Admitting Patients

[psymed]

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Being a new intern, I'm trying to get used to my new surroundings. I'm and IMG but have been involved in outpatient care in the US for a number of years. I don't understand a few things and was wondering if someone could help me out.

I was told that every patient being admitted needs a baseline EKG and a Chest X ray. Why is this? What if the H & P does not indicate the need for one? They also want me to put almost everyone on DVT prophylaxis and do a suicide risk assesment on them. I don't get it.

 

[RussianJoo]

Being a new intern, I'm trying to get used to my new surroundings. I'm and IMG but have been involved in outpatient care in the US for a number of years. I don't understand a few things and was wondering if someone could help me out.

I was told that every patient being admitted needs a baseline EKG and a Chest X ray. Why is this? What if the H & P does not indicate the need for one? They also want me to put almost everyone on DVT prophylaxis and do a suicide risk assesment on them. I don't get it.

i don't know why you would need a baseline EKG and C-xr on everyone that sounds really wasteful and stupid, what if it's a 26 year old male admitted for diarrhea do you get an EKG and C-XR on him too?

the DVT prophylaxis is a must in all elderly hospitalized pts cause DVTs are a major problem in hospitalized pts especially the elderly who lie in bed all day and then get up to go to the bathroom and boom PE. suicide risk assesment? are you doing a psych residency? that could answer why you need that.. it should be part of your initial history. when i did my psych rotation everyone was asked if they feel depressed and if they want to hurt themselves or others. in IM we never asked nor did we care, unless the pt presented with depression.

 

[psymed]

I am a Psych Intern but currently rotating through medicine. I agree with the DVT prophyalxis but I really don't understand the need for baseline EKGs, CXR and suicide risk assesment on everyone.

 

[lord_jeebus]

As a medicine intern I certainly did not do an EKG or CXR on every admission. Similarly, I only ordered DVT prophylaxis when it was indicated.

As for suicide risk, I would routinely ask two questions as part of Review of Systems -

Do you feel down or depressed? Do you have less interest or enjoyment in doing things than you have in the past?

If both are "no," I leave it at that, assuming I'm not admitting for drug overdose or something like that.

 

[Winged Scapula]

Ordering an EKG and CXR on everyone makes no sense and is incredibly wasteful.

DVT is a big cause of morbidity and for bedridden patients, it makes sense to prophylax against it. But if your patient is ambulatory and has no other risk factors (cancer, prior history, post-op, etc.), I'm not sure they need anything else.

 

[RTrain]

I echo the sentiments of previous posters and agree that a CXR and EKG on every patient you admit is wasteful. If that's what your attending or senior resident wants, then you should do it, but know that you're right to question the practice.

As for DVT prophylaxis, many internists (including me) favor addressing it with every patient, because venous thromboembolism is such a huge issue. The final problem on my list with every admission is always "DVT Prophylaxis," with my plan being LMWH, subQ heparin in renal patients, warfarin if they're chronically anticoagulated and are therapeutic on admission, or - if they are at particularly low risk - SCD's or ambulation. So even if I don't put every patient on prophylaxis, I always address it. That seems like a good way to approach it.

 

[psymed]

Thanks everyone for the replies. At least now I know that I'm not the only one thinking........"Are you for real?"

 

[pillowhead]

unfortunately, I think many IM residents (at least where I did my intern year) have been trained to think this way. If it shows up on the differential, they seem to want a test to rule it out. I had some senior residents on my services have a hard time realizing that test can include the history, physical, and clinical judgement. I had more than my share of admissions delayed to IM services (both when rotating on IM and rotating on EM) blocked because I did not have the mandatory chest xray and EKG. Not every admission seemed to need this, but the (IMHO) weaker residents would block admissions without these.

I was admitted to our univ. hospital as an intern with pneumonia. Despite meeting all SIRS criteria and having a whopping RML lung infiltrate, they still drew a d-dimer on me to rule out PE because I had pleuritic chest pain. With an obvious diagnosis (pneumonia) and no risk factors for PE (like family hx or OCPs), I would never have ordered a d-dimer on myself. And quite frankly, if it had come back positive, I would have refused a PE protocol chest CT.

When I was admitted, I refused the SQ heparin for DVT prophylaxis. I was not bedbound (heck, I went to the cafeteria for every meal because the food was so bad) and did not meet any criteria for requiring SQ heparin. Ambulation is effective for DVT prevention in appropriate patients. Not everyone needs drugs.

Summing up: you don't always need an intervention like CXR, EKG, lab tests, and drugs. It's totally appropriate in the right circumstances to rule things in or out clinically and to treat and prevent disease non-pharmacologically.

 

[docB]

They did a study a few years back where they asked admitting residents why they ordered all the tests they did. the #1 answer was because they thought the attending would want to see it.

Someone saying that anything is "required" for admission sounds like a senior who doesn't want to have to explain why such and such wasn't ordered. The fact is (and it's not a good thing) that most attendings will bitch more about stuff that wasn't done instead of why unnecessary stuff was done.

The suicide screen is a Joint Commission requirement. It's stupid (which is redundant given that it's a JC req) but it's usually taken care of by nursing.