consultant asking for labs being sent then discharge without waiting for results

[Painter1]

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walked in to a shift with a patient who had been evaluated by ortho and who had discharge paperwork ready. i didn't see the patient but apparently he came in with knee pain and redness after a fall a week ago. diagnosis per the er note was quadracept rupture.

the ortho attending runs to the nurse and asks if an esr, crp and cbc can be drawn and then he can go home. nurse surprisingly says "sure". she then comes to me asking for the other to which I said: "no". the ortho attending never talked to me. i reviewed his note and he mentioned a concern for cellulitis, he wanted esr, crp and f/u at his office.

basically, he wanted me to order this without waiting for the results sending him home. i'm I wrong to think this is inappropriate. i can't just order labs and not wait for the results. i tried calling him back and spoke with his resident who thought i was the crazy one for not ordering the labs afterall: "we'll follow the results". the ortho attending later came down angry demanding an explaination to which i answered it was not standard of care to order labs without waiting for the results and acting on them.

would any of you order the labs?

 

[EctopicFetus]

walked in to a shift with a patient who had been evaluated by ortho and who had discharge paperwork ready. i didn't see the patient but apparently he came in with knee pain and redness after a fall a week ago. diagnosis per the er note was quadracept rupture.

the ortho attending runs to the nurse and asks if an esr, crp and cbc can be drawn and then he can go home. nurse surprisingly says "sure". she then comes to me asking for the other to which I said: "no". the ortho attending never talked to me. i reviewed his note and he mentioned a concern for cellulitis, he wanted esr, crp and f/u at his office.

basically, he wanted me to order this without waiting for the results sending him home. i'm I wrong to think this is inappropriate. i can't just order labs and not wait for the results. i tried calling him back and spoke with his resident who thought i was the crazy one for not ordering the labs afterall: "we'll follow the results". the ortho attending later came down angry demanding an explaination to which i answered it was not standard of care to order labs without waiting for the results and acting on them.

would any of you order the labs?

Truly depends on the ortho person and what system you have in place at your spot. Think about it.. when you order a urine culture do you keep the patient in the ED to follow the result? Of course not cause it takes days.

Here in the Southwest I order Cocci Serologies and those take days too.

We have a system that our nurses call back the positives.

In a strict sense you are right. Any lab you order you are responsible for follow up. Could the ortho doc not order this test? I think you would be more than covered though if you ordered and charted that you spoke with Ortho and they said they would follow up the labs. I personally would at the end of my shift or during down time look up the ESR and CRP in case it was crazy high. Hope this helps some.

 

[gro2001]

If the patient is reliable and close follow up could be arranged, I don't think there is any reason not to send a person home if you are ruling out something not immediately life/limb threatening. Especially if there is a clear understanding that the consultant/PCP will follow the results and you have a way of contacting the patient for a call back if the labs are critically abnormal. Just document it really well.

 

[xaelia]

Those points regarding follow-up aside, it should be embarrassing to your consultant to stick the patient with the costs of, essentially, the most expensive outpatient lab draw possible.

 

[The White Coat Investor]

Give me a break. He says he'll follow it up. Put that in your note, ask the patient if he'd like to wait for the results, if not, discharge him and tell him to discuss it with ortho when he sees them. A good relationship with your consultant is worth way more than a fight over this.

 

[ccfccp]

Give me a break. He says he'll follow it up. Put that in your note, ask the patient if he'd like to wait for the results, if not, discharge him and tell him to discuss it with ortho when he sees them. A good relationship with your consultant is worth way more than a fight over this.

Agreed. Documentation is the key in this situation. I've gotten burned in a similar situation once because I didn't write the discussion in the chart. However, in this case if the Ortho attending asked the nurse for the labs, I don't see why he/she can't put those labs in as a verbal order from the Ortho attending.

 

[EctopicFetus]

Agreed. Biggest issue in this case is that the ortho guy didnt communicate with you.. Thats unfortunate and is bad patient care.