Nurse sent labs without orders.....

[EMallclear]

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So here is the case....41 y/o male comes in with c/o vomiting/diarrhea since last night. went out to dinner, ate muscles, started v/d during the night, several times each. little stomach cramps. woke up with fever. no sig pmhx, no meds, no sx, all to pcn and sulfa. no tob, social etoh. no travel, no abx use. PE temp of 101. belly soft, nt, nd, no guard, increased bowel sounds. everything else normal. so my first thought is clear cut gastroenteritis, give the guy some zofran and fluids. hour later, he feels great, fluids almost done, ready to d/c him home. my attending tells me to d/c him, and as i am he asks if i am worried about him, and i say not really, seemed like simple gastro. well, somehow the attending was aware of his "labs." never ordered by him or I. well the guy had a 24k wbc w/ 88 neutrophils. long enough story short, i get the speech to f/u on everything.....how the hell was i to know labs were sent w/o an order, which is why i never figured to follow up on them. anyhow, can i get some thoughts on this-both the case and the lab situation. thanks,
allclear

 

[spyderdoc]

Some ERs, like ours have standing nursing protocols to get things rolling on patients. The nurses can send blood, start IV's, and order x-rays(ankle, etc) from triage. They are usually protocols written by the docs, so sort of count as "pre-written" orders.... Seems to help improve patient flow....

 

[CueDoc]

This happens in every ED in the country. Hospitals have protocols to send labs based on certain situations to try and increase the efficiency in the ED. In the day of defensive medicine most people get labs anyway so the triage nurse just orders them. Perfect example - 29 y/o AAF comes in c/o HA and basically other URI symptoms. However, when triage asked her about Chest pain she answered yes and no one explored this further and it was written on the chart. Thus, the nurses ordered CBC, BMP, Enzymes, ekg, CXR, etc. etc. When I saw her and asked about the "chest pain" she said that it hurts when she coughs but only a little. It hurts when I cough. That is not cardiac related chest pain, however due to protocol and writing the words "chest pain" on the chart, this pt. stayed in the ED for 2-3hrs longer than necessary to get her script for robitussin AC and a pat on the back. Alternatively, it is extremely helpful for cardiac labs to be ordered early when you have a 65 year old man with atypical chest pain that seems clinically to be cardiac in origin. Bottom Line, its going to happen, just get used to it. Academic Medicine is being ousted by defensive medicine and a call for increased productivity/efficiency. I realize it is counter-intuitive to order labs to increase efficiency but that is the society we live in.

 

[edinOH]

This is a classic example of the missed appy. Not saying he had that (did he? 😉).

Most of us eat three times a day so there can always be a temporal relationship between the last time the pt ate and the onset of symptoms.

Your WBC and diff can be explained by the GE but in other instances these labs might have pointed you in a different direction.

Our nurses rarely if ever send labs without an order but they routinely draw them in case we need them.

 

[docB]

The reality is that you are on the hook for anything that got sent wether you ordered it or not. This is really a problem in the patients who elope. I just had a patient who disappeared out of the ED (he wanted to go smoke, the nurse told him "no" so he just walked out) and his troponin came back at 5. So now we've gotta try to call all the fake numbers he gave us and send a certified letter to general delivery to document that we tried to let him know. I wonder if he made it out of the parking lot.

 

[WilcoWorld]

As doc B said, you are responsible for follow-up. On the other hand, I could've, and likely would've d/c'd the same H&P you described. But if labs are ordered under your name YOU are responsible for following up on their results. It can be painful, but that's just the way it is.

In short, both you and your attending were correct.

 

[EMallclear]

so after seeing the white count, we held d/c, drew cultures, gave him levaquin 500mg iv, called pcp to see what they wanted and like previous post stated, they were concerned about possible appy, so we scanned him. scan just showed mild colitis from cecum to midtransverse. got admitted for more fluids and more iv abx. this was on my second shift of my residency, so i guess lesson learned is that always check for possible labs before d/c whether ordered or not.

 

[Rugby MD]

So I am currently studying for step 1 and having been spending hours and hours doing Kaplan Qbank and USMLEworld.
Is I start reading the above case, I realize that I am trying to highlight it with my cursor.😕
Is 2nd year over yet?

 

[Jeff698]

As for your case, I don't think the CT was unreasonable given the elevated WBC but it does point out that a WBC isn't all that helpful.

Demargination is a common cause for elevated WBC under physiologic stress so an elevated count doesn't nail down an infectious etiology. On the other hand, a normal count doesn't rule one out and it certainly doesn't rule out appy.

I'll typically order a CBC for my consultants and will certainly review the data it provides but only use it as an additional piece of the whole picture.

The CT or not CT, especially with appy, is always tough. If you think it's a slam dunk, the question becomes do you need it to get the patient to the OR. If you think it isn't needed at all, you just tell the patient that and send 'em out. It's the ones in between that are tough.

I'm becoming a really big beliver in serial exams and frank discussions with the family. I'll document several repeated abd exams over time. If they're all negative, I'll document (after actually doing it, of course) that I told the patient I didn't think it was appendicitis but could be wrong. I'll include that I gave them specific examples of both when and why to return to the ED and that the patient understood and agreed with the plan.


As for nurses ordering labs, I try to check our ordering system to see if any labs were sent, although I've been burned like you have. Some times it is irritating but others its very helpful.

Last shift, I had a young, healthy 19 year old with vomiting that I was set to discharge. I saw her in the room just as she came in and hadn't seen that she was febrile. I left the room and saw the rest of the 6 patients that I'd just been bolused with. As I was working on her discharge, I checked her temp and saw it was a little high. I also noticed she had labs and saw she had a raging UTI. I went back in and reassessed. Nope, still no dysuria but, now that you mention it, I am having flank pain and having been peeing more frequently.

In this case, those nursing labs caught something I would have otherwise missed in my hurry to get on to the next patient. They work both ways. 🙂

Take care,
Jeff

 

[SolidGold]

I have limited experience with it, but I think it's great. I've had chest pain patients already with an IV, put on a monitor, that already have an ECG and cardiac biomarkers back and a CBC, coags, and electrolytes pending before their chart even hits the box and is ready to be seen. The nurses will put what they ordered on the orders sheet, so it's easy to keep track, plus they are good at telling us about what they got.

For extremity trauma, xrays are ordered by the nurses if they think its needed and are usually done before the patient is even seen.

 

[Hard24Get]

.... so i guess lesson learned is that always check for possible labs before d/c whether ordered or not.

A great lesson to learn. On IM, watch out for meds you didn't order, etc. During my Sub-I I had an IM attending that would order labs and change meds on patients without telling anyone. She did this to both myself and my co-intern (who was a real intern BTW), then complained that we weren't keeping our med lists up to date, didn't follow-up the lab she surreptitiously ordered, or had multiple orders in!

Ever since then I scan for any and all results, orders, and new allergies, etc.

On the other hand, nursing orders can throw you off but if you know to check for them it is extremely convenient since you have extra data to work with from the get-go, as is the automatic IV setup for those who they know will need it. If it is off the beaten path they should let you know they sent it out of courtesy, of course.

 

[The White Coat Investor]

I tell the nurses they can order anything they want, except a D-dimer.

 

[Jeff698]

I tell the nurses they can order anything they want, except a D-dimer.

"Thank you for your kind order of a D-Dimer. Can I get you a CT to go with that? 'cause now I'm pretty well locked in."

Take care,
Jeff

 

[docB]

It occured to me that this is one of those things that's also dependent on the type of system used for ordering and reporting labs. If you're looking around for random pieces of paper (like I am) and you didn't know something else had been added so you don't know to look for it that adds to the problem. If you are pulling up the labs on a computer that shows all result and all pending studies you'll have less chance of missing something. Most of us, particularly the residents and students, are just stuck with the system we have but the goal should be the latter. Just a thought.