Random ER Metrics Thread

[RustedFox]

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So you guys don't ever get ophtho sending in patients to get a "stat" MRI? (There is one on our board right now.) I see this about 1-2x/month.

W-whats... Op-ophtho?

 

[CliveStaples]

So you guys don't ever get ophtho sending in patients to get a "stat" MRI? (There is one on our board right now.) I see this about 1-2x/month.

My institution had a problem with these too (I.e. Ophtho finds bilateral optic disc edema in clinic and sends to ED for MRI of the brain/orbits). Because I work in an ED where obtaining an ER MRI is a ticket to a 12 hour ED LOS, we ended up coming up with an agreed upon protocol where some of these go home for outpatient MRI and some get admitted to Neurology for their MRI.

These kinds of systems problems are really the job of your hospital leadership/medical directors. Usually a good leadership team can figure out it's in everybody's best interest (I.e. makes more people more money) to not have a ridiculous ER LOS for somebody that should have an earlier "stay or go" disposition decision made.

 

[BoardingDoc]

So you guys don't ever get ophtho sending in patients to get a "stat" MRI? (There is one on our board right now.) I see this about 1-2x/month.

Literally never once in the past 6 years. I don't even know what the theoretical indication would be unless it was for some kind of visual cortex stroke in which case they simply get admitted per my comment above.

 

[southerndoc]

Literally never once in the past 6 years. I don't even know what the theoretical indication would be unless it was for some kind of visual cortex stroke in which case they simply get admitted per my comment above.

Optic neuritis (admit for high dose steroids), MS, IIH (not an emergency). MS isn't really an emergency either unless you can't walk. Doubt they would go to the ophthalmologist first if they can't walk.

 

[Groove]

So you guys don't ever get ophtho sending in patients to get a "stat" MRI? (There is one on our board right now.) I see this about 1-2x/month.

I get "stat MRI" requests from some local "optometrists" but not "ophthalmologists". If it's one of the optometrists then I just consult ophthalmology and they might request it or tell me that it doesn't need to be done. This only really happens to me about once every 6 months or so. Sometimes I feel confident enough (with our limited equipment) to have a conversation with ophthalmology over the phone regarding the case and many times they ask me to just send them straight over to their office which greatly speeds up disposition.

 

[maxxor]

Optic neuritis (admit for high dose steroids), MS, IIH (not an emergency). MS isn't really an emergency either unless you can't walk. Doubt they would go to the ophthalmologist first if they can't walk.

Usually it’s concern for tumor due to bilateral papilledema.

I’d say this should be urgent but not emergent. Outpatient scan would be fine.

 

[WilcoWorld]

So you guys don't ever get ophtho sending in patients to get a "stat" MRI? (There is one on our board right now.) I see this about 1-2x/month.

Usually it’s concern for tumor due to bilateral papilledema.

I’d say this should be urgent but not emergent. Outpatient scan would be fine.

I agree that it could/should be done outpatient, but when an "expert" ophthalmologist sends the patient for an "emergent" MRI, it really puts @thegenius between a rock & a hard place.

 

[maxxor]

I agree that it could/should be done outpatient, but when an "expert" ophthalmologist sends the patient for an "emergent" MRI, it really puts @thegenius between a rock & a hard place.

One workplace I was affiliated with created an urgent imaging pathway where patients could get sent for imaging but bypass the ER. Maybe worth discussing if these people keep clogging up beds for you guys.

 

[RustedFox]

One workplace I was affiliated with created an urgent imaging pathway where patients could get sent for imaging but bypass the ER. Maybe worth discussing if these people keep clogging up beds for you guys.

Yeah, this would be ideal.
Because: "Go to the ER and do this test" is not how the ER should be used.
I'm not your intern; go order your own imaging, Dr. Outpatient.

 

[xaelia]

Right? Tele neuro is a joke. My old shop had that, one of them (my favorite) would call after his "assessment" and say something along the lines of 'obviously a video exam is not that useful, I'll put in my note recommendations for w/e you want'.

It's what you get from a specialty that recommends tpa for stroke mimics.

Only 25% of tPA in telestroke is stroke mimics! Good job, us!

Thrombolysis of stroke mimics via telestroke

Background The rate of intravenous tissue plasminogen activator (IVtPA) administered to stroke mimics (SM) occurs in 24%–44% of telestroke series.Methods We reviewed 270 suspected acute ischaemic stroke (AIS) patients who were evaluated by telestroke and received IVtPA from 1 July 2016 to 30...

svn.bmj.com

Re: MRI, at Kaiser I probably ordered one or two MRIs a month from the ED, mostly for minor stroke vs. cervical radiculopathy/plexopathy in paraesthesias with risk factors or someone with prior stroke deficits and ?new extension. The calculation re: costing was MRI vs. inpatient bed, and MRI will always win that as long as it's not terribly overused. These folks frequently sat in chairs in the waiting room for the MRIs (and inevitably failed their stroke NPO until swallow eval metric, oh well).

Here in NZ, definitely never order MRI from the ED for minor stroke. A CT perfusion is about as far as we go for most mimic-y young folks, but those with persistent deficits will get admitted for an MRI. Most MRIs done from our ED are for potentially surgical causes of back pain + deficit/fever, probably do the same one or two a month (covering a pod of 20 beds in a 330 visit per day ED).

 

[BoardingDoc]

Optic neuritis (admit for high dose steroids), MS, IIH (not an emergency). MS isn't really an emergency either unless you can't walk. Doubt they would go to the ophthalmologist first if they can't walk.

Yeah that's fair, though it still wouldn't equate to an emergent MRI for me. I'd admit them for MR +/- Neuro consult.

 

[WilcoWorld]

Yeah that's fair, though it still wouldn't equate to an emergent MRI for me. I'd admit them for MR +/- Neuro consult.

That's facilitated by the fact that you can admit patients.

 

[thegenius]

I know this isn't our problem...but getting outpatient scans for a population that is 85% medicaid is near impossible. At least in a timely fashion. I mean hell it takes 1 month for these peeps to see their primary care doctor for a refill of lisinopril, let alone the hoops they need to jump through to get an MRI.

I would who would win in a legal battle. An ophthalmologist says to a patient "you need a STAT MRI of your brain, go to the ER and give them this paper." They go to the ER and the ER doc says "Not an emergency, I'm discharging you and your ophthalmologist or PCP needs to order the MRI." They go to court for a "delay in diagnosis"

 

[thegenius]

That's facilitated by the fact that you can admit patients.

I do wonder how many of these attendings here who "admit" for all acute to subacute neuro stuff for imaging work at a place where they are allowed to do that (e.g. academics). In the community this is pshawwed.

 

[VA Hopeful Dr]

I know this isn't our problem...but getting outpatient scans for a population that is 85% medicaid is near impossible. At least in a timely fashion. I mean hell it takes 1 month for these peeps to see their primary care doctor for a refill of lisinopril, let alone the hoops they need to jump through to get an MRI.

I would who would win in a legal battle. An ophthalmologist says to a patient "you need a STAT MRI of your brain, go to the ER and give them this paper." They go to the ER and the ER doc says "Not an emergency, I'm discharging you and your ophthalmologist or PCP needs to order the MRI." They go to court for a "delay in diagnosis"

Location dependent of course, but there are only 2 reasons that I send a stable patient to the ED for urgent imaging. 1) I order it for same day and insurance denies it (medicaid usually), 2) Its late in the day and the test I won't can't get done that day (DVT imaging usually).

But I'm lucky to work in an area where same day CT/dopplers can usually get done.

 

[WilcoWorld]

I do wonder how many of these attendings here who "admit" for all acute to subacute neuro stuff for imaging work at a place where they are allowed to do that (e.g. academics). In the community this is pshawwed.

Beds are the rate-limiting factor at my academic shop. I see posters here saying "I never do a therapeutic paracentesis in the ED, admit and let IR do it in the morning" - that patient's going to sit in my ED waiting room (because we have to move stable admits to my waiting room so I can have rooms to see new patients) for a day or two waiting for that inpatient bed. So I just do the tap and discharge.

It's unfortunate how much we judge each other on this forum, failing to appreciate how much of medicine is determined by local practice patterns.

 

[BoardingDoc]

I do wonder how many of these attendings here who "admit" for all acute to subacute neuro stuff for imaging work at a place where they are allowed to do that (e.g. academics). In the community this is pshawwed.

Your experience vis-a-vis what is and is not standard in the community is evidently not generalizable to the rest of the country.

I work in a community shop. Standard of care here is that non-emergent but also not generally dischargable neuro stuff (TIA workup, optic neuritis eval etc) would get admitted for an MRI. This is what the general practice pattern has been at all 5 of the community EDs that I've worked at in my region.

 

[BoardingDoc]

That's facilitated by the fact that you can admit patients.

Sounds like you work at my local tertiary care center (or similar). They never have beds. We, thankfully, rarely board people in the ED for more than 12 hours.

 

[BoardingDoc]

I would who would win in a legal battle. An ophthalmologist says to a patient "you need a STAT MRI of your brain, go to the ER and give them this paper." They go to the ER and the ER doc says "Not an emergency, I'm discharging you and your ophthalmologist or PCP needs to order the MRI." They go to court for a "delay in diagnosis"

I'm sure this is highly dependent on where you practice. In NJ (a notorious medicolegal hellhole) you'll probably lose your shirt. In GA, they probably wouldn't even get to levy the suit as you wouldn't meet the threshold for gross negligence.

 

[thegenius]

Location dependent of course, but there are only 2 reasons that I send a stable patient to the ED for urgent imaging. 1) I order it for same day and insurance denies it (medicaid usually), 2) Its late in the day and the test I won't can't get done that day (DVT imaging usually).

But I'm lucky to work in an area where same day CT/dopplers can usually get done.

For some reason I don't have nearly as much of a problem with PCP's sending people to the ED for "stat" US and CT nonsense. I really don't get why diagnosis of DVT's needs to be STAT, unless the PCP is willing to admit it's for legal reasons. diagnosis of DVT can be done in the next 1-2 days. I work night shifts at a place that doesn't have ultrasound, and I regularly get people coming in wanting DVT studies and I usually just order them as an outpatient the next day, and occasionally will give them a shot of lovenox before they go. Or I'll get a DDimer and go from there.

 

[turkeyjerky]

For some reason I don't have nearly as much of a problem with PCP's sending people to the ED for "stat" US and CT nonsense. I really don't get why diagnosis of DVT's needs to be STAT, unless the PCP is willing to admit it's for legal reasons. diagnosis of DVT can be done in the next 1-2 days. I work night shifts at a place that doesn't have ultrasound, and I regularly get people coming in wanting DVT studies and I usually just order them as an outpatient the next day, and occasionally will give them a shot of lovenox before they go. Or I'll get a DDimer and go from there.

So much this. I had a patient pcp sent in for a dvt study once. They had already been given a dose of elliquis in the clinic (and had sample pack dispensed) but had been sent to the ER b/c they couldn’t get the US until the next day.

 

[southerndoc]

I'm sure this is highly dependent on where you practice. In NJ (a notorious medicolegal hellhole) you'll probably lose your shirt. In GA, they probably wouldn't even get to levy the suit as you wouldn't meet the threshold for gross negligence.

The gross negligence clause in Georgia is not as solid as it once was. In this case, by fact that you say it's not an emergency, then gross negligence clause wouldn't apply and you could be held liable. It's a catch 22. You discharge the patient, and you could be held liable for ordinary negligence.

The case was tested with Wadsworth vs Houston Medical Center Complex. A patient presented with leg pain, was evaluated by a PA, had documented pulses (albeit weak pulses), had a negative DVT ultrasound, and was discharged with a diagnosis of cellulitis. It was documented there was some erythema. The patient was found unresponsive later in the day and was taken to the Medical Center of Central Georgia. A physician documented weak pulses, but a CTA showed an occlusion. The patient ultimately lost both of her legs.

The defendants own expert witness messed up by acknowledging that you can have a blockage with faint pulses. The jury was tasked with determining whether the defendants were grossly negligent, ordinariliy negligent, or not negligent. The jury determined they breached ordinary negligence. The judge decided that gross negligence protection didn't apply to this patient because OCGA § 51-1-29.5 excludes non-urgent patients in stable conditions.

There has been discussion for bringing this back up for additional laws or possibly putting it before the voters (similar to what Texas did).

 

[thegenius]

The gross negligence clause in Georgia is not as solid as it once was. In this case, by fact that you say it's not an emergency, then gross negligence clause wouldn't apply and you could be held liable. It's a catch 22. You discharge the patient, and you could be held liable for ordinary negligence.

The case was tested with Wadsworth vs Houston Medical Center Complex. A patient presented with leg pain, was evaluated by a PA, had documented pulses (albeit weak pulses), had a negative DVT ultrasound, and was discharged with a diagnosis of cellulitis. It was documented there was some erythema. The patient was found unresponsive later in the day and was taken to the Medical Center of Central Georgia. A physician documented weak pulses, but a CTA showed an occlusion. The patient ultimately lost both of her legs.

The defendants own expert witness messed up by acknowledging that you can have a blockage with faint pulses. The jury was tasked with determining whether the defendants were grossly negligent, ordinariliy negligent, or not negligent. The jury determined they breached ordinary negligence. The judge decided that gross negligence protection didn't apply to this patient because OCGA § 51-1-29.5 excludes non-urgent patients in stable conditions.

There has been discussion for bringing this back up for additional laws or possibly putting it before the voters (similar to what Texas did).

So gross negligence in Georgia only applies to emergency medical conditions?

 

[thegenius]

The gross negligence clause in Georgia is not as solid as it once was. In this case, by fact that you say it's not an emergency, then gross negligence clause wouldn't apply and you could be held liable. It's a catch 22. You discharge the patient, and you could be held liable for ordinary negligence.

The case was tested with Wadsworth vs Houston Medical Center Complex. A patient presented with leg pain, was evaluated by a PA, had documented pulses (albeit weak pulses), had a negative DVT ultrasound, and was discharged with a diagnosis of cellulitis. It was documented there was some erythema. The patient was found unresponsive later in the day and was taken to the Medical Center of Central Georgia. A physician documented weak pulses, but a CTA showed an occlusion. The patient ultimately lost both of her legs.

The defendants own expert witness messed up by acknowledging that you can have a blockage with faint pulses. The jury was tasked with determining whether the defendants were grossly negligent, ordinariliy negligent, or not negligent. The jury determined they breached ordinary negligence. The judge decided that gross negligence protection didn't apply to this patient because OCGA § 51-1-29.5 excludes non-urgent patients in stable conditions.

There has been discussion for bringing this back up for additional laws or possibly putting it before the voters (similar to what Texas did).

You hear these cases and it seems like you, the ER Doc, just can't win. All we read about on here are jury verdicts and settlements against ER docs. The case above (as you presented it) does not seem like negligence at all. A person with routine cellulitis doesn't become unresponsive 6 hours later. Maybe there's more to it.

 

[southerndoc]

So gross negligence in Georgia only applies to emergency medical conditions?

Basically. Unfortunately by our standards and not CMS EMTALA standards.

 

[thegenius]

Basically. Unfortunately by our standards and not CMS EMTALA standards.

What if they had an emergency, and you stabilized it?

Like a septic cellulitis that improved in the ED (e.g. improved vitals and lactate...)

"Pt had an emergency medical condition that I stabilized and now no longer has one. They are safe for discharge."

 

[southerndoc]

What if they had an emergency, and you stabilized it?

Like a septic cellulitis that improved in the ED (e.g. improved vitals and lactate...)

"Pt had an emergency medical condition that I stabilized and now no longer has one. They are safe for discharge."

You'd probably be OK, but I'm not aware of it being tested.

 

[lucid_leprechaun]

This thread is blowing my mind based on our jnstitutional practice patterns. Not unusual to order an MRI ever shift or so. MRI has become so ubiquitous that previously second, third visit diagnoses are made on a first visit. I can’t tell you how many subtle strokes in young patients have come to us for a second visit because CT negative and random ER doc X said it couldn’t be a stroke. I guess you can punt these decisions to the inpatient service in cases where time doesn’t change much however you’re risking missing the ischemic cord, DVST, orbital apex syndrome, etc. that may do better with earlier therapy. I absolutely agree though the outpatient dumps blow my mind sometimes. It mainly tells me that outpatient medicine is broken. “Patient referred to ER because of DVT/PE diagnosed as an outpatient.” Normal vitals, low risk by Hestia for PE, go home on Eliquis. You do wish someone could have just called in a script.

 

[2brads]

Not unusual to order an MRI ever shift or so.

You must work at my hospital.

 

[Clean7795]

This thread is blowing my mind based on our jnstitutional practice patterns. Not unusual to order an MRI ever shift or so. MRI has become so ubiquitous that previously second, third visit diagnoses are made on a first visit. I can’t tell you how many subtle strokes in young patients have come to us for a second visit because CT negative and random ER doc X said it couldn’t be a stroke. I guess you can punt these decisions to the inpatient service in cases where time doesn’t change much however you’re risking missing the ischemic cord, DVST, orbital apex syndrome, etc. that may do better with earlier therapy. I absolutely agree though the outpatient dumps blow my mind sometimes. It mainly tells me that outpatient medicine is broken. “Patient referred to ER because of DVT/PE diagnosed as an outpatient.” Normal vitals, low risk by Hestia for PE, go home on Eliquis. You do wish someone could have just called in a script.

We don't do MRI overnight for the vast, vast majority of ?strokes (CT/CTA +/- CT perfusion is sufficient). It has never changed management for the neurologists.

If someone has a cord infarct, you can't acutely revascularize that. Central thrombus will be generally seen on CTA. Even for punctate infarcts (i.e. CT & CT perfusion occult), most will not reach criteria for our stroke neurologists to administer tPA (because they are near asymptomatic and walking about).

 

[2brads]

We don't do MRI overnight for the vast, vast majority of ?strokes (CT/CTA +/- CT perfusion is sufficient). It has never changed management for the neurologists.

If someone has a cord infarct, you can't acutely revascularize that. Central thrombus will be generally seen on CTA. Even for punctate infarcts (i.e. CT & CT perfusion occult), most will not reach criteria for our stroke neurologists to administer tPA (because they are near asymptomatic and walking about).

Exactly this. When I ask why they need an urgent MRI, I either get *crickets* or "Because I want to know". Not appropriate.

 

[WilcoWorld]

I guess you can punt these decisions to the inpatient service in cases where time doesn’t change much however... that may do better with earlier therapy.

And after 10+ years and dozens of thousands of patients studied...we still haven't shown a benefit to emergently diagnosing sub-acute neuro complaints.

Exactly this. When I ask why they need an urgent MRI, I either get *crickets* or "Because I want to know". Not appropriate.

I've said it before and I'll say it again - tPA indication creep has destroyed Emergency Medicine Neurology. We used to make decisions. Now patients with syncope come in as Stroke Alerts and have delayed diagnosis of non-stroke conditions, and non-emergent neuro sx clog up MRIs and MRI wait times delay the care of other patients stuck in the waiting room.

 

[alpinism]

And after 10+ years and dozens of thousands of patients studied...we still haven't shown a benefit to emergently diagnosing sub-acute neuro complaints.

I've said it before and I'll say it again - tPA indication creep has destroyed Emergency Medicine Neurology. We used to make decisions. Now patients with syncope come in as Stroke Alerts and have delayed diagnosis of non-stroke conditions, and non-emergent neuro sx clog up MRIs and MRI wait times delay the care of other patients stuck in the waiting room.

We don't often talk about it but another reason why EM sucks in this country is that everything has become super proticolized without the opportunity for any type of critical thinking or attempted clinical diagnosis. Its all these ridiculous stroke and sepsis alerts with everyone getting panscanned regardless of how likely they are to actually have any real emergency pathology.

 

[Arcan57]

Location dependent of course, but there are only 2 reasons that I send a stable patient to the ED for urgent imaging. 1) I order it for same day and insurance denies it (medicaid usually), 2) Its late in the day and the test I won't can't get done that day (DVT imaging usually).

But I'm lucky to work in an area where same day CT/dopplers can usually get done.

I'm triggered because of your user name and the fact that the entirety of the healthcare system I'm in sends their patients to the ED for any workup that can't be done exclusively with test tubes. I saw a hypothetical patient yesterday with a history of 8+ prior Moh's surgeries for BCC and SCC. He had a hyperkeratotic nodule that had been growing for last 3 months. No signs of secondary infection, no systemic systems, just derm sending us a nodule so that I could call the derm attending to get patient follow-up with (checks notes)... derm. Vascular sending dialysis pt's from clinic to the ED for fistulograms, the ever present papilledema w/u's, ID turfing monkeypox evals to us... arggh.

 

[VA Hopeful Dr]

I'm triggered because of your user name and the fact that the entirety of the healthcare system I'm in sends their patients to the ED for any workup that can't be done exclusively with test tubes. I saw a hypothetical patient yesterday with a history of 8+ prior Moh's surgeries for BCC and SCC. He had a hyperkeratotic nodule that had been growing for last 3 months. No signs of secondary infection, no systemic systems, just derm sending us a nodule so that I could call the derm attending to get patient follow-up with (checks notes)... derm. Vascular sending dialysis pt's from clinic to the ED for fistulograms, the ever present papilledema w/u's, ID turfing monkeypox evals to us... arggh.

So the VA in my username is for the state of Virginia. I joined SDN as an undergrad going to school in Virginia. I didn't even know what VA hospitals were back then.