Improving efficiency as attending

[dotcb]

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I've worked at 2 tertiary centers and 2 county facilities. At none of those settings would 1 trop, CV US, and a GB US have flown for ruling out significant disease. There has always been consistency that unexplained chest pain usually needs provocative testing, and US is reasonable for answering a limited number of binary questions. In all 4 settings, the range of practice variation has been relatively narrow, and I think - appropriate.

 

[Apollyon]

I'm a new attending, coming from an academic program and now in the community. I've been told in 2 short months that I 'tend to order more scans than most,' and gotten feedback from the nurses that I'm overly cautious (better than cavalier I suppose?). So, I've actually found the opposite is true about ordered more CTs in the community, at least by my partners. Maybe that's why they're turning patients over faster.

How many positive CT results are there? If you're hitting a whole bunch of negatives, then that is something to consider. Remember the old caveat - too many negatives, you're ordering too much, and, too many positives, you're not ordering enough. I, myself, had a night shift radiologist tell me that I have the most positive studies of all the clients. Am I that good? I'd like to think so, but I also think Elvis is bagging groceries at the Tops International on Maple Road. That leaves that I am not ordering enough. At the same time, my patient volume isn't that much that I have the room to order any more. Also, I have not had (knock wood) a bad outcome return due to a mismanagement by me, or something I should have scanned but didn't (although I did get dinged in SC for a guy who had no blood in his urine and 10 minutes of pain, that came back one week later with the same complaint, and had a non-obstructing stone, and a mother who complained because I didn't CT - again - her daughter for stones - although mom said that "she always gets an MRI!" - and just symptomatically treated her for renal colic).

You'll develop. Look at it this way - things can only get better!

 

[old_boy]

I've worked at 2 tertiary centers and 2 county facilities. At none of those settings would 1 trop, CV US, and a GB US have flown for ruling out significant disease. There has always been consistency that unexplained chest pain usually needs provocative testing, and US is reasonable for answering a limited number of binary questions. In all 4 settings, the range of practice variation has been relatively narrow, and I think - appropriate.

Good points made re the to-CT-or-not-to-CT question and I appreciate the responses. The problem with our patient population is that "chest pain" ends up on the triage sheets of an awful lot of our patients. It is extremely common to see CC as "abd pain/chest pain/med refill" and when you go see the patient they look well with nl vitals and nl ekg and give a vague story as to their multiple complaints including chest pain. We do not have timely outpatient stress test capability, we do not have ops beds, and we do not have space in our hospital to admit otherwise healthy 56 year olds with nl EKGs and vague multiple complaints for rule out + stress test in all cases. Therefore, the typical algorithm at our shop for multiple vague complaints in otherwise healthy middle aged people that includes Chest Pain relies a lot on gestault. Does this sound cardiac? Was this REALLY the reason why this person came in to the ED (often it's not despite it being their chief complaint)? Although we admit some, the reality is that we dispo a lot of these pts with CP as one of their chief complaints and nl ekg based on history alone. I realize this is not standard-of-care in the community and so do our attendings, and we are explicitly taught this and also see a more conservative approach at other hospitals that we rotate at. For this reason I find the to-pan-CT-or-not-to-CT question more interesting.

Good points re limited utility of bedside u/s and this is obviously a topic that continues to be controversial.

Another point is radiation and contrast exposure. Most of our patients do not have regularly and timely PCPs and may have several vague abd and cp visits per year. If we scanned them all everywhere it hurt every time we would be talking significant radiation/dye exposure and resource utilization issues.

As this is a time efficiency thread, I do see how shotgunning CTs saves time and I agree that often it is the path of least resistance. I find threads like VERY helpful as I continue to learn what practice style I feel comfortable with and how things are done elsewhere. These are the topics that are poorly covered in certain residencies and are obviously extremely important to successful community practice.

 

[deleted109597]

You don't have to admit all chest pain patients, especially not ones who their chief complaint reads "I need a shot of dilaudid and a refill of my lortab then I'll be ready to go home." I kid you not, I have a picture of it.

However, you can not rely on one negative trop to make this decision. You can do a 2 hour delta, and many of the patients at our shop get those while still in the waiting room. My favorite NSTEMI patients are the ones where a nurse comes to me and says "doc, we need to get this guy back, his second set bumped."

 

[WilcoWorld]

Good points made re the to-CT-or-not-to-CT question and I appreciate the responses. The problem with our patient population is that "chest pain" ends up on the triage sheets of an awful lot of our patients. It is extremely common to see CC as "abd pain/chest pain/med refill" and when you go see the patient they look well with nl vitals and nl ekg and give a vague story as to their multiple complaints including chest pain. We do not have timely outpatient stress test capability, we do not have ops beds, and we do not have space in our hospital to admit otherwise healthy 56 year olds with nl EKGs and vague multiple complaints for rule out + stress test in all cases. Therefore, the typical algorithm at our shop for multiple vague complaints in otherwise healthy middle aged people that includes Chest Pain relies a lot on gestault. Does this sound cardiac? Was this REALLY the reason why this person came in to the ED (often it's not despite it being their chief complaint)? Although we admit some, the reality is that we dispo a lot of these pts with CP as one of their chief complaints and nl ekg based on history alone. I realize this is not standard-of-care in the community and so do our attendings, and we are explicitly taught this and also see a more conservative approach at other hospitals that we rotate at. For this reason I find the to-pan-CT-or-not-to-CT question more interesting.

Good points re limited utility of bedside u/s and this is obviously a topic that continues to be controversial.

Another point is radiation and contrast exposure. Most of our patients do not have regularly and timely PCPs and may have several vague abd and cp visits per year. If we scanned them all everywhere it hurt every time we would be talking significant radiation/dye exposure and resource utilization issues.

As this is a time efficiency thread, I do see how shotgunning CTs saves time and I agree that often it is the path of least resistance. I find threads like VERY helpful as I continue to learn what practice style I feel comfortable with and how things are done elsewhere. These are the topics that are poorly covered in certain residencies and are obviously extremely important to successful community practice.

The point I was trying to make is, if you think a complaint does need to be addressed, a non-focused bedside US isn't a sufficient work-up.

My apologies if I wasn't clear on this before, but I do not think all CP or and pain requires a work-up. If the triage note reports CP, but I think there is no reason to work it up, I'll write a note acknowledging the triage note, and explain why it isn't getting worked up this visit. (Something like, "Patient's chief complaint is 'med refill' and patient states that the CP mentioned in triage is the same CP that was evaluated one month ago when the patient was found to have a negative CT PE, and the same pain that was evaluated three months ago at which time the patient had a negative cardiac catheterization. There has been no change in the pain and there are no new symptoms. Risk vs benefit of further work-up was discussed with the patient...blahbity blahbity, don't sue me, blah...")

I think that, especially for return visitors, a little chart review, a little discussion and a lot of documentation goes a long way towards decreasing testing (thereby increasing efficiency) and limiting liability.

 

[Interpolfanclub]

The key is liability reform. For most abdominal pain it's completely reasonable to order labs, discharge the patient home and have them return in 12 hours if they still have pain, thus avoiding unnecessary CTs. Unfortunately the threat of liability for "missing" an acute appendicitis or other surgical problem makes this reasonable disposition impossible and requires us to CT most abdominal pain.

This. Unfortunately the abdominal pain recheck which was taught so often in residency just doesn't fly in community practice for two reasons. One is the legal threat. The other is that patients do not want to wait. About once a shift I will have a patient who fits in the CT vs recheck category. I ALWAYS offer the option to those patients and their family of CT or come back later. 100% of the time patients opt to CT now even after risk/benefit discussion.

 

[WilcoWorld]

This. Unfortunately the abdominal pain recheck which was taught so often in residency just doesn't fly in community practice for two reasons. One is the legal threat. The other is that patients do not want to wait. About once a shift I will have a patient who fits in the CT vs recheck category. I ALWAYS offer the option to those patients and their family of CT or come back later. 100% of the time patients opt to CT now even after risk/benefit discussion.

That's funny, I find that the vast majority of the times I offer the option of CT vs recheck my patients choose to not get CT'd. Now, I throw "several hundred chest X-rays worth of radiation" and "at least 4 more hours here" into the R v B discussion, so there's that.

 

[GeneralVeers]

This. Unfortunately the abdominal pain recheck which was taught so often in residency just doesn't fly in community practice for two reasons. One is the legal threat. The other is that patients do not want to wait. About once a shift I will have a patient who fits in the CT vs recheck category. I ALWAYS offer the option to those patients and their family of CT or come back later. 100% of the time patients opt to CT now even after risk/benefit discussion.

Head injuries are my least favorite. The general public now assumes that any head injury no matter how minor is a "concussion" and that it must have a CT to diagnose.

I had one young patient sent in by Urgent care after a very minor head injury with no LOC, no significant trauma, and no neuro symptoms. The patient was sent in "to get a CT". I had a long discussion with the patient about why I didn't think a CT was warranted, and the patient seemed to understand. The patient left with follow-up instructions. A month later I get the Press-Ganey survey back where the patient had written: "Urgent care sent me in for CT, doctor did not do one! I saw my private doctor that week and he said ER doctor should have done one!" Needless to say I got a "1" in every category and that survey will bring down my scores for the next 6 months.

Nevermind the patient had no bad outcome, and I practiced completely appropriate medicine. In fact it arguably would have been malpractice to do a head CT on that patient.

 

[TrumpetDoc]

Head injuries are my least favorite. The general public now assumes that any head injury no matter how minor is a "concussion" and that it must have a CT to diagnose.

I had one young patient sent in by Urgent care after a very minor head injury with no LOC, no significant trauma, and no neuro symptoms. The patient was sent in "to get a CT". I had a long discussion with the patient about why I didn't think a CT was warranted, and the patient seemed to understand. The patient left with follow-up instructions. A month later I get the Press-Ganey survey back where the patient had written: "Urgent care sent me in for CT, doctor did not do one! I saw my private doctor that week and he said ER doctor should have done one!" Needless to say I got a "1" in every category and that survey will bring down my scores for the next 6 months.

Nevermind the patient had no bad outcome, and I practiced completely appropriate medicine. In fact it arguably would have been malpractice to do a head CT on that patient.

This is so true, and complete Bull
This is one thing that burns at me more than anything.
I will bet you did have a rather long conversation with this person and they really did "seem"to be down with the plan.
I had a nearly identical case a few months back. From what it sounds... The same PG sheet too.

PG coupled with liability...it's amazing we just don't pan scan at triage.

It is really disheartening, we learn and try to perfect diagnostic skills/history skills and a lot if times we feel cornered into it.

My Dave quakes about CT scans by a lecture at ACEP while back.

"we don't NEED to scan, we HAVE to"


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[GeneralVeers]

We have the deadly triad in this country looming:

Press-Ganey

Medical Liability

Government-run Healthcare

These three things cannot coexist in any semblance of their current form, or the entire system will quickly and catastrophically collapse.

What observers in Europe don't get about our healthcare system is that currently the first two in the triad make the last one impossible to implement.

 

[WilcoWorld]

Full disclosure - We don't follow our PG scores at my shop.

 

[TrumpetDoc]

We have the deadly triad in this country looming:

Press-Ganey

Medical Liability

Government-run Healthcare

These three things cannot coexist in any semblance of their current form, or the entire system will quickly and catastrophically collapse.

What observers in Europe don't get about our healthcare system is that currently the first two in the triad make the last one impossible to implement.

Completely agree.

 

[hurricanemd]

I'm also a new attending. During residency I was one of the slower residents and getting up to 2 pts/hr was sometimes hard. A few times I hit the 2.5pts/hr mark as an upper level but was always staying after 1-2 hrs charting.

I'm not sure what the other docs in my group average. I know I'm not the slowest, but also nowhere near the fastest. I'm probably averaging 2-2.3 pts/hr. Hit 2.6/hr the other day and still got out on time, which for me was awesome. Our director recently placed emphasis on quick dispos to keep the department flowing smoothly. He said that before picking up another chart, we should check to see if there's anyone we can dispo first. Since I started using that tip, I've found myself getting a little more efficient.

I'm usually carrying 5-6 patients at a time. I go see one and then come and order the tests (we use CPOE which is a pain in the @$&) before picking up another. While waiting for a consultant to call back, I usually check to see what's waiting in the rack and order any "no brainer tests," like the UA/UPT for the abd pain female, CXR for the dyspneic pt, etc. This keeps things going while I'm stuck at the desk.

 

[Pinner Doc]

Most are minor complaints that are treat and street, or need one X-ray. Usually throw in 5-6 chest pains, 1-2 lacs, and a few abdominal pains.

The key to efficiency, especially with abdominal pains is to order everything up front. If you're female with lower abdominal pain, you're getting a CT, pelvic ultrasound, labs, UA and pregnancy test immediately. You get one visit from me when you arrive, and another visit when everything's back and you are getting discharged for your 10/10 menstrual cramps.

It is impossible to see 3/hour and not cut corners somewhere. For me it's time spent with patients, as I rarely spend more than 5 minutes even with admitted patients.

To make matters worse is administration is forcing us to do a "new" triage protocol where we have to drop anything we are doing and run out to triage every time a patient comes in, just to greet them and get stuff started. As you can imagine that's going to be really help my efficiency. "Sorry Mr. Heart Attack, I have to interrupt our conversation because the nurse wants me to see Ms. Stuffy Nose out front".

I'm *really* sorry to bring up an old thread. I'm just doing a search on how to improve efficiency. This reply from General Veers was interesting to me.

At my current job, one of our metrics is how many CT scans we order - this is discussed at our annual review. We also get anonymous feedback from the staff, who have been known to say that certain providers seem to "shotgun cases" or "order everything with very little thought," sometimes making staff think "this doctor doesn't know what they're doing, so they order everything." I could never fathom seeing a pelvic pain and ordering an ultrasound AND a CT. I can see how this might be efficient, but literally my director is known to sit at home and call the department to ask us, "Why did you order that test on so-and-so?" I know I'd hear from the higher-ups about an approach like the above within just a few shifts.

 

[Pinner Doc]

Ah, kept reading and it seems like we addressed my question a little bit already. I'd love to hear anyone's thoughts if they have any, though.

 

[dotcb]

literally my director is known to sit at home and call the department to ask us, "Why did you order that test on so-and-so?" I know I'd hear from the higher-ups about an approach like the above within just a few shifts.

Talk about micromanaging - that sounds incredibly annoying. I'm all for appropriate resource utilization, but didn't they hire you for your doctoring abilities? (Rhetorical question)

 

[Birdstrike]

I agree w you, but obviously many people ARE seeing that many patients.

How are people compensated in your group? RVUs, hourly, a mixture? That's key here.

 

[deuist]

I could never fathom seeing a pelvic pain and ordering an ultrasound AND a CT.

What about RLQ pain and rebound tenderness on a young female with known ovarian cysts? I've ordered the U/S expecting to see a ruptured cyst, only to find normal ovaries. Now what? Do you say, "Well, I can't get a CT now, so you'll just have to go home."

 

[bougiecric]

What about RLQ pain and rebound tenderness on a young female with known ovarian cysts? I've ordered the U/S expecting to see a ruptured cyst, only to find normal ovaries. Now what? Do you say, "Well, I can't get a CT now, so you'll just have to go home."

In a well appearing patient with normal Hb and vital signs, why do you need to look for a ruptured cyst? Not an emergent diagnosis. Either ask them to look for the appendix on ultrasound, or just start with the CT.

 

[Arcan57]

In a well appearing patient with normal Hb and vital signs, why do you need to look for a ruptured cyst? Not an emergent diagnosis. Either ask them to look for the appendix on ultrasound, or just start with the CT.

It's not like all ruptured cysts are well appearing. It's not uncommon for them to have peritoneal signs if the cysts were hemorrhagic and saving young women's ovaries from radiation isn't the worst use of resources. I'll agree that there shouldn't be a CT or U/S done in this patient population prior to a pelvic though.

 

[Pinner Doc]

What about RLQ pain and rebound tenderness on a young female with known ovarian cysts? I've ordered the U/S expecting to see a ruptured cyst, only to find normal ovaries. Now what? Do you say, "Well, I can't get a CT now, so you'll just have to go home."

Allow me to modify... "I could never order an ultrasound and a CT *up front.*" And yeah, I know... never say never.

I have been known to order the two in one visit. I usually start with the ultrasound - no radiation or contrast. Then order the CT if the exam is very concerning and there's no answer yet. But then I DO hear about it from the nurses and the higher-ups (in terms of LOS). Gotta do what's right for the pt.

 

[bougiecric]

It's not like all ruptured cysts are well appearing. It's not uncommon for them to have peritoneal signs if the cysts were hemorrhagic and saving young women's ovaries from radiation isn't the worst use of resources. I'll agree that there shouldn't be a CT or U/S done in this patient population prior to a pelvic though.

You make a good point. I hate to admit it, but working under heavily emphasized metrics for awhile now has jaded me to some cavalier CT ordering. So much emphasis is placed on throughput and LOS... I feel like the culture of the department I'm in creates a cult of personality in which the radiation from CTs is "no big deal." I try to remain vigilant, but I will say the system has changed me.

 

[gman33]

What about RLQ pain and rebound tenderness on a young female with known ovarian cysts? I've ordered the U/S expecting to see a ruptured cyst, only to find normal ovaries. Now what? Do you say, "Well, I can't get a CT now, so you'll just have to go home."

Agree. You get a neg u/s, then what?
You have no diagnosis. Outside of academics/peds, u/s for appy usually results in not visualized or a non-useful official read.
Then you are stuck with no diagnosis. Still need a CT scan.
I know some docs who will have them drink contrast before the u/s.
If U/S neg, they can go get a CT with no real delay.
Waste of contrast in some patients, but I don't think it's a major problem.

The bigger problem is working in a system that expects a zero miss rate and won't put some responsibility on patients to return if things get worse.

 

[deuist]

I know some docs who will have them drink contrast before the u/s.

I actually do this for most of my belly/pelvic pain patients. It saves me loads of time in the LOS arena. And what's the worst that will happen from drinking gastrograffin? A little diarrhea?

 

[deleted109597]

And what's the worst that will happen from drinking gastrograffin? A little diarrhea?

You might relieve their constipation and forgo the CT altogether.

 

[deuist]

You might relieve their constipation and forgo the CT altogether.

I didn't say that I always order the CT. I usually get patients started on drinking contrast first as it's the rate-limiting step. The ultrasound and its reading won't be done for another hour. If the U/S is unremarkable, I can then order a CT and I haven't lost any time. If the U/S gives the diagnosis, then I'm done.

 

[TooMuchResearch]

PO contrast? I thought this thread was about improving LOS. I think there are better references, but this will do on an early, early Saturday: http://www.ncbi.nlm.nih.gov/m/pubmed/22633722/

 

[deuist]

PO contrast? I thought this thread was about improving LOS. I think there are better references, but this will do on an early, early Saturday: http://www.ncbi.nlm.nih.gov/m/pubmed/22633722/

True, I'm aware of the literature regarding PO/IV contrast versus IV only, but the radiologists aren't.

 

[deleted109597]

True, I'm aware of the literature regarding PO/IV contrast versus IV only, but the radiologists aren't.

Our radiologists are. I mean, it's in the ACR recs. They just claim they aren't trained to read uncontrasted images, and prefer PO. They also mention the studies are done with 64 slice or higher scanners, and not every place has them, specifically rural places. They'll do it without, but there's the radiologist byline that is almost as common as "clinically correlate."
"This exam is limited by the absence of oral contrast. If clinical suspicion for intraabdominal pathology is high, recommend repeating the study with oral contrast."

 

[Birdstrike]

It's not like all ruptured cysts are well appearing. It's not uncommon for them to have peritoneal signs if the cysts were hemorrhagic and saving young women's ovaries from radiation isn't the worst use of resources. I'll agree that there shouldn't be a CT or U/S done in this patient population prior to a pelvic though.

If you are ordering a (non-pregnancy) pelvic ultrasound to look for a "ruptured cyst" per se, you have to ask yourself, why am I?

If there's was a cyst, and it ruptured, you may not see it after it's popped. If you do see a cyst, that can be completely normal, incidental and may not be causing their pain.

In EM, always think "rule out." Beware of "rule in." A little incidental cyst "ruled in," doesn't means it's causing the RLQ pain.

Sure, if you see a torsion, ovarian abscess, or cyst with clinically significant hemorrhage (very, very, uncommon) your ultrasound has been worthwhile. However, 2 of those three can also be seen on CT. In the non-pregnant female patient, how often is a pelvic ultrasound really helpful on an emergency basis?

Before you order your pelvic ultrasound, ask yourself what you are looking for and if you'll be satisfied it if it either shows it, or shows nothing. If they are not pregnant and you are not looking for torsion, should you just order a CT, or no imaging at all?

Or is this what's going through your head, "I really think this is nothing, but because I did some imaging study, any imaging study, I feel better now"?

Are you ordering a "patient satisfaction" ultrasound just because the patient wants one? In today's world, maybe it is valid to put in the chart, "patient insists upon ultrasound, study ordered." I don't know. We are so far away from being able to focus on what's medically right, and what's medically alone, it's a near impossible situation to be in often times.

 

[Birdstrike]

The "Big Picture," and why it is so difficult:

"My training and textbook says I shouldn't order the expensive test, but the patient and 'patient satisfaction' says I must. My CEO would say I shouldn't because that might increase my length of stay, but the CFO says, more expensive tests generate revenue, order it. My gut tells me it's really a waste and I shouldn't order the test, but a lawyer may sue me and tell a judge and jury I should have. Medically I know it's best to admit this patient, but it's been 29 days since discharge and the government says 're-admission within 30 days' is bad, so they're telling me to send a sick patient home to delay admission 24 hours to make some arbitrary numbers look good. Choosing Wisely says I shouldn't order it, but I saw a patient last week who didn't fit the decision rule and would have lost life or limb without the 'wasteful' test." And so on, and so on...

Any Medical School that's teaching only the, "My training and textbook says..." part of that paragraph, is negligent in preparing your for your career ahead as a physician.

Honestly, I wonder if science and biology should even be considered prerequisites or desirable as pre-med classes for medical school applicants. If I was on an admissions committee, I would look for and value people with undergrads degrees and careers in business, politics, marketing, "policy," public relations, service industries and good-old-fashion ass kissing. Having medical knowledge only seems like a necessary evil that just gets in the way of a physicians primary job of serving his many masters. That's how warped things have become.

We're torn to pieces in a tug of war, between numerous players who aren't doctors, and share no ultimate responsibility for our patients or their outcomes, yet feed off of the scraps from our and our patients' struggles.

 

[The White Coat Investor]

PO contrast? I thought this thread was about improving LOS. I think there are better references, but this will do on an early, early Saturday: http://www.ncbi.nlm.nih.gov/m/pubmed/22633722/

I still have the skinny kiddos drink contrast. I want no possible reason why they might need to be scanned again. I shotgun the whole work-up- blood, urine, US for appy, start drinking contrast. By the time they're done drinking, the rest of the work-up is back and I can either go through with the CT or cancel it. I'll bet I go through with it 50-75% of the time.

 

[Arcan57]

Not always possible, but for EDs that don't have pediatric surgery coverage it may make sense to transfer possible appy's earlier rather than later. We have two pediatric megalodon hospitals 15 minutes from us, so it makes no sense to me to drink and scan a kid when I can't deal with the outcome if it's positive and they may avoid radiation with the more experienced pediatric sonographers.

 

[Janders]

(1) I do transfer the young kids with highly suspicious appys to the pedi-mecca for U/S first.

In teenagers, I typically discuss it with them and mom/dad, and let them choose transfer versus CT at my hospital. They are pretty evenly split on what they choose.

(2) A few years ago, my shop insisted EVERY CT belly, unless looking for stone/vascular disaster, have an extended 3 hour oral prep. We changed it for a year, and had minimal oral preps (only in the truly thin, inflammatory bowel disease, s/p whipple...). It was great. Decreased median LOS in the ED by roughly 35 minutes... ALL COMERS... not just patients with CTs! That was a miraculous change. Then radiology and GI decided they didn't like it... no bad outcomes, but a few reads of "colon non-distended with oral contrast, ?thickening, needs endoscopy to r/o colitis." So we had to switch back to rapid oral preps (at least not 1 hour...).

Its an interesting battle. Certainly I loved the rapid/no oral prep days. I didn't feel we missed anything, and that the improved LOS was worth it. But some of the radiologist truly felt they were giving inadequate reads, despite the studies to the contrary. Tough to argue with another doctor who really feels you are forcing them to do a bad job.

 

[Arcan57]

(1) I do transfer the young kids with highly suspicious appys to the pedi-mecca for U/S first.

In teenagers, I typically discuss it with them and mom/dad, and let them choose transfer versus CT at my hospital. They are pretty evenly split on what they choose.

(2) A few years ago, my shop insisted EVERY CT belly, unless looking for stone/vascular disaster, have an extended 3 hour oral prep. We changed it for a year, and had minimal oral preps (only in the truly thin, inflammatory bowel disease, s/p whipple...). It was great. Decreased median LOS in the ED by roughly 35 minutes... ALL COMERS... not just patients with CTs! That was a miraculous change. Then radiology and GI decided they didn't like it... no bad outcomes, but a few reads of "colon non-distended with oral contrast, ?thickening, needs endoscopy to r/o colitis." So we had to switch back to rapid oral preps (at least not 1 hour...).

Its an interesting battle. Certainly I loved the rapid/no oral prep days. I didn't feel we missed anything, and that the improved LOS was worth it. But some of the radiologist truly felt they were giving inadequate reads, despite the studies to the contrary. Tough to argue with another doctor who really feels you are forcing them to do a bad job.

Our literature looks at being able to rule in/out a specific surgical diagnosis. The radiologist feels that they are responsible for finding every abnormality on the CT and to some extent every abnormality with the patient that was contained within the area imaged. Because we only care about the acute, we don't need it. I would like the radiologists to live in a world where they are just answering a focused clinical question, but in fairness we're usually giving them crappy information about the patient prior to their looking at the scan.

 

[Janders]

Our literature looks at being able to rule in/out a specific surgical diagnosis. The radiologist feels that they are responsible for finding every abnormality on the CT and to some extent every abnormality with the patient that was contained within the area imaged. Because we only care about the acute, we don't need it. I would like the radiologists to live in a world where they are just answering a focused clinical question, but in fairness we're usually giving them crappy information about the patient prior to their looking at the scan.

Yeah, it is compromise. Super-fast LOC with minimal/no oral prep, bedside rapid testing to ensure renal function good b/f IV contrast. Could have them in the scanner w/i 10 minutes of arrival. And for the great majority of patients, this would answer the ?appy, ?divert, ?SBO just fine. But speed and r/o surgical diagnosis isn't the ONLY thing we care about.

Of course, oral contrast is not just slow. Ever here of an elderly SBO aspirating on the floor? Think a stomach with a gallon of oral contrast is good for them? How fast you putting that NG tube down? etc. Lots of unintended consequences either way.​

 

[southerndoc]

Our radiologists are. I mean, it's in the ACR recs. They just claim they aren't trained to read uncontrasted images, and prefer PO. They also mention the studies are done with 64 slice or higher scanners, and not every place has them, specifically rural places. They'll do it without, but there's the radiologist byline that is almost as common as "clinically correlate."
"This exam is limited by the absence of oral contrast. If clinical suspicion for intraabdominal pathology is high, recommend repeating the study with oral contrast."

Our radiologists sometimes write something similar. Some of our docs hate it. My feeling is I would probably write something similar if I had to see and discharge a 55-year-old hypertensive, diabetic, dyslipidemic patient with chest pain without having access to an EKG.

 

[Dr.Evil1]

I haven't had the heart to read the entire thread but want to make two points:

You can't compare pts/hr from one institution to another. I consider myself decently fast, at one place I may struggle to keep 2.2 pts/hr, at another I can easily drink my coffee and see 3/hr. The emergency physician isn't the only variable that makes a difference in the pts/hr metric. The system, the acuity, the expectations from the admitting physicians, the nurses, the lab, the radiology dept all make a big difference in the flow and efficiency of your work. It also helps to really know your consulting physicians. You will have less fight back from the neurosurgeon when you know him/her on a first name basis which keeps you on the phone less and seeing patients more.

The OP (original poster) referenced a EP with 15 years of experience that was able to fly through patients. From the description it seems that the experienced/fast physician has a much greater risk tolerance than the OP. This is to be expected and untill the OP has been in practice seeing patients and developing his/her own personal database of experience they shouldn't just be relying on clinical accumen. After you have been recognizing the patterns of illness in a couple of thousand ER patients you start to be able to tell sick from not-sick quickly and need less testing. What is more is that you are more likely to make a mistake and do something to get sued in the first 5 years out of residency. OP you would do well to learn from the experienced doc but not emulate him/her until you are comfortable recognizing these patterns. Also check up on the patients that you thought were "questionable admits" and see if the admitting docs actually find anything/do anything for the pt.

 

[deleted109597]

But speed and r/o surgical diagnosis isn't the ONLY thing we care about.

Well, speed is what most places care about now.
But acute diagnosis (surgical or otherwise) is the only thing I care about. That adrenal hypodensity on the other side of the abdomen from the pain? Yeah, it might be important, but it isn't an emergency. I don't check cholesterol levels on patients either, and for the same reason.
Sure, sometimes I admit the incidental cancer patients I find, but for lack of outpatient workup. Not because they need to, and they certainly don't need their biopsy in the ED.
We find incidental findings on 2-6% of CTs. Enough for self fulfillment of those EPs with >30% CT rates. They're serious roughly 0.1% of the time. No enough to warrant this behavior.

Remember, it's the Emergency Department, not the Diagnosis Department. You don't have to tell people what they have, only if it is or isn't an emergency.

Our radiologists sometimes write something similar. Some of our docs hate it. My feeling is I would probably write something similar if I had to see and discharge a 55-year-old hypertensive, diabetic, dyslipidemic patient with chest pain without having access to an EKG.

I would argue it's more like seeing and discharging them without posterior and right sided leads. You get a good idea from the EKG, but if you could do 20 leads it would be better, regardless of what the literature shows.