Low utility tests you (usually) shouldn't order in the ER

[Angry Birds]

What are some tests you see people ordering in the ER which are usually unnecessary?

I think Utox is one. I once had a colleague of mine tell me that we should order a Utox on a patient when I signed the patient out to her with the words "This patient came in for chest pain and admits to cocaine use..." The patients admits to using cocaine... What's the utility of the Utox then?

I feel the Utox is rarely helpful. It's much better to just look at the Toxidrome of the patient and treat accordingly. I usually only order the Utox if another specialty requires it (i.e. Psych), but it has little relevance to my medical management. I'm sure there are a few exceptions to this, such as undifferentiated altered mental status (although I still think toxidrome and overall clinical picture is more important).

What other tests do you find to be needlessly ordered? (I'm creating this thread so we can discuss tests and maybe change our own practice... )

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[southerndoc]

Lumbar spine x-rays without history of trauma (I can see ordering it in elderly to rule out pathologic fracture or malignancy)

 

[Angry Birds]

Lumbar spine x-rays without history of trauma (I can see ordering it in elderly to rule out pathologic fracture or malignancy)

Speaking of, how about c-spine x-ray. I am of the view that if you think you need imaging on a c-spine, it should be a CT scan. Otherwise, no imaging needed. I think there was some sort of study on this...

And I would include t-spine x-rays without trauma.

 

[GeneralVeers]

- Rapid Strep test
- RSV in clinically well children
- Monospot
- Flu test in adults/children not being admitted
- Plain film abdominal x-rays in the adult
- CMP on every patient instead of BMP regardless of complaint
- Quant HCG on pregnant patients with demonstrated fetal heart tones
- Blood cultures pretty much all the time
- ABG on stable paitents with good vital signs being admitted

 

[Apollyon]

- Flu test in adults/children not being admitted
- Plain film abdominal x-rays in the adult

Is flu tracked in your state? It is in mine.

As for abdominal x-rays, what, CT? Like the woman I saw the shift before this, who has had 5 abd CTs in the last year at our hospital alone? If you're CTing all your abd pain, too much. If you're not imaging any, too little.

I order more abd x-rays, and fewer CTs, than anyone else, here. Quicker, useful, and 1/100 the radiation.

If you meant something else, let me know.

 

[Zebra Hunter]

- CK-MB (even if the patient had an MI a week ago)
- BNP
- ABG rather than VBG in majority of ER patients
- Abdominal X-rays (if you're concerned about obstruction, get the appropriate imaging)
- RSV for any child, including sick (bronchiolitis is bronchiolitis, regardless of whether it's RSV+)
- Utox
- Ammonia levels

 

[Apollyon]

Obstructive series is appropriate imaging.

 

[Zebra Hunter]

Obstructive series is appropriate imaging.

It's essentially worthless unless you are doing it for therapeutic radiation. It cannot rule out obstruction and if obstruction is present, most surgeons will still request CT. Skip the unnecessary step and go straight to CT.

 

[Apollyon]

It's essentially worthless unless you are doing it for therapeutic radiation. It cannot rule out obstruction and if obstruction is present, most surgeons will still request CT. Skip the unnecessary step and go straight to CT.

Maybe in the academics. More than once, for me, the surgeon has admitted with an x-ray only.

To blanket call it useless is, well, useless.

 

[Angry Birds]

Maybe in the academics. More than once, for me, the surgeon has admitted with an x-ray only.

To blanket call it useless is, well, useless.

Maybe. But you said you order more x-rays and less than CT's than anyone else in your group. I'd strongly reconsider this. Here is a good summary of when to use abdominal films (which is rarely, not frequently):

Emergency Radiology Question: Is the abdominal x-ray dead?
ED abdominal x-rays, in one observational study, lead to a change in management only 4% of the time. Nonetheless there still remains several indications for the use of abdominal x-rays in emergency radiology.

Indications for ED abdominal x-ray

1. Radio-opaque foreign body – metal, leaded glass or large objects such as packets found in drug mules

2. To look for free air in suspect perforated viscous in patient who is not stable enough to leave the ED for a CT

3. Known chronic diagnosis with multiple frequent recurrent acute exacerbations such as recurrent small bowel obstruction, especially in patients who have had multiple CT scans in the past (note that the sensitivity of x-rays for bowel obstruction is poor – approx 50-70%, but specificity is 98%)​

This may be your practice, in which case, cool beans.

- Rapid Strep test
- RSV in clinically well children
- Monospot
- Flu test in adults/children not being admitted
- Plain film abdominal x-rays in the adult
- CMP on every patient instead of BMP regardless of complaint
- Quant HCG on pregnant patients with demonstrated fetal heart tones
- Blood cultures pretty much all the time
- ABG on stable paitents with good vital signs being admitted

I agree with all of these, except that the nurses will jump and order most of these reflexively. After the patient has been swabbed for strep test, it's hard to tell them "we don't need to wait for the results" or that it was a useless test. (But, I agree with you!)

Exception: I do order blood cultures in septic patients.

 

[EctopicFetus]

Mag levels..

 

[Rendar5]

Obstructive series is appropriate imaging.

As long as you're not depending on a negative X-ray to rule out bowel obstruction. I'll occasionally order an XR on someone w/ recurrent SBO just to see if I can shortcut to admission, but if it's negative I'm usually stuck getting the CT because 50% of SBO's are missed on XR.

I agree mostly w/ Veers list though I still get blood cultures on a lot of my fevers because at my site our average age is 80+years old in our ED and bacteremia is a sneaky beast in that age group. I would also add that PT/PTT are useless the majority of the time it is ordered.

 

[Angry Birds]

Mag levels..

Can you explain? I don’t often get them but in an alcoholic with significant hypokalemia ? Or do you just give them a dose of mag then ? Not that it’s super important down in the ER.

 

[deleted547339]

- Rapid Strep test
- RSV in clinically well children
- Monospot
- Flu test in adults/children not being admitted
- Plain film abdominal x-rays in the adult
- CMP on every patient instead of BMP regardless of complaint
- Quant HCG on pregnant patients with demonstrated fetal heart tones
- Blood cultures pretty much all the time
- ABG on stable paitents with good vital signs being admitted

Gonna disagree on blood cultures and abgs. If the Er doesn’t get cultures, it screws the docs upstairs.

And you can’t identify complex acid/base disorders without an abg. This is relatively rare, but important not to miss. Also defines an P:F ratio. I realize this is heresy in EM circles, but I’ve definitely become a believer since CCM fellowship.

 

[GonnaBeADoc2222]

- Rapid Strep test
- RSV in clinically well children
- Monospot
- Flu test in adults/children not being admitted
- Plain film abdominal x-rays in the adult
- CMP on every patient instead of BMP regardless of complaint
- Quant HCG on pregnant patients with demonstrated fetal heart tones
- Blood cultures pretty much all the time
- ABG on stable paitents with good vital signs being admitted

Will also disagree with not ordering rapid strep. Cheap, non-invasive test that provides clinically useful information. I don't care how low the incidence of acute rheumatic fever is in 2018, I will treat group A+ strep throat every single time as it decreases the chance of ARF and suppurative complications. Also puts mom's/dad's mind at ease as this was probably the only reason they even came to be seen.

Group A Strep | Strep Throat | For Clinicians | GAS | CDC

I will throw TSH into the ring as a (mostly) useless test in the ED. Not only does it take FOREVER to come back, but it has never changed my management - except that one time where my patient presented with a core temp of 88 F and synthroid was on their med list,

 

[GonnaBeADoc2222]

Also disagree with Mg levels. Definitely important for your alcoholics, EKG interval abnormalities, also people with hypo-Mg and hypo-K - makes A-fib w RVR difficult to manage if you don't replete this stuff.

 

[link2swim06]

Sometimes its honestly just easier to do the test, than try to explain to the nurse, patient, his family, and their pediatrician why he didn't need a strep swab.

 

[deleted859535]

Also disagree with Mg levels. Definitely important for your alcoholics, EKG interval abnormalities, also people with hypo-Mg and hypo-K - makes A-fib w RVR difficult to manage if you don't replete this stuff.

Sometimes its honestly just easier to do the test, than try to explain to the nurse, patient, his family, and their pediatrician why he didn't need a strep swab.

Both of these.

Especially the latter. I'm interested in fighting and hopelessly explaining things as little as possible.

 

[EctopicFetus]

Can you explain? I don’t often get them but in an alcoholic with significant hypokalemia ? Or do you just give them a dose of mag then ? Not that it’s super important down in the ER.

Yes. i just treat. If you K is 2.5 I will be giving you mag with your K. NO need to know what it is.

It is cheaper to give the Mg than it is to check the level.

 

[EctopicFetus]

Also disagree with Mg levels. Definitely important for your alcoholics, EKG interval abnormalities, also people with hypo-Mg and hypo-K - makes A-fib w RVR difficult to manage if you don't replete this stuff.

I only said checking the level. Not giving Mg. Its not an ED appropriate test.

 

[Brigade4Radiant]

Flu swabs on young patients that you are going to discharge anyway you would be better of just ordering an xray.

 

[Brigade4Radiant]

Can you explain? I don’t often get them but in an alcoholic with significant hypokalemia ? Or do you just give them a dose of mag then ? Not that it’s super important down in the ER.

If your hypokalemic then you are low on magnesium. Mag levels don't even really tell you about the body's Mg levels.

 

[WilcoWorld]

Maybe in the academics. More than once, for me, the surgeon has admitted with an x-ray only.

To blanket call it useless is, well, useless.

Yeah, the above tests are usually useless in the ED, but almost all of these admit of exceptions. Maybe it's to make the patient more comfortable with their workup. Maybe it's to make the inpatient team more comfortable accepting the patient. Maybe I'm ordering the flu test because the patient's a nurse at a Chemo infusion clinic. Maybe this patient with lumbar pain and no trauma or neuro symptoms has had 3 weeks of pain and has a history of prostate cancer and I want to see if there's a big ol' mass before I tell him to take naproxen and find a PCP.

Funny that the thread title covers this with its parenthetical "usually", but then we start arguing with each other as if there's absolute dogma at stake.

 

[southerndoc]

Will also disagree with not ordering rapid strep. Cheap, non-invasive test that provides clinically useful information. I don't care how low the incidence of acute rheumatic fever is in 2018, I will treat group A+ strep throat every single time as it decreases the chance of ARF and suppurative complications. Also puts mom's/dad's mind at ease as this was probably the only reason they even came to be seen.

Group A Strep | Strep Throat | For Clinicians | GAS | CDC

I will throw TSH into the ring as a (mostly) useless test in the ED. Not only does it take FOREVER to come back, but it has never changed my management - except that one time where my patient presented with a core temp of 88 F and synthroid was on their med list,

Isn't antibiotics without a positive Strep screen one of the MIPS data that CMS follows and ties to your pay? In other words, any pharyngitis that gets antibiotics must have a positive Strep screen if I remember correctly.

 

[KinesiologyNerd]

it has never changed my management - except that one time where my patient presented with a core temp of 88 F and synthroid was on their med list,

This strikes me as a time to not trust TSH.

Maybe this patient with lumbar pain and no trauma or neuro symptoms has had 3 weeks of pain and has a history of prostate cancer and I want to see if there's a big ol' mass before I tell him to take naproxen and find a PCP.

A well placed small met can be as painful as one big enough to show up on lumbar XR.

 

[Apollyon]

I was right in the middle of being ground down on shift. I order the obs series because I can get it quickly, and it's a low risk intervention. If the pt is not really sick, sometimes it's enough. If the obs series is nondiagnostic, then, I'll CT. My point was, to go directly to CT is not the most prudent.

 

[deleted859535]

This strikes me as a time to not trust TSH.


A well placed small met can be as painful as one big enough to show up on lumbar XR.

Can't CT or MR everyone. Strikes me as a due diligence thing. Middle-aged folks with back pain get an XR for me. Would rather at least look for badness understanding the potential remains and tell them there may be more to do than to not look at all. But as usual, more than one way about things.

 

[RustedFox]

None of this matters if it's not "what the patient wants" (with regards to xrays, flu swabs, etc).

It's easier to order the useless test than it is to explain to an idiot why it's not useful... and to field the inevitable complaint.

 

[bravotwozero]

I find UDS to be useful when something doesn't seem right and my BS detector is going off. I once had a woman in her 60s complaining of altered loc/syncope (now returned to baseline), denied drug or ETOH, and UDS was positive for cocaine use...I also had a 18 month old with a UDS positive for cocaine - it was the day after halloween and turns out there was a major drug bust in the area and they found boatloads of candy laced with drugs.

CMP can be useful in the context of obstructive gallbladder disease. Sometimes these patients have a ultrasound that will show cholelithiasis without cholecystitis, but LFTs will be elevated, which raises suspicion for choledocholithiasis.

ESR and CRP, URIC ACID - mostly useless. I'll get ESR if I'm suspecting temporal arteritis and because ophtho/surgery wants me to get it.

 

[WilcoWorld]

This strikes me as a time to not trust TSH.


A well placed small met can be as painful as one big enough to show up on lumbar XR.

You appear to have missed the point of my post, oh well.

 

[VA Hopeful Dr]

None of this matters if it's not "what the patient wants" (with regards to xrays, flu swabs, etc).

It's easier to order the useless test than it is to explain to an idiot why it's not useful... and to field the inevitable complaint.

I feel like this should be tattooed on everyone's chest at residency graduation.

 

[Siggy]

Will also disagree with not ordering rapid strep. Cheap, non-invasive test that provides clinically useful information. I don't care how low the incidence of acute rheumatic fever is in 2018, I will treat group A+ strep throat every single time as it decreases the chance of ARF and suppurative complications. Also puts mom's/dad's mind at ease as this was probably the only reason they even came to be seen.

Group A Strep | Strep Throat | For Clinicians | GAS | CDC

Except that that a rapid strep test doesn't have a high enough sensitivity to emperically rule out Group A Strep and doesn't test for non-group A strep or fusobacterium. Both of which can make up a non-insignificant portion of rapid strep negative patients.
Presentation of Bacterial Pharyngitis in a University Health Clinic | Annals of Internal Medicine | American College of Physicians

 

[VA Hopeful Dr]

Except that that a rapid strep test doesn't have a high enough sensitivity to emperically rule out Group A Strep and doesn't test for non-group A strep or fusobacterium. Both of which can make up a non-insignificant portion of rapid strep negative patients.
Presentation of Bacterial Pharyngitis in a University Health Clinic | Annals of Internal Medicine | American College of Physicians

But those don't cause the same problems untreated strep can, do they?

 

[Siggy]

But those don't cause the same problems untreated strep can, do they?

Fusobacterium causes Lemierre's which can have some horrifying consequences.

 

[engineeredout]

PT/PTT - unless someone is on Coumadin and you want to check their levels, otherwise almost always useless. Despite what your nurses and/or pharmacy might believe, you do NOT need coags prior to starting heparin gtt, the dosing is not based on the baseline PTT (something like argatroban is, but really how often are you ordering that?) I see some people getting coags with every chest pain patient and it is just pissing money away.

Dig level - people don't need dig levels just because they happen to take digoxin.

BNP - useless. Unreliable in the old, obese, chronic CHFers (sound like most of your patients?) I don't use BNP at all for management. If I think they're in CHF, I treat accordingly.

ABG - no reason to obtain over a VBG unless you can't get a pulse ox.

UTOX - I agree it's pretty unhelpful. I have to say that I end up ordering quite a few of them because our local psych facilities won't accept a patient without one

 

[VA Hopeful Dr]

Fusobacterium causes Lemierre's which can have some horrifying consequences.

Incidence?

Edit: and when doing UC work I often will throat culture (not just strep culture) weird throats but I'm not sure its ever paid off.

 

[gutonc]

- CMP on every patient instead of BMP regardless of complaint

FWIW, many POC machines (which your ED may or may not use) only run a CMP. If you order a BMP, they still do the CMP, they just don't report out the extra stuff. Our POC lab bills $2 more for a CMP than a BMP. Once I discovered this, I quit trying to conserve resources.

 

[Rendar5]

Incidence?

Edit: and when doing UC work I often will throat culture (not just strep culture) weird throats but I'm not sure its ever paid off.

Probably on the same order of magnitude as complications of untreated strep (most complications of strep occur regardless of treatment)

My main ED doesn’t actually have the ability to do rapid streps interestingly enough so I just treat clinically based on Centor criteria and send a throat culture if it’s an unclear case.

 

[WilcoWorld]

Rib films.
What we really care about is the lungs and mediastinum. Just get the CXR.

 

[Psai]

- Rapid Strep test
- RSV in clinically well children
- Monospot
- Flu test in adults/children not being admitted
- Plain film abdominal x-rays in the adult
- CMP on every patient instead of BMP regardless of complaint
- Quant HCG on pregnant patients with demonstrated fetal heart tones
- Blood cultures pretty much all the time
- ABG on stable paitents with good vital signs being admitted

If you're giving antibiotics, you should always get a blood culture first. It drove me nuts to get patients on vanc/zosyn from the ED with no source.

 

[deleted547339]

PT/PTT - unless someone is on Coumadin and you want to check their levels, otherwise almost always useless. Despite what your nurses and/or pharmacy might believe, you do NOT need coags prior to starting heparin gtt, the dosing is not based on the baseline PTT (something like argatroban is, but really how often are you ordering that?) I see some people getting coags with every chest pain patient and it is just pissing money away.

Dig level - people don't need dig levels just because they happen to take digoxin.

BNP - useless. Unreliable in the old, obese, chronic CHFers (sound like most of your patients?) I don't use BNP at all for management. If I think they're in CHF, I treat accordingly.

ABG - no reason to obtain over a VBG unless you can't get a pulse ox.

UTOX - I agree it's pretty unhelpful. I have to say that I end up ordering quite a few of them because our local psych facilities won't accept a patient without one

I’m all for trying to conserve resources, but not getting a PTT before you start a heparin drip!?!? That’s nuts.

And, as above, there’s a ton of utility of abgs in the critically ill.

 

[Raryn]

- Rapid Strep test

Huh?

So are you giving antibiotics to everyone with an equivocal exam or no one?

- RSV in clinically well children
- Monospot

No clue here on the utility.

- Flu test in adults/children not being admitted

If symptoms are present <2 days in a patient with a viral illness, are you then giving all of them or none of them Tamiflu? If you actually have flu PCR (as opposed to the generally crappy antigen assays), it makes a meaningful difference in clinical management. Unless you don't believe in Tamiflu at all, which is an argument that's not totally unreasonable (if not in line with general medical practice).

- Plain film abdominal x-rays in the adult
- CMP on every patient instead of BMP regardless of complaint
- Quant HCG on pregnant patients with demonstrated fetal heart tones

*shrug*. Generally true.

- Blood cultures pretty much all the time
- ABG on stable paitents with good vital signs being admitted

The blood culture thing I absolutely have to disagree with. >90% of patients admitted with infections get their first set of antibiotics in the ED. The blood cultures should be drawn before those antibiotics are given. When they result 1-2 days from now, they often make a meaningful difference to inpatient management. So of course they won't change your management in the ED (given they'll almost never result before the patient is upstairs), but if you don't get them, you're screwing your admitting physician.

ABGs on patients not going to the unit I'll agree are overutilized.

I will throw TSH into the ring as a (mostly) useless test in the ED. Not only does it take FOREVER to come back, but it has never changed my management - except that one time where my patient presented with a core temp of 88 F and synthroid was on their med list,

Stop ordering the TSH and I'll get a fair bit fewer phone calls which I'll be grateful for... but a good number of those calls are legit. It all depends on the settingOrdering for every single altered patient? Probably useless, generally leads to discovering some mild abnormalities irrelevant to the clinical situation at best. Getting it for the patient with new onset atrial fib? Generally useful, because thyrotoxicosis can be a big deal.

Regardless, if you want to stop ordering it and just let the admitting service deal with it, that's fine. I'd just say I would still order it on the 30 year old with palpitations you're sending home.

The UTox thing in residency was a huge sticking point between our ED (who never ordered it) and our cardiologists (who always talked smack on the ED for not ordering it). Outside of obvious situations like when the patient told you they're on drugs, the presence of cocaine/meth can make a difference in management for the cardiac stuff.

The other huge sticking point I recall in residency was probably ordering troponins on what seemed like every single patient even with a clear alternate diagnosis and nothing indicative of MI. So LOL in septic shock with a clear pneumonia and an EKG notable only for sinus tach without any chest pain would inevitably get one drawn and have it be slightly off (due to the septic shock) with cardiology immediately called. Drove them nuts.

 

[PlutoBoy]

Huh?

So are you giving antibiotics to everyone with an equivocal exam or no one?

No clue here on the utility.


If symptoms are present <2 days in a patient with a viral illness, are you then giving all of them or none of them Tamiflu? If you actually have flu PCR (as opposed to the generally crappy antigen assays), it makes a meaningful difference in clinical management. Unless you don't believe in Tamiflu at all, which is an argument that's not totally unreasonable (if not in line with general medical practice).


*shrug*. Generally true.



The blood culture thing I absolutely have to disagree with. >90% of patients admitted with infections get their first set of antibiotics in the ED. The blood cultures should be drawn before those antibiotics are given. When they result 1-2 days from now, they often make a meaningful difference to inpatient management. So of course they won't change your management in the ED (given they'll almost never result before the patient is upstairs), but if you don't get them, you're screwing your admitting physician.

ABGs on patients not going to the unit I'll agree are overutilized.


Stop ordering the TSH and I'll get a fair bit fewer phone calls which I'll be grateful for... but a good number of those calls are legit. It all depends on the settingOrdering for every single altered patient? Probably useless, generally leads to discovering some mild abnormalities irrelevant to the clinical situation at best. Getting it for the patient with new onset atrial fib? Generally useful, because thyrotoxicosis can be a big deal.

Regardless, if you want to stop ordering it and just let the admitting service deal with it, that's fine. I'd just say I would still order it on the 30 year old with palpitations you're sending home.

The UTox thing in residency was a huge sticking point between our ED (who never ordered it) and our cardiologists (who always talked smack on the ED for not ordering it). Outside of obvious situations like when the patient told you they're on drugs, the presence of cocaine/meth can make a difference in management for the cardiac stuff.

The other huge sticking point I recall in residency was probably ordering troponins on what seemed like every single patient even with a clear alternate diagnosis and nothing indicative of MI. So LOL in septic shock with a clear pneumonia and an EKG notable only for sinus tach without any chest pain would inevitably get one drawn and have it be slightly off (due to the septic shock) with cardiology immediately called. Drove them nuts.

I agree with most of what you said but I'll add that if I think a patient may have the flu and is a candidate for therapy I'm treating them regardless of the result of the POC test. I still test them because it is nice to have a definitive test but I don't base my decision to treat on the result of the test.

My point is that it isn't an all or none scenario. Treating empirically is absolutely within the standard of care. I'd assume that this is @GeneralVeers practice.

In regards to your other point, waiting for a PCR result will often delay care.

 

[PlutoBoy]

Fusobacterium causes Lemierre's which can have some horrifying consequences.

A point often overlooked. I have seen a case. It wasn't pretty.

 

[engineeredout]

I’m all for trying to conserve resources, but not getting a PTT before you start a heparin drip!?!? That’s nuts.

Why?

 

[coachB]

If you're giving antibiotics, you should always get a blood culture first. It drove me nuts to get patients on vanc/zosyn from the ED with no source.

In a critically ill patient, sure. All patients getting antibiotics? Absurd. Even in the sick patients where they are appropriate to draw, blood cultures very rarely change management. There is plenty of data to support this. The IDSA specifically recommends against blood cultures in things like CAP, cellulitis, and uncomplicated pyelo. Of course, with all of the new concern about the CMS sepsis measure, any patient who hits the door with a single SIRS criteria, much less two, gets everything ordered via nursing protocol, leading to a cascade of unintended harms.

 

[coachB]

Why?

Exactly. No reason to check the PTT prior to starting heparin.

 

[Psai]

In a critically ill patient, sure. All patients getting antibiotics? Absurd. Even in the sick patients where they are appropriate to draw, blood cultures very rarely change management. There is plenty of data to support this. The IDSA specifically recommends against blood cultures in things like CAP, cellulitis, and uncomplicated pyelo. Of course, with all of the new concern about the CMS sepsis measure, any patient who hits the door with a single SIRS criteria, much less two, gets everything ordered via nursing protocol, leading to a cascade of unintended harms.

If you have cap, cellulitis, uncomplicated pyelo you have a source by definition. But there are plenty of times when the ED just starts antibiotics which really screws the admitting doc in fuo.

I’m all for trying to conserve resources, but not getting a PTT before you start a heparin drip!?!? That’s nuts.

And, as above, there’s a ton of utility of abgs in the critically ill.

Why do you need a ptt before starting a heparin drip? It's dosed by weight.

 

[LaBusqueda]

Wonder how the new standard of having a provider in triage is increasing the ordering of low yield tests?


Sent from my iPhone using Tapatalk

 

[Siggy]

If you have cap, cellulitis, uncomplicated pyelo you have a source by definition. But there are plenty of times when the ED just starts antibiotics which really screws the admitting doc in fuo.

1. That doesn't change the fact that, at least for CAP, ISDA doesn't recommend blood cultures in most cases.

2. If the fever just started, by definition, it can't be fever of unknown origin. There might not be a source yet, but unless you're looking at multiple intermittent fevers, a 3 week outpatient duration of fevers, or a 1 week of inpatient fevers, it isn't FUO.