AJM said:
This thread is beginning to degrade into an "us vs them", and I hope it won't continue to do so.
Much of the literature that our EM colleagues are referring to are specifically discussing patients with pneumonia. I'd like to remind both my EM and IM colleagues that it is very well known in both the EM and pulmonary literature that blood cultures in pneumonia are not very helpful. However, patients with pneumonia are a small minority of patients who end up getting admitted to the medical service. Of course there are many patients with CXR's that are read as "question of pneumonia" by the ER radiologists that end up actually being atelectasis, effusion, or just chronic changes -- if there's a concern for infection but the source is not clear, those patients should have cultures done - not just assume that there's a pneumonia present. In other words, if it's not a "slam-dunk" pneumonia, and there's a concern about infection, these patients should have blood cultures drawn before their antibiotics. Sure it won't change their management in the ED, but it does change their management on the floor or in the MICU. As for getting a hard time from the ER staff, it takes about 5-10 seconds to order blood cx, urine cx, and sputum cx, so I don't understand why this should really be a point of contention in an infected/septic patient.
AJM has the real point here. Proper management of a patient with suspicion of infection would include acquisition of blood cultures, ideally before the administration of antibiotics. Now you can find a journal article that says the sky is purple and humans really breath helium...so having a bulletin board war using obscure B-rated journals up against peer reviewed guidelines is bit folly and frankly stupid. In other words, its the ER's job to do the proper evidence based and guideline supported initial steps in diagnosing and managing the patient acutely for the suspected diagnoses, keeping mind the patient's further care during admission and the inpatient admitting service handles the rest.
Having worked on the floor and in the ER for a while, now the ICU I have few observations as to the rights of the parties involved.
The admitting physician has rights:
1. The right to admit the patient
2. The right to request evaluation of a patient in the ER prior to admission
3. The right to notify a receiving MD/team of a likely admission in a timely manner.
4. The right to be respected as a colleague and not be hassled by housestaff or other MDs posing as NFL linemen trying to block all possible admissions.
5. The right to perform initial diagnostic and treatment maneuvers based on best evidence available.
6. The right to defer longer term decision making to MD assuming responsibilities for definitive inpatient care.
The receiving physician has rights:
1. The right to accept the admission
2. The right to know of and review the requested admission and examine the patient themselves in a timely manner
3. The right to make alternative arrangements for a patient whose admission may not be necessary but f/u is
4. The right to a clear and concise review of the patient's presentation and acute management
5. The right to request alternative service evaluation for admission if chosen service is not deemed appropriate.
6. The right to request specifics from ER physicians admitting the patient to their service before the patient is officially dispositioned as an inpatient(i.e. antibiotic and acute lab choices, if not already performed, etc)
Here is my last point, then I am done. If anyone in the ER or on the floor is "too busy" to provide proper, evidence based and uniform care to a patient or patients...then it is that person's responsibility to call for help to do the right thing...e.i draw the blood cultures yourself, get the charge nurse to hang the antibiotics if the patient's nurse can't/won't do it. This argument about the ER being so busy that proper care can't be delivered is crap. Half-assed care is as good as no care at all, and is likely more dangerous.
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