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

[Raryn]

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.

Fever of an unclear etiology*

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[Redrox]

Haven't seen it mentioned yet but stool cultures, couple of my colleagues routinely ask patients to poop in a bucket for them but I haven't been.

 

[SpacemanSpifff]

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.

I'd be interested in seeing the specific data you reference above. I can believe that blood cultures never change management in the ED in anyone, but have a harder time seeing that play out in the inpatient realm when a source has not been identified.

If you're giving antibiotics without an obvious source, you should always try to get two blood cultures first. It drove me nuts to get patients on vanc/zosyn from the ED with no source.

Bolded mine. That's how I feel. I would hope that in cases where cultures were not drawn before, or in close proximity to, antibiotics the EP had good reason, logistical or otherwise. This will not always be the case. I think we can all agree that in the crashing patient, time to antibiotics is one of the most important metrics to meet, both for the patient and for billing purposes. In academic centers, the flow should be able to support getting cultures in a timely manner (except maybe CSF in some cases). In a community or more resource limited setting, maybe not so much.

 

[GeneralVeers]

Blood cultures - I agree they are clinically useful only in the setting of unclear etiology. I see a lot of blood cultures drawn on clinically well patients who are being discharged home, or on patients with obvious treatable sources with a likely pathogen.

Strep pharyngitis - NNT to prevent rheumatic fever is on the order of 1:2,000,000. I don't give antibiotics to any uncomplicated pharyngitis in patients > 6yo, therefore no need to test for strep. We are harming about 10% of patients either through allergic reaction, or diarrhea by treating uncomplicated pharyngitis with antibiotics. The data is there, it's just that widespread medical practice has not caught up yet.

 

[KinesiologyNerd]

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

It’s hit or miss for me. They’ll often leave imaging decisions to us in the back, but order unnecessary blood tests like cultures and dimers.

 

[bearstanley]

Haven't seen it mentioned yet but stool cultures, couple of my colleagues routinely ask patients to poop in a bucket for them but I haven't been.

this is a therapeutic intervention for patients complaining of diarrhea. somehow they stop pooping when i order it.

 

[Hercules]

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


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Thankfully, I wouldn’t call PIT the standard yet. But, yes it would drastically increase unnecessary testing. Efficiency in ordering tests is not the goal if you’re using PIT. The goal is to see and dispo some in waiting room while having all possible needed tests back by the time the patient is seen by the doc so they can be dispositioned.


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[LaBusqueda]

Thankfully, I wouldn’t call PIT the standard yet. But, yes it would drastically increase unnecessary testing. Efficiency in ordering tests is not the goal if you’re using PIT. The goal is to see and dispo some in waiting room while having all possible needed tests back by the time the patient is seen by the doc so they can be dispositioned.


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IDK...seems like the standard in the West for sure.
Haven’t seen any data on it.

Ours certainly has incr the ordering of tests/imagine. Where I have been previously that also had a PIT process-same.



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[engineeredout]

Thankfully, I wouldn’t call PIT the standard yet. But, yes it would drastically increase unnecessary testing. Efficiency in ordering tests is not the goal if you’re using PIT. The goal is to see and dispo some in waiting room while having all possible needed tests back by the time the patient is seen by the doc so they can be dispositioned.


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I thought the purpose of the doc in triage was to game the "Door to Doc" metric, and convert people from "Left Without Being Seen" to "Left Without Treatment Complete"

 

[GonnaBeADoc2222]

In my experience, PIT is useless in terms of improving patient care, and is all a scheme to massage the metrics.

My favorite PIT experience was when the midlevel in triage ordered both a CT PE study and a d dimer.

 

[Redrox]

this is a therapeutic intervention for patients complaining of diarrhea. somehow they stop pooping when i order it.

^^ hahaha

Don't know how many times I've thought maybe it's Cdiff but 5 hours later => still no poop, gets a sigh and a shrug and a discharge.

 

[dchristismi]

I find that 90% of the patients I order stool cultures will have no further diarrhea from the time of the click. To the point that I joke about just ordering them and now they're fixed!

Cholesterol is something that everyone always asks about. But no one ever has a cholesterol emergency, so I have never ordered it. (Maybe this one is obvious?)

Same goes for B-12 levels... I've always said that it was a lab we never ordered in the ED. And, exactly once, a few months ago, I saw a young woman with stocking-glove paresthesias who happened to have a weird macrocytic anemia. And after I chatted with the hospitalist, we ordered one (the level came back the next day, I think, but I followed up on this one) and sure enough, she actually had it. It was so classic I actually ordered a B-12 shot. Now, she followed up as an outpatient, but I never thought I'd actually order that test.

 

[Hamhock]

Cholesterol is something that everyone always asks about. But no one ever has a cholesterol emergency, so

Just don't forget it with pancreatitis...especially in obese, diabetics with alcoholism.

It can change ED management, as sometimes transfer for plasmapheresis is required; if your ICU doc isn't comfortable with insulin drips for hypertriglyceridemia pancreatitis.

HH

 

[WilcoWorld]

Just don't forget it with pancreatitis...especially in obese, diabetics with alcoholism.

It can change ED management, as sometimes transfer for plasmapheresis is required; if your ICU doc isn't comfortable with insulin drips for hypertriglyceridemia pancreatitis.

HH

Good thing you're never sarcastic.

 

[WilcoWorld]

Add the Brain Trauma Indicator to the list.

 

[Angry Birds]

Just don't forget it with pancreatitis...especially in obese, diabetics with alcoholism.

It can change ED management, as sometimes transfer for plasmapheresis is required; if your ICU doc isn't comfortable with insulin drips for hypertriglyceridemia pancreatitis.

HH

Wtf

 

[GTP]

In my experience, PIT is useless in terms of improving patient care, and is all a scheme to massage the metrics.

My favorite PIT experience was when the midlevel in triage ordered both a CT PE study and a d dimer.

 

[deleted547339]

Wtf

It’s a thing.

 

[Raryn]

Wtf

A triglyceride level is certainly indicated in all admitted patients with acute pancreatitis. Doesn't really need to be done by the ED though - the admitting team can order it.

I've seen a number of cases of pancreatitis initially attributed to alcohol alone where it turned out the guy also had trigs of well over 1000, and it's important to treat those too. (and as he said, the treatment if they're that high is typically high dose insulin vs plasmapheresis, depending on the culture of your institution and whether the patient has concurrent hyperglycemia)

 

[TooMuchResearch]

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


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That's not our standard.

 

[TooMuchResearch]

^^ hahaha

Don't know how many times I've thought maybe it's Cdiff but 5 hours later => still no poop, gets a sigh and a shrug and a discharge.

You wait 5 hours for patients to not poop before discharging them?

 

[turkeyjerky]

You wait 5 hours for patients to not poop before discharging them?

Lol! I definitely have had that experience in residency with crazy attendings though.

I agree that ordering any type of stool study is great therapy for diarrhea. Typically I'll order them along with blood work and IVF, and once the other stuff is done discharge the patient.

 

[cbrons]

try not to order troponins unless necessary.. really drives me nuts when pts are then on the wards and the teams all want to "trend" someone with chronic nonischemic myocardial damage

 

[filhodeinferno]

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.

Had a similar experience with a baby that was just as fussy as hell. Did the whole agitated baby workup, and absolutely nothing. Baby was screaming bloody murder, something just wasn't right. Decided to run a Utox because the mom looked kinda meth-y. Sure enough, baby positive for meth. When confronted with the info, mom then admitted that she was aware that the baby had eaten some of her stash. Occasionally the old Utox will shed some helpful light.

 

[Angry Birds]

try not to order troponins unless necessary.. really drives me nuts when pts are then on the wards and the teams all want to "trend" someone with chronic nonischemic myocardial damage

Are you EM?
This thread is not for non-EM folks if not.

As for me, I have a low threshold for troponins. I’ve had cases where the troponin was the only thing that tipped us off that it was cardiac related. Troponin doesn’t delay my dispo so yeah I have a low threshold to order it. I think from a medico-legal perspective it’s pretty good.

As for trending on the floor, ain’t my problem. They don’t need to do that if they don’t want to.

 

[Angry Birds]

this is a therapeutic intervention for patients complaining of diarrhea. somehow they stop pooping when i order it.

bawhahahaa so true

 

[slurpy15]

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

Disagree for two reasons- it's easier to avoid abx with a definitive dx, and a positive flu allows me to encourage family members more effectively to get vaccinated,

 

[TooMuchResearch]

Disagree for two reasons- it's easier to avoid abx with a definitive dx, and a positive flu allows me to encourage family members more effectively to get vaccinated,

You have a viral illness, antibiotics won't help and will give you diarrhea or an allergic reaction.

 

[Zebra Hunter]

Disagree for two reasons- it's easier to avoid abx with a definitive dx, and a positive flu allows me to encourage family members more effectively to get vaccinated,

I find it very easy to avoid antibiotics when unwarranted. I just say “No”.

 

[Brigade4Radiant]

try not to order troponins unless necessary.. really drives me nuts when pts are then on the wards and the teams all want to "trend" someone with chronic nonischemic myocardial damage

Uh troponins are pretty much the only usefull blood work that we order in the ED. Most ED lawsuits are for missed MI.

 

[Brigade4Radiant]

Disagree for two reasons- it's easier to avoid abx with a definitive dx, and a positive flu allows me to encourage family members more effectively to get vaccinated,

I tell them antibiotics have risks. With all the data about the importance of the microbiome just giving people antibiotics willy nilly does a lot more harm.

 

[deleted859535]

Uh troponins are pretty much the only usefull blood work that we order in the ED. Most ED lawsuits are for missed MI.

For sure. I'm hyper aggressive about troponins in people that even slightly smell like they have a reason to have a relevantly abnormal test. If it's abnormal and I can explain it with something benign (e.g., the ESRD patient with a similar TnT of 0.06 a billion times in the past with chronic chest pain and a nonischemic stress test last week), fine. If it's newly 0.3? Not fine.

With hsTnT coming of age, I'm going to have a new assay to consider.

 

[TooMuchResearch]

Uh troponins are pretty much the only usefull blood work that we order in the ED. Most ED lawsuits are for missed MI.

Just last night I ordered a low probability troponin on a patient I had already prepped for discharge, then it came back at 2, then my disposition changed.

Old + short of breath + wheezy + seemed like a COPD exacerbation = NSTEMI.

 

[Apollyon]

On a tangent, I still just don't get how IM people can't "get it" that not everyone with an MI will be showing you Levine's sign. Old women that are nauseated can really be having a true cardiac issue.

 

[Angry Birds]

Just last night I ordered a low probability troponin on a patient I had already prepped for discharge, then it came back at 2, then my disposition changed.

Old + short of breath + wheezy + seemed like a COPD exacerbation = NSTEMI.

This.

 

[Rendar5]

NSTEMI or PE...!

I personally think troops are over-ordered but sometimes my clinical gestalt will send out alar,s to get a trop though for old and vague sx

 

[TooMuchResearch]

NSTEMI or PE...!

I personally think troops are over-ordered but sometimes my clinical gestalt will send out alar,s to get a trop though for old and vague sx

Vital signs were fine, and I put the patient on heparin. Hospitalist can dig deeper upstairs if they want.

 

[shoal007]

Trops can also help risk stratisfy. If you find out your 80 yo F with sob has the flu or pna but their trop is 0.4... even if there bun, cr, oxygen sat and wob are good enough to DC, they're still being admitted.

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[RoyBasch]

I agree, troponin is a high yield test. Although it is not specific for ACS per se; if a troponin is elevated, something important is going on. Now it could be there is an (obvious) and chronic explanation, i.e. patient is ESRD on dialysis and always has an elevated trop secondary to poor clearance. However, I would argue in that patient, the elevated trop is still correctly signifying a very significant aberration of the patient's physiology that in this case requires significant extracorporeal support to mitigate. A newly elevated troponin is almost always an admit disposition in my mind.

 

[Alvarez13]

I agree, troponin is a high yield test. Although it is not specific for ACS per se; if a troponin is elevated, something important is going on. Now it could be there is an (obvious) and chronic explanation, i.e. patient is ESRD on dialysis and always has an elevated trop secondary to poor clearance. However, I would argue in that patient, the elevated trop is still correctly signifying a very significant aberration of the patient's physiology that in this case requires significant extracorporeal support to mitigate. A newly elevated troponin is almost always an admit disposition in my mind.

Just wait until we get the next generation troponins. ADMIT EVERYBODY!

 

[seebelcherrun]

I agree, troponin is a high yield test. Although it is not specific for ACS per se; if a troponin is elevated, something important is going on. Now it could be there is an (obvious) and chronic explanation, i.e. patient is ESRD on dialysis and always has an elevated trop secondary to poor clearance. However, I would argue in that patient, the elevated trop is still correctly signifying a very significant aberration of the patient's physiology that in this case requires significant extracorporeal support to mitigate. A newly elevated troponin is almost always an admit disposition in my mind.

Poor clearance as an explanation for elevated trops in CKD and ESRD isn't as clear cut as you might think.

Really surprised when i was digging into the evidence for this article.

http://www.emdocs.net/positive-troponin-ckd-esrd-clinical-relevance-pearls-pitfalls/

 

[Siggy]

Poor clearance as an explanation for elevated trops in CKD and ESRD isn't as clear cut as you might think.

Really surprised when i was digging into the evidence for this article.

http://www.emdocs.net/positive-troponin-ckd-esrd-clinical-relevance-pearls-pitfalls/

I really like the Circulation article because it covers how we got to this point of "Troponin = MI" despite a lot of different issues that can cause an elevated troponin.

How to Interpret Elevated Cardiac Troponin Levels

That said, every troponin of 20 had to go through 0.5 at some point. I agree that it's dangerous to grab 1 troponin and immediately attribute it too the ESRD/CHF/aortic stenosis. Now if the second troponin is the same as the first, then that's a different situation entirely.

 

[Angry Birds]

Just wait until we get the next generation troponins. ADMIT EVERYBODY!

I dunno. I discharge 90 percent of patients. You just see the 10 percent I admit.

 

[deleted859535]

I dunno. I discharge 90 percent of patients. You just see the 10 percent I admit.

Seriously. If I wouldn't have discharged my mother without X/Y/Z including if it means admission for things that get done upstairs, I'm not discharging this gentleman in room 24. That's still a minority, but God forbid anyone remember that that's still a minority.

 

[GeneralVeers]

Once again I gotta ask about the RSV/Strep/Flu testing on febrile infants.

I worked with another NP last night, who just can't discharge a febrile (but well) infant without any testing. What the heck is the point of all of these swabs other than to delay door-to-discharge time by 1-2 hours?

 

[VA Hopeful Dr]

Once again I gotta ask about the RSV/Strep/Flu testing on febrile infants.

I worked with another NP last night, who just can't discharge a febrile (but well) infant without any testing. What the heck is the point of all of these swabs other than to delay door-to-discharge time by 1-2 hours?

Parents getting mad if you don't?

 

[Angry Birds]

Parents getting mad if you don't?

I don't think parents expect swabs... unless they are being offered to every Tom, Dick, and Harry. If we stop offering these stupid tests, people will stop expecting them as much.

I've never had a major issue with just saying to the patient's parents, "Clinically, your child has the flu. If not the flu, then some other virus that we treat the same way. So, let's treat it by...." and then proceed with your treatment plan. Ninety percent of the time the parents are happy after this.

If they buck and complain and ask about the swabs, just say, "Here's the thing. The X swab isn't that useful. You can get false negatives, and remember, we're treating your child anyways, because we know it's the flu or some other similar virus. Getting the swab won't change our plan, and it will just keep you waiting here in the ER for another couple hours... And we'll be in the same spot once those results come back. Because remember, we're gonna treat your child no matter what. So, I recommend that we start the treatment right away. Do you have any questions for me?"

 

[VA Hopeful Dr]

I don't think parents expect swabs... unless they are being offered to every Tom, Dick, and Harry. If we stop offering these stupid tests, people will stop expecting them as much.

I've never had a major issue with just saying to the patient's parents, "Clinically, your child has the flu. If not the flu, then some other virus that we treat the same way. So, let's treat it by...." and then proceed with your treatment plan. Ninety percent of the time the parents are happy after this.

If they buck and complain and ask about the swabs, just say, "Here's the thing. The X swab isn't that useful. You can get false negatives, and remember, we're treating your child anyways, because we know it's the flu or some other similar virus. Getting the swab won't change our plan, and it will just keep you waiting here in the ER for another couple hours... And we'll be in the same spot once those results come back. Because remember, we're gonna treat your child no matter what. So, I recommend that we start the treatment right away. Do you have any questions for me?"

And there's the problem, at least in my experience. And it is very regional dependent. In my last job (PP) I didn't even have flu swabs because they are expensive and rarely surprise me with the results. Never got any push back on that (same with unneeded antibiotics). Moved 90 miles up the road, now everyone gets mad if they don't get either a test or a antibiotic/Tamiflu/medrol shot.

Seriously, in 2 years of PP I was an antibiotic/test nazi and lost like 5 patients in that time. 3 months here with literally the exact same practice pattern/bedside manner and getting swamped in complaints. And doing a chart review its likely because I was solo before and built the practice myself while here I took over for a zpack candyman and my current partner is the medrol shot candyman.

 

[Angry Birds]

And there's the problem, at least in my experience. And it is very regional dependent. In my last job (PP) I didn't even have flu swabs because they are expensive and rarely surprise me with the results. Never got any push back on that (same with unneeded antibiotics). Moved 90 miles up the road, now everyone gets mad if they don't get either a test or a antibiotic/Tamiflu/medrol shot.

Seriously, in 2 years of PP I was an antibiotic/test nazi and lost like 5 patients in that time. 3 months here with literally the exact same practice pattern/bedside manner and getting swamped in complaints. And doing a chart review its likely because I was solo before and built the practice myself while here I took over for a zpack candyman and my current partner is the medrol shot candyman.

I’d rather just give them the tamiflu or z pack instead of wait for a chest X-ray or flu swab. Throughput is king and it trumps good medicine. I’m a discharge machine.

 

[VA Hopeful Dr]

I’d rather just give them the tamiflu or z pack instead of wait for a chest X-ray or flu swab. Throughput is king and it trumps good medicine. I’m a discharge machine.

I'm not EM, but I've definitely given up on good medicine. If something will not actively harm the patient and won't jeopardize my licence/livelihood, I just don't care anymore.