discrepancy I call the lab and tell them to change theirs to reflect mine. Usually it's when mine is positive and theirs is negative and I know they just probably didn't even look at it!! Another great thing is the dollar store pregnancy tests. Great in a pinch when you don't want to delay your shift or a CT for a one hour lab version. Of course send the lab version as well. Another item are urine dip sticks for when you want to get a real quick reliable indicator of stone pain. I like to know if my chain is getting yanked early on instead of waiting for the negative UA and CT.

 

[VienneseWaltz]

We still keep contraband developer in the physician's desk drawer. Just gotta make sure we don't get any poop smears on the handle.

Yep! I wonder if the supplies manager noticed that the use of hemoccult cards approximately doubled (one for me, one for the lab)...

 

[MLT2MT2DO]

I confiscated a box of developer before they changed our policy to similar one. I do 2 of them. One goes to the lab and one for me to make a real decision with acutely. If there is ever a discrepancy I call the lab and tell them to change theirs to reflect mine. Usually it's when mine is positive and theirs is negative and I know they just probably didn't even look at it!! Another great thing is the dollar store pregnancy tests. Great in a pinch when you don't want to delay your shift or a CT for a one hour lab version. Of course send the lab version as well. Another item are urine dip sticks for when you want to get a real quick reliable indicator of stone pain. I like to know if my chain is getting yanked early on instead of waiting for the negative UA and CT.

I'm guessing you're currently in the Navy and this is why you can get away with the majority of this.