Do you do this?

[DrQuinn]

So I'm in the Pedi ED this month, and we get a LOT of stuff sent from the pediatrician's office for stuff that really doesn't need to be seen emergently. I had a 4 month old baby sent to me for an "urgent abdominal x-ray" because the mom said the baby's belly gets big in the morning sometimes and goes away throughout the day. The MD sent a script for it to be done in the ER.

I'm not giving a stupid clinician story at all, but pose a question.

If someone is referred to your ED with a relatively noninvasive test to be done, but in your judgement, it does NOT need to be done, do you do it?

An x-ray isn't really going to hurt anyone, and Lord knows we do x-rays for the therapeutic value, but what do you guys do? Most of the time I think I do it anyways, especially on the triage sheet is says "sent here by MD for x-ray," Lord knows if I missed something by a bad stroke of luck the fingers would be pointing at me.

Q

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[BatmanMD]

This way you can CYA and keep the family doc/int med doc happy. Its a lot easier to take the xray than to argue with their PMD. Kinda sucks, b/c you and the PMD know its crap, but what are ya gonna do?

 

[Sessamoid]

If it's just a plainfilm, I'll generally do it. The risk is minimal, so even if the benefit is minimal to zero the only thing anybody has lost is time. The insurance company loses a little, but I really don't care that much about them.

More involved workups I'll do if indicated, or if not I'll call the primary and ask them if they have specific concerns or information that wasn't available to me. A lot of times, they'll know more about the case than the patient is able to relate.

 

[mikecwru]

If it's just a plainfilm, I'll generally do it. The risk is minimal, so even if the benefit is minimal to zero the only thing anybody has lost is time. The insurance company loses a little, but I really don't care that much about them.

More involved workups I'll do if indicated, or if not I'll call the primary and ask them if they have specific concerns or information that wasn't available to me. A lot of times, they'll know more about the case than the patient is able to relate.

The sticky question is when the imaging doesn't full answer the question "My PCP sent me to get a head CT for this bad headache I'm having." I've also done these nonindicated images and had findings suggestive of cancer incidentally.... a real treat.

mike

 

[docB]

I voted yes but I agree with Sessamoid and Mikecwru, if the workup they're asking for is invasive or if it's a Pandora's box test (more on this) then I'll be much more hesitant. The comment that even if the requested work up is stupid but you miss anything you're hosed is well taken.

The "Pandora's Box" tests are things like a CT only for a headache (gotta rule out mening and SAH so it's LP time, "Did your PMD tell you you were going to get a spinal tap?"), D-Dimer for PE, cardiac enzymes, etc. These are tests that wouldn't actually rule out anything and if we embark on those workups the patient will need admission regardless of what the PMD says.

 

[banner]

It's completely inappropriate and wasteful. If the PMD wants an X-ray, patient should be sent to private radiology practice.

What a wasteful strain on the healthcare system! An ER visit is expensive and shouldn't be used for such things.

 

[Febrifuge]

As a side-liner, I'm curous about the utility of being able to chart "placed phone call to [or paged] the PCP, Dr. X., to discuss Dr. X's request for this exam." Obviously if you can have the talk that Sessamoid mentions, things could get much clearer, but even if Dr. X is off someplace enjoying prime rib and never calls back, does it serve a purpose (billing-wise, anti-malpractice-wise, or CYA wise) to at least be able to chart "hey, I tried to get the story?"

I'm also curious to know if the "sure, I'd do it" people feel differently than the "this test is bogus" people about the uses of such a note.

 

[docB]

It's completely inappropriate and wasteful. If the PMD wants an X-ray, patient should be sent to private radiology practice.

What a wasteful strain on the healthcare system! An ER visit is expensive and shouldn't be used for such things.

In a perfect world you're right. In my ED I see ~5 of these a day and sometimes the PMD is right.

 

[docB]

As a side-liner, I'm curous about the utility of being able to chart "placed phone call to [or paged] the PCP, Dr. X., to discuss Dr. X's request for this exam." Obviously if you can have the talk that Sessamoid mentions, things could get much clearer, but even if Dr. X is off someplace enjoying prime rib and never calls back, does it serve a purpose (billing-wise, anti-malpractice-wise, or CYA wise) to at least be able to chart "hey, I tried to get the story?"

I'm also curious to know if the "sure, I'd do it" people feel differently than the "this test is bogus" people about the uses of such a note.

Good ?. I'd say there is some utility in charting that you tried to get the story from a CYA angle. I don't think it would help significantly with billing unless you actually talked to the doc and documented a discussion. From a hospital politics point of view it helps if you document that you tried to call especially if you don't get a call back. We have situations all the time where a patient comes in, has a PMD but winds up getting admitted to the on call doc. The next day the PMD will get POd and call the director to gripe. If the note shows that I called and got no response it's not my problem.

 

[Seaglass]

Most of the time when I overhear attendings dicussing this with PMDs they say things like "well you can send him/her in and we'll tkae a look and let you know what we find but we're not committing to doing any particular test." I think it helps to let the doc know right where you stand. IMHO if they're worried enough to get an eval RIGHT NOW then the patient should be admitted. If not then do it as an outpatient. If you are goint to send them to the ER the it's my ballgame now and I'd be happy to let you know what I decide to do but I'm not going to take orders. IMHO of course.

 

[Doczilla]

I'd probably place the call first. Though it sounds like BS, the PCP may have picked up on a little something in the history that didn't mean anything to the patient/mother (and may require quite a bit of teeth-pulling to get) but may be indicative of something worrisome, in which case there may be other available tests that would also be warranted. This would also give me the opportunity to do a little education of the PCP about other available resources such as writing a script to go directly to the hospital lab or radiology (as Banner suggested). This may save the patient the $50 or $100 ER visit copay, though not for this visit. If the patient has already made it through triage, it's likely too late, as potential liability and EMTALA concerns warrant an evaluation by the ER staff.

I agree with DocB about buying the workup and the "Pandora's Box" tests. If you've bought one set of enzymes, you've bought all 3.

'zilla

 

[Febrifuge]

... From a hospital politics point of view it helps if you document that you tried to call especially if you don't get a call back. We have situations all the time where a patient comes in, has a PMD but winds up getting admitted to the on call doc. The next day the PMD will get POd and call the director to gripe. If the note shows that I called and got no response it's not my problem.

Cool. Thanks. That's pretty much what I'd been thinking.

 

[docB]

Just to give you guys a little private practice perspective this stuff happens for economic reasons that are no fault of the PMDs.
-Often, especially with HMOs an outpatient test like a CT scan can take weeks to happen. Same with specialty consults. PMDs will dump on the ER to avoid the wait.
-If a doc is seeing an uninsured pt (like at a community clinic) there's no way that pt will get a study or a consult as an outpt, they necessarily get dumped on the ER.
-If a PMD wants to direct admit a patient he has to get approval from the insurance company. If it's after hours or if the insurance company balks but the PMD still wants to admit the pt it has to go through the ER.
-If the hospital is full all admits have to go through the ER.

These are a little different than the PMD sending in a pt for a specific test but it's all part of the vast tapestry that is dumping on the ER.

 

[Febrifuge]

...it's all part of the vast tapestry that is dumping on the ER.

What's really interesting is working at a hospital where the EM docs have unrestricted admitting privileges (well, as long as there's physically a room for the pt). If our people think the pt is sick and needs a bed, they get a bed.

The interesting thing is, this way the admitting services get to experience some of those admits as a similar "dumping" phenomenon. It's not better than avoiding the dumps entirely, but the smooth transition of dumpage from the PMD to the ED to the floors does perhaps encourage in-hospital solidarity, as opposed to the interdepartmental bad mojo I sometimes hear about.