Neuro sending pts to ED for LP

[Lexdiamondz]

There's a neuro group locally that has made a habit of sending patients in for non-urgent LPs (mostly massively overweight women getting pseudotumour cerebri workups).

We used to refuse however as of late, a couple of their midlevels have been writing down on the ED referrals "r/o meningitis" on patients who are afebrile, nonmeningeal and have had chronic headaches for months.

Is it worth continuing to fight these? I'm not RVU based (salaried hospital employee) so I literally gain nothing from doing the procedure, but the risk (not to mention the technical challenges) of doing a non-emergent procedure that may be particularly time consuming is rather unpalatable.

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[thegenius]

Yes it is. Continue to fight. Headache for months does not require an emergency LP. Headache for months does not require the services of an Emergency Physician. Whether they are skinny, fat, or whatever.

We have a Neurologist who does this as well. I have said no. Thankfully it only happens a few times a year.

 

[coffeebythelake]

I wonder how much more these patients are charged for going to the ED to get a non-urgent diagnostic LP vs. getting it done somewhere else. This in of itself should put a damper on this practice.

 

[RustedFox]

"Just go to the ER".

It's the chant of the outpatient world.
Need anything done today, at your convenience?

"Just go to the ER."

Nevermind indications, contraindications, etc.
Insurance approval is too much of a headache (lol... headache, and the thread is about LPs) that this has become the Dao of the clinic dweller.

 

[thegenius]

I wonder how much more these patients are charged for going to the ED to get a non-urgent diagnostic LP vs. getting it done somewhere else. This in of itself should put a damper on this practice.

I don't know if most people (e.g. patients) are smart enough to discern this. Obviously it's not worth the Neurologists's time to do the LP.

The system is so broken:

Neuro: "I think you need an LP for your chronic headache. Please go to the ER to have it done."
Patient: "My ER copay is $200. The entire visit will cost a few thousand dollars. Can you do it please? It will cost me much less."
Neuro: "I don't want to do it. Please go to the ER."

 

[bravotwozero]

Just like GI sending their cirrhotics to the ED for a tap…

 

[RustedFox]

And admin will never say "no" to these types of visits. And the metrics will be held against you.

 

[Lexdiamondz]

Just like GI sending their cirrhotics to the ED for a tap…

At least the tap is an easy medicine admission. I throw in a quick pigtail and take off a liter, the hospitalist keeps it going and deals with the albumin and then pt is gone by noon the next day. easy money for everyone.

 

[Dr Mantis Toboggan]

Yes it is. Continue to fight. Headache for months does not require an emergency LP. Headache for months does not require the services of an Emergency Physician. Whether they are skinny, fat, or whatever.

We have a Neurologist who does this as well. I have said no. Thankfully it only happens a few times a year.

Here our neurologists send these folks to radiology, for outpatient fluoro guided LP. As many of these folks are BMI challenged I think that’s a really good move.

 

[Dr Mantis Toboggan]

At least the tap is an easy medicine admission. I throw in a quick pigtail and take off a liter, the hospitalist keeps it going and deals with the albumin and then pt is gone by noon the next day. easy money for everyone.

Our radiologists do these for us if they are in house. They have some new machine that like sucks it out or something. It’s pretty cool.

 

[bravotwozero]

Our radiologists do these for us if they are in house. They have some new machine that like sucks it out or something. It’s pretty cool.

Ours don’t as most of these patients are not insured and they won’t get paid lol

 

[Lexdiamondz]

Ours don’t as most of these patients are not insured and they won’t get paid lol

Same. If we had IR willing to do these then it would be a gamechanger but as it stands nobody does.

 

[johnny_bananas]

Unreal!

Why don't you consult the on call neurologist at your hospital so it ceases to be your problem. You could let them know of a complicated chronic headache, and it is unclear if it is pseudotumor cerebri, intracranial hypotension, or chronic meningitis so you are unsure if an LP is indicated. It was so complicated in fact, that their community neurologist couldn't figure it out so they sent it to the ED.

 

[wendalltwolf]

Why don't you consult the on call neurologist at your hospital so it ceases to be your problem. You could let them know of a complicated chronic headache, and it is unclear if it is pseudotumor cerebri, intracranial hypotension, or chronic meningitis so you are unsure if an LP is indicated. It was so complicated in fact, that their community neurologist couldn't figure it out so they sent it to the ED.

The admitting Neurology team hates this one simple trick!

 

[thegenius]

At least the tap is an easy medicine admission. I throw in a quick pigtail and take off a liter, the hospitalist keeps it going and deals with the albumin and then pt is gone by noon the next day. easy money for everyone.

We could never do this where I work!

 

[Dr Mantis Toboggan]

Ours don’t as most of these patients are not insured and they won’t get paid lol

Our payor mix ain’t the greatest but I’m glad they help us out with these.

 

[Groove]

There's a neuro group locally that has made a habit of sending patients in for non-urgent LPs (mostly massively overweight women getting pseudotumour cerebri workups).

We used to refuse however as of late, a couple of their midlevels have been writing down on the ED referrals "r/o meningitis" on patients who are afebrile, nonmeningeal and have had chronic headaches for months.

Is it worth continuing to fight these? I'm not RVU based (salaried hospital employee) so I literally gain nothing from doing the procedure, but the risk (not to mention the technical challenges) of doing a non-emergent procedure that may be particularly time consuming is rather unpalatable.

Take a paperclip end and twirl it against the donut skin at the base of their back. Then consult IR for fluoro tap and tell them you tried already.

 

[Birdstrike]

There's a neuro group locally that has made a habit of sending patients in for non-urgent LPs (mostly massively overweight women getting pseudotumour cerebri workups).

These are outrageously easy to do with fluoroscopic guidance. The BMI makes little difference when you have x-ray vision. Isn't there a way for neuro to set up an outpatient, fluoro-guided LP through your hospital's radiology department? If so, is it possible neuro just doesn't know about it? That might be your best bet. Otherwise, if you take it through admin, they look at it like this, "Which generates a higher bill for us to charge? Going through the ER or neuro doing it in their office?" Bingo! Sending them to ER wins.

Or, like @Groove said, these can be easy. Take one quick stab, with the understanding that it'll be a frustration and struggle-free attempt, and instantly send to IR if unable to get in quickly and easily. Otherwise, being tempted to fight the "Doesn't need to be here" battle, is just asking for frustration since the majority of the patients in your career, don't need to be.

 

[GonnaBeADoc2222]

I am not RVU, hence I do not do non-emergent LPs or paracentesis. Some other simp can pick up the patient, or it can be arranged for outpatient.

 

[thegenius]

I am not RVU, hence I do not do non-emergent LPs or paracentesis. Some other simp can pick up the patient, or it can be arranged for outpatient.

First, an LP never saved anybody’s life. It’s not really an emergency procedure. It’s more a test. At best you’ll pick up a SAH which will lead you down the pathway of identifying a large cerebral aneurysm, and getting that person appropriate surgical care. However even that kind of situation is extremely rare these days with how good our CT imaging is. LPs don’t save your life if you have meningitis or encephalitis.

I think the only time I force myself to do an LP is if I have to r/o an SAH or meningitis. Most of these pts go home if the test is neg. I do this 1-2x/year.

Second, I am RVU and I still won’t do an LP or paracentesis unless it falls under the guidelines of the above point. It’s not worth the money. Procedures rarely are worth the money unless they are orthopedic.

 

[Dr Mantis Toboggan]

First, an LP never saved anybody’s life. It’s not really an emergency procedure. It’s more a test. At best you’ll pick up a SAH which will lead you down the pathway of identifying a large cerebral aneurysm, and getting that person appropriate surgical care. However even that kind of situation is extremely rare these days with how good our CT imaging is. LPs don’t save your life if you have meningitis or encephalitis.

I think the only time I force myself to do an LP is if I have to r/o an SAH or meningitis. Most of these pts go home if the test is neg. I do this 1-2x/year.

Second, I am RVU and I still won’t do an LP or paracentesis unless it falls under the guidelines of the above point. It’s not worth the money. Procedures rarely are worth the money unless they are orthopedic.

Minor nit but a therapeutic LP for cryptococcal meningitis with horribly elevated pressures is definitely life saving. That’s about the only case tho.

 

[WorkNoteEmergency]

Someone sent to the ER to “rule out meningitis” doesn’t always need an LP. In your case OP if the tap wasn’t clearly needed that day, then I would have ordered an outpatient radiology LP.

A couple years ago a nursing home sent someone in to the ED on a Monday afternoon to get a PICC line removed because his antibiotics were done. I refused on principle and sent the patient back.

 

[Apollyon]

These are outrageously easy to do with fluoroscopic guidance. The BMI makes little difference when you have x-ray vision. Isn't there a way for neuro to set up an outpatient, fluoro-guided LP through your hospital's radiology department? If so, is it possible neuro just doesn't know about it? That might be your best bet. Otherwise, if you take it through admin, they look at it like this, "Which generates a higher bill for us to charge? Going through the ER or neuro doing it in their office?" Bingo! Sending them to ER wins.

Or, like @Groove said, these can be easy. Take one quick stab, with the understanding that it'll be a frustration and struggle-free attempt, and instantly send to IR if unable to get in quickly and easily. Otherwise, being tempted to fight the "Doesn't need to be here" battle, is just asking for frustration since the majority of the patients in your career, don't need to be.

I recall a pt from about 15 years ago. 18-20ish female, don't recall the indication, but, the LP was indicated. I'll be kind and say she was larger than average. I get nada, and call rads. This was at the uni hospital, so, rads in-house, and no residents. After the procedure, rads calls me back, and told me he had to use what he called "the harpoon", which was a 5.5" or 6" needle, and hubbed it to just barely get in there. He said the needle was bowing under fluoro as he inserted it.

 

[Birdstrike]

I recall a pt from about 15 years ago. 18-20ish female, don't recall the indication, but, the LP was indicated. I'll be kind and say she was larger than average. I get nada, and call rads. This was at the uni hospital, so, rads in-house, and no residents. After the procedure, rads calls me back, and told me he had to use what he called "the harpoon", which was a 5.5" or 6" needle, and hubbed it to just barely get in there. He said the needle was bowing under fluoro as he inserted it.

I have 7.0 inch quincke needles

 

[emergentmd]

Hard NO. If they start to make up diagnosis, then I start to state an LP not indicated in ER and send them right back out. After awhile, they will stop.

 

[EM Junkie]

Definitely no. For both nonemergent LPs and cirrhotics with ascites my approach is simple — if you have insurance and a doctor that practices at my hospital, OBS for IR. If you do not, then discharge home.

 

[BoardingDoc]

I recall a pt from about 15 years ago. 18-20ish female, don't recall the indication, but, the LP was indicated. I'll be kind and say she was larger than average. I get nada, and call rads. This was at the uni hospital, so, rads in-house, and no residents. After the procedure, rads calls me back, and told me he had to use what he called "the harpoon", which was a 5.5" or 6" needle, and hubbed it to just barely get in there. He said the needle was bowing under fluoro as he inserted it.

I once had to use the harpoon to do a diagnostic para on a 700 lb patient as a resident. I knew that I had a long way to go from the ultrasound, but when I hubbed it and was actively leaning into his rather corpulent abdomen to make it the last few cm,I definitely started to get nervous.

 

[bingbongbink]

At least the tap is an easy medicine admission. I throw in a quick pigtail and take off a liter, the hospitalist keeps it going and deals with the albumin and then pt is gone by noon the next day. easy money for everyone.

At some shops i’ve been too, the ER docs will simply admit the pt to medicine and then either the hospitalist does it later on, or it gets sent to IR.

Practices can vary

 

[bingbongbink]

We could never do this where I work!

Why?

 

[thegenius]

Why?

The hospitalist would say "you've done the hard part. Can't you take off 3 more liters and discharge him?" And refuse to admit if the pt isn't sick.

 

[Pigg-O-Stat]

I do paracentesis when there is tense ascites. It gives the patients relief and I find the procedure satisfying and easy. I've never admitted one though.

As for the OP, I would not do the LP unless it was clinically indicated for something emergent. Its a time consuming, pain-in-the ass procedure and seems medically and medico-legally risky when there is no justification for doing it emergently.

 

[deleted1114045]

At some shops i’ve been too, the ER docs will simply admit the pt to medicine and then either the hospitalist does it later on, or it gets sent to IR.

Practices can vary

My hospitalists would never admit this. It is like pulling teeth to get anyone admitted at my shop, for anything.

 

[DrSnips]

Ditto for leptomeningeal disease, it can produce some really high ICP. LP is mostly a temporizing measure to get you chemo / XRT at that point, but it is urgent to do the LP.

 

[qxrt]

Same. If we had IR willing to do these then it would be a gamechanger but as it stands nobody does.

Why would IR do LPs? Fluoro-guided LPs are a diagnostic radiology procedure, not an IR procedure. We don't do any of these in IR fellowship.

 

[nimbus]

There's a neuro group locally that has made a habit of sending patients in for non-urgent LPs (mostly massively overweight women getting pseudotumour cerebri workups).

We used to refuse however as of late, a couple of their midlevels have been writing down on the ED referrals "r/o meningitis" on patients who are afebrile, nonmeningeal and have had chronic headaches for months.

Is it worth continuing to fight these? I'm not RVU based (salaried hospital employee) so I literally gain nothing from doing the procedure, but the risk (not to mention the technical challenges) of doing a non-emergent procedure that may be particularly time consuming is rather unpalatable.

Isn’t an LP a bread n butter neuro procedure? If they don’t do it, who does? It’s akin to anesthesia sending a patient to ER to get a spinal injection, be intubated or to get an IV started. “This one looks like it could be challenging, think I’ll send it down to ER. This gentleman will be having a gastric bypass. Could you intubate him and send him back to the OR? Thanks, Anesthesia”.

ER is truly the dumping ground.

 

[deleted1114045]

Isn’t an LP a bread n butter neuro procedure? If they don’t do it, who does? It’s akin to anesthesia sending a patient to ER to get a spinal injection or to get an IV started. ER is truly the dumping ground.

Or nephrologists who claim they don’t know how to put a dialysis catheter. “Well, your training has failed you. This is pretty much why you exist, to help people get dialysis.”

 

[southerndoc]

Or nephrologists who claim they don’t know how to put a dialysis catheter. “Well, your training has failed you. This is pretty much why you exist, to help people get dialysis.”

I bet most hospitals don't credential nephrology for dialysis catheters when they recredential. They probably get enough during fellowship, but after that they mainly turf to surgery, vascular surgery, etc. So I doubt they have the numbers to stay credentialed in doing them.

 

[nimbus]

I bet most hospitals don't credential nephrology for dialysis catheters when they recredential. They probably get enough during fellowship, but after that they mainly turf to surgery, vascular surgery, etc. So I doubt they have the numbers to stay credentialed in doing them.

They’d have the numbers if they didn’t turf.

 

[rokshana]

They’d have the numbers if they didn’t turf.

I do t think they even learn to do dialysis cath in fellowship anymore

 

[The kitchen sink]

I do t think they even learn to do dialysis cath in fellowship anymore

Because it doesn’t pay to do them or be responsible for them in the real world. So it goes to vascular or IR for quintons/permacaths/fistulas etc

 

[Kuratz]

Rads/IR resident. Have to chuckle because must be a universal thing that neither Neuro/Rads/ED wants to do these. Usually we don't give pushback if the ED has given a legitimate attempt or the patient is clearly going to be a hard stick. It's never questioned if felt clinically to be truly urgent and necessary. The problem is that seemingly 9 out of 10 times it's ordered as a soft call: patient is not that sick, neuro/IM says "get an LP" to the ED (but doesn't do it) and it feels like a total dump especially when there is a building list of other CTs etc waiting for you. Its total CYA and a frustrating (and low paying) use of resources. I get why medicine is practiced like this but its a huge part of the problem, especially the way patient expectations are nowadays.

It's true, an average BMI patient with relatively healthy spine is easy as hell to do under fluoro. The frustration is the near zero pre-test probability BMI 40+ with a **** interlaminar space that takes numerous attempts. Patients at our hospital recently are being given the option by the Neuro team of a bedside LP or one "image-guided". So they end up getting sent down because they "refused" a bedside attempt. Makes me wonder why they don't try to have their interns and residents try to learn. Nevertheless I guess that's one way to get around doing them haha.

 

[The kitchen sink]

Rads/IR resident. Have to chuckle because must be a universal thing that neither Neuro/Rads/ED wants to do these. Usually we don't give pushback if the ED has given a legitimate attempt or the patient is clearly going to be a hard stick. It's never questioned if felt clinically to be truly urgent and necessary. The problem is that seemingly 9 out of 10 times it's ordered as a soft call: patient is not that sick, neuro/IM says "get an LP" to the ED (but doesn't do it) and it feels like a total dump especially when there is a building list of other CTs etc waiting for you. Its total CYA and a frustrating (and low paying) use of resources. I get why medicine is practiced like this but its a huge part of the problem, especially the way patient expectations are nowadays.

It's true, an average BMI patient with relatively healthy spine is easy as hell to do under fluoro. The frustration is the near zero pre-test probability BMI 40+ with a **** interlaminar space that takes numerous attempts. Patients at our hospital recently are being given the option by the Neuro team of a bedside LP or one "image-guided". So they end up getting sent down because they "refused" a bedside attempt. Makes me wonder why they don't try to have their interns and residents try to learn. Nevertheless I guess that's one way to get around doing them haha.

Ive done a few bedside LPs with pretty decent success using ultrasound beforehand to mark my site. I think it should be used more often at the bedside.

 

[turkeyjerky]

Ive done a few bedside LPs with pretty decent success using ultrasound beforehand to mark my site. I think it should be used more often at the bedside.

Yeah, for the real fatties it's a real help.