Pre Op Workups in the ED

[docB]

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So how much “Routine Pre-Op” stuff do you do in the ED. We had a little discussion about this in a hijacked thread which was interesting:

Sorry to hijack but at my places the secretary puts in the "reason" for the study. Sometimes this results in less than optimal requests. Yesterday I had an 80 yo guy with a likely busted hip so I ordered the usual preop stuff including the CXR. The reason given for the CXR... you guessed it "Eval hip fx." The rads gave me some well deserved flack.

Back to your regularly scheduled thread.

OFF TOPIC
We audited those 'routine preop chest' charges on cracked hips last year. We didn't get paid for a single one of them. They routinely get kicked out as 'medically not necessary'.
If the ordering provider invests 12 seconds of thinking, everyone in the age range to crack a hip will have 2-3 supporting diagnoses for a CXR. Hypertension, diabetes, fall, trauma all get paid.

END OFF TOPIC

I’m getting more and more requests to do stuff in the ED that I ordinarily wouldn’t do. The consultants want it because it’s more convenient for them and/or the patient is uninsured and it will never get done otherwise. A good example is the patient I had yesterday with a mildly displaced tibial plateau fracture. My plan after getting the plain films was splint, crutches, non weight bearing, pain meds follow up with ortho. I talked to ortho and she requested CT of the knee in the ED because she said that would guide her decision on operative vs. conservative management. So OK, the patient needs a CT but do they need it in the ED. I did it but it delayed discharge and locked up a bed for an extra 3 hours. This is becoming so prevalent that our “hip fracture protocol” which is ordered by the nurses when a hip fracture is suspected includes a CXR and blood work.

Should we be doing this? Are we helping out our colleagues and our patients or are we just helping the ship sink faster?

 

[roja]

I do these. When i was in medical school, we were told taht the complaint had to be tied to the study. Apparantly where I am now, it dosent' matter.

So, in a billing sense, I find what I need to do and do it.

For the theory part: (should we be doing it) I tend to go ahead and do it. It is a little more prevelant but I think that in the end, it helps patient care. For patients without insurance, or ones in our clinic, it might be weeks before outpatient studies can get done. So I will sometimes go ahead and do it because it is easier to do it from the ER. And that once a week or twice a week occurance doesn't make that much of a difference in my ED. I also do it if I believe it will help out my consults adn 'grease' the wheel a little bit. Sometimes it just fosters good will because it makes life easier for them. So I wiegh the advantages of making things easier for my patient and for my consultant against the time in my ED and the few minutes it takes to order the test. Most days I end up getting the study (unless its just something ridiculous....)

 

[BADMD]

So how much “Routine Pre-Op” stuff do you do in the ED. We had a little discussion about this in a hijacked thread which was interesting...<snip>

Should we be doing this? Are we helping out our colleagues and our patients or are we just helping the ship sink faster?

I'm torn. I want to do what is best for the patient. If I think they are going to go to the OR in a semi-elective fashion, I'd like to facilitate that. At the same time, I don't want to be on the hook for a chest xray or a set of coags that I'm really not sure what the heck the surgeons need it for except to check off some boxes on their preop sheet.

I guess if my consultants want the stuff, I'll probably order it, however I want to have a discussion with them about how things will change if there is an abnormality.

 

[kungfufishing]

Whatever gets them out of the dept. quicker.

 

[Hayduke]

I’m getting more and more requests to do stuff in the ED that I ordinarily wouldn’t do. The consultants want it because it’s more convenient for them and/or the patient is uninsured and it will never get done otherwise.

This discussion highlights the soft, dark underbelly of this specialty. We don't definitively treat anything.

There. I said it.

My interpretation of our role is to facilitate the treatement of our patients by getting what is required for those that will actually fix them. I chafe at this recognition of the impotence of our position. But, I still recognize the reality.

While EMTALA extension to consulting docs continues its toothless bark, and insurance for so many of our peeps remains a myth, we are becoming increasingly dependent on the good will of consultants to see these folks. To maintain any hope that dialing consultants will actually result in a "hello" on the other end of the line, we must provide them with whatever will make their job less painful.
We don't carry pagers. We don't have clinic. We get paid faily well. This is the payoff for being their biaotch.

 

[sleepymed]

So let me start with a disclaimer before people tear me down... I am a fourth year med student, and I've only done two sub-I months and one elective month in the ER... but, from what i've seen in the limited time I was there, I felt like we do definitively treat things...

Pts who need an abscess drained --- we treated
Bacterial pharyngitis, given abx, sent home --- we treated
CAP in a 20 year old --- we treated
sprains, migraines, threatened abortion --- all us

while it might chafe you that many of these compaints are primary care complaints, it doesn't change the fact that we are treating people

only 20-30% of patients are sick enough to be admitted... and even in those patients, we MAKE the diagnosis, start the treatment, and decide where they have to go (be it an ICU, step down unit, etc); if getting a cxr will get my patient where they have to go sooner and it serves an actual purpose, then by all means, i will get it!!

*sleepy is preparing for the inevitable throwing of large objects at her

This discussion highlights the soft, dark underbelly of this specialty. We don't definitively treat anything.

There. I said it.

My interpretation of our role is to facilitate the treatement of our patients by getting what is required for those that will actually fix them. I chafe at this recognition of the impotence of our position. But, I still recognize the reality.

While EMTALA extension to consulting docs continues its toothless bark, and insurance for so many of our peeps remains a myth, we are becoming increasingly dependent on the good will of consultants to see these folks. To maintain any hope that dialing consultants will actually result in a "hello" on the other end of the line, we must provide them with whatever will make their job less painful.
We don't carry pagers. We don't have clinic. We get paid faily well. This is the payoff for being their biaotch.

 

[Hayduke]

Sleepy-
I'm not throwing anything. In fact I think your examples are spot-on.
Yes. We treat these things because we have become defacto surrogate pcps for a large percentage of patients.
I ask that you recognize that all of these people will need follow up. It is part of our job to align these patients with people who will eventually, hopefully, miraculously take care of them definitively until they no longer require treatment.
It is in our interest to coddle these consultants so that we can continue to get folks what they really need. That is a doc who will see them routinely and will continue to care for them through their acute to convalescent needs (ortho), or who will take them on cradle-to-grave (FP/IM).

 

[Hard24Get]

Sleepy-
I'm not throwing anything. In fact I think your examples are spot-on.
Yes. We treat these things because we have become defacto surrogate pcps for a large percentage of patients.
I ask that you recognize that all of these people will need follow up. It is part of our job to align these patients with people who will eventually, hopefully, miraculously take care of them definitively until they no longer require treatment.
It is in our interest to coddle these consultants so that we can continue to get folks what they really need. That is a doc who will see them routinely and will continue to care for them through their acute to convalescent needs (ortho), or who will take them on cradle-to-grave (FP/IM).

Another rosy 4th year, here. 🙂 Your argument is true for the truly PCP stuff, although I would submit that most of the cases sleepymed mentioned may go to the ER whether they have their own PCPs or not. Our medical system simply cannot absorb "problem" visits (indeed rarely the regular ones) in a timely manner, and many PCPs these days can't handle the issues because of discomfort or lack of resources and punt the patients to the ER, anyway. I would never, therefore, say that we never definitely treat anything, since most people in sleepy's category ARE definitely treated when they leave the ER. That being said, I doubt many of us are interested in EM for definitive treatment, but rather for diagnosis and stabilization. I think the "dark underbelly" of medicine in general is that no doc is an island.

And sure, sometimes we coddle consultants. But most of the time it is after we have already diagnosed the condition and initiated treatment (and many times, even admitted the pt). Though sometimes actually needed, working with consultant is a part of a compassionate dispo, as you alluded to.

 

[roja]

I think the "dark underbelly" of medicine in general is that no doc is an island.
.

😍😍😍

I think the dark underbelly is that many med students, residents and attendings loose sight of this.


I suppose some have a misconception of the ED: that you only deal with stabilization. however, part of why I like it is I like small doses of primary care. And there are many things I treat and diagnose. And many I dont. Just like EVERY other doctor.

 

[SoCuteMD]

😍😍😍

I think the dark underbelly is that many med students, residents and attendings loose sight of this.


I suppose some have a misconception of the ED: that you only deal with stabilization. however, part of why I like it is I like small doses of primary care. And there are many things I treat and diagnose. And many I dont. Just like EVERY other doctor.

You should see roja massage those consultants (figuratively, of course). SHe knows how to butter 'em up! 🙂

 

[roja]

its my ultrasweet disposition. 😀

 

[Wackie]

We wouldn't do CXR on a broken hip admit. The surgeon will put it in themselves and it'll get done in the ED. Our stuff is all computerized so the doc orders it and if they don't put in what is being r/o then rads will call if they're in a bad mood. Back when it was paper, they had standard "r/o infiltrate" things, but any CT, MRI, sono the secretary was told what to put.

Should we be doing this? Are we helping out our colleagues and our patients or are we just helping the ship sink faster?

Rather than throw a frog into a pot of boiling water, you can put it in the room temp water and slowly crank up the heat and it'll never know.
That's what I've been likening it to anyway...(not regarding colleagues but administration and billing)

 

[Jeff698]

I almost always get the ECG, CXR and coags on hips. Obviously, I'm only doing this for our ortho colleagues. This I don't mind doing. It helps them (and they're some of the most overworked residents in our hospital) and keeps the patient in the ED for very little extra time.

What drives me up the friggin' wall is when our medicine colleagues demand that a CT Abd/Pelv be done before moving the patient upstairs. I had a pt with chronic pancreatitis the other day (that, had they not been sent by their PCP for admission I would have sent home). The admit team got all pissy with me b/c I told them the 6 hours it would take for the CT (another story in itself) wasn't justified as part of the ED workup. Especially when I had 30 people in the waiting room and 1/4 of our ED beds full of admitted patients.

To docB's initial question, I think we're being expected to do much, much more of the initial workup on admitted patients than is really necessary in the ED. Under most circumstances, I don't mind. When the wheels are coming off my ED, on the other hand, I do mind. I also think it is reasonable for our consultants to accept that we do much more of the work-up than is necessary in the vast majority of the time and, when we're dying with over-stuffed waiting rooms, to accept that they need to do the non-emergent part of the work-up upstairs.

Take care,
Jeff

 

[spyderdoc]

I generally do "pre-op" labs, ECG, and CXR if I have a patient that I am sure will go to the OR, like an old lady with a hip fracture, etc.

I don't mind doing these since it fosters good relationships with the consultants and medical staff. It doesn't really add any more time to the visit since you are drawing blood already for the ED workup, sending them to XR anyhow for the hip XR, etc....

Since we are a group that contracts with the hosptial, it is nice to have the medical staff "on our side" should we need them to back us if the admin comes down on us for any reason....

In the FFS world (and if paid by RVUs), it may boost your billing for that patient as well...CXR interp...ECG interp...

I agree with Jeff though when the admitting doc tries delay tactics, like asking for CTs or more labs to be done, then calling them back afterwards.

 

[southerndoc]

I almost always get the ECG, CXR and coags on hips. Obviously, I'm only doing this for our ortho colleagues. This I don't mind doing. It helps them (and they're some of the most overworked residents in our hospital) and keeps the patient in the ED for very little extra time.

What drives me up the friggin' wall is when our medicine colleagues demand that a CT Abd/Pelv be done before moving the patient upstairs. I had a pt with chronic pancreatitis the other day (that, had they not been sent by their PCP for admission I would have sent home). The admit team got all pissy with me b/c I told them the 6 hours it would take for the CT (another story in itself) wasn't justified as part of the ED workup. Especially when I had 30 people in the waiting room and 1/4 of our ED beds full of admitted patients.

To docB's initial question, I think we're being expected to do much, much more of the initial workup on admitted patients than is really necessary in the ED. Under most circumstances, I don't mind. When the wheels are coming off my ED, on the other hand, I do mind. I also think it is reasonable for our consultants to accept that we do much more of the work-up than is necessary in the vast majority of the time and, when we're dying with over-stuffed waiting rooms, to accept that they need to do the non-emergent part of the work-up upstairs.

Take care,
Jeff

One way to send the patient upstairs when medicine demands a patient remain in the ED for X, Y, or Z study is to tell the admitting resident that you're going to give his/her pager number to every patient in the waiting room so he/she could personally explain why patients are needing to wait to be seen.

 

[DrQuinn]

I do the preop stuff if I know the patient is going to the OR or going ot be admitted.

One thing that ruffles my feathers is when I get an ophtho consult for some weirdo-eye thing, and they send hte patient back, to follow up in clinic, but to get
"ANA, ANCA, RPR, TSH, Sickle Prep, CRP...."

Its usually like 10 blood tests whcih I could care less about but they always say "Its hard for us to get these tests." Its because they probably can't be reimbursed for them as the vast majority are uninsured.... Depends on my mood if I'll do them or not.

Q

 

[docB]

Its usually like 10 blood tests whcih I could care less about but they always say "Its hard for us to get these tests." Its because they probably can't be reimbursed for them as the vast majority are uninsured.... Depends on my mood if I'll do them or not.

Q

That's what I've been running into with the stuff like the CT of the tibial plateau fracture. The ortho actually asked for it by saying "If she's uninsured get the CT in the ER." Of note these docs get paid to take call.

 

[emtp6811]

It sounds to me like y'all have been nicely going the extra mile for so long that the consultants now expect these things to be done as a matter of routine. If they can't or don't want to do it themselves, don't worry, the ED will do it.