Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Saturday, October 20, 2007

ER Follow-Up

Chief Complaint: "ER follow-up"

No, it's not an oxymoron.

Virtually all ER visits include as a prominent discharge instruction:
Much of the time it's a good idea; often I have no idea you were there or what happened to you, and I appreciate the opportunity to get up to speed. If it was an acute illness for which treatment was begun (say, pneumonia) a re-check is often appropriate to make sure you're getting better. If it's something more minor, like a bladder or ear infection, then it can be a waste of time (though sometimes a chance for me to discuss the role of antibiotics in ear infections, even though they're universally prescribed by ER docs.) Obviously if you've got stitches or some other wound, it makes sense for me to check it out, remove the sutures when it's time, and so forth.

But what about the role of the ER in following up with what was done there?

Despite the impression given -- especially by trainees -- of Emergency Medicine as shift work, there's always follow-up. Just because one doctor goes off-duty, there are virtually always aspects of the patient encounter that remain to be followed up later. And make no mistake: ER follow-up is as vital to good medical care as it is to risk management (AKA not getting sued, or, more cynically, making sure the inevitable lawsuits are as defensible as possible.)

Any time you do a test that doesn't provide a final result prior to the patient's discharge, someone has to be responsible for following up. Making sure the results are back, taking note of what they are, and contacting someone -- patient, primary or other consultant -- is part and parcel of ER care.

Oh no, I hear you cry. We never discharge patients until we have all their results. Really? You mean you never send a urine, blood or CSF culture (not just rapid antigen tests) from the ER? You can't make bacteria grow any faster, you know. You really keep people in the ER for 48-72 hours, just waiting for cultures? You've never sent out a serologic test for Lyme or anything else? Or does every single one of you work in an enormous medical center where every possible test is run on site 24/7? Do you not have radiologists reading your films on a backup basis, and have they never found something you missed? It's appropriate -- and often vital -- to send these tests from the ER, but it's just as important to make sure the results come back, are noted and disseminated to the appropriate parties.

There are many ways to accomplish this, but ideally it needs to be systematic. Keeping track of (and tracking down) results can be delegated to clerical staff, but review of results should probably be done by physicians or nurses. During an ER rotation I did at CHOP during my residency, the job was assigned to one of the senior residents each day. (That's why they were always yelling at us to get phone numbers from parents, that often didn't work anyway. Things may be a little better now in the cell phone era, but I'll bet not by much.) In one small-ish community hospital I know, the chief of the department comes in on a day (not middle of the night) he's not working a shift and goes through them. (That's the guy who called -- during office hours -- about a concern with a patient seen earlier.)

There are good ways and not-so-good ways to handle this issue. At my current hospital, the policy is only to call patients back with sent-out test results if they're positive. I think this is a terrible idea. My patient was frantically calling me for her Lyme result. That's the only way I found out about their policy and believe me, I'm going to be calling someone about it.

So to all you ER residents out there, although you may not be involved with it or see it happening, and even though it's not nearly as sexy or exciting as actually moving the meat, following up on cultures and send-outs and unexpected radiology findings is part of the job. Being in training gives you the luxury of imagining that once you dispo the patient your responsibility is over. It's as naive as an FP or IM resident saying, "I just want to practice medicine, and not be bothered with the business aspects of practice." Don't kid yourself.


At Sat Oct 20, 01:28:00 PM, Blogger Nurse K said...

Is placing 70 phone calls per day (many to indigents/homeless people etc) to relay negative results the best way to spend one's time at the highest and most expensive levels of care? Remember, we in the ER are concerned with emergencies. Negative results would indicate a non-emergency with respect to that result and using valuable and rare ER resources to tell a discharged patient that they were right---there really is no emergency---is just silly.

Makes more sense to really, really make sure the surprise positive MRSA blood culture results or the hm-that-might-be-a-hairline-cervical-fracture-afterall review of a film are relayed to a patient than telling every little girl with her routine 4 am STD check that she doesn't actually have the clap.

At Sat Oct 20, 02:16:00 PM, Blogger shadowfax said...

Follow up on cultures is essential, and as you correctly say, needs to be done in a systematic fashion. We have had people die (and settled the lawsuits, since we were truly at fault) because a blood culture or radiology over-read was not followed up.

But let's be realistic. Phone calls are time-consuming and fraught with problems. If there is an urgent need to communicate a result -- i.e. there is a necessary treatment action associated with it, then yes, we need to call. But a negative result can be sent out via US mail (just like my own PCP does).

At Sat Oct 20, 11:09:00 PM, Anonymous Anonymous said...

Perhaps you could say "if you don't hear from us in 5 days, you can assume the results are negative" so the patient doesn't worry needlessly. It's all about setting expectations. If you don't have the resource to call regarding all negative results, then at least let the patient off the hook after a certain time!

At Sun Oct 21, 12:13:00 AM, Blogger Manda said...

I would have liked a follow up call after I had my son into our Podunk ER for croup. The ER Doc kept telling me croup doesn't come up suddenly, that it builds up over several days. A chest x-ray and two hours later he finally got a wee dose of steroid (all I wanted) and we went home. I would have loved to have given that Doc a piece of my mind - it's easy to google croup and find "spasmodic croup" - a sudden onset of croup. The nurses were awesome though.

At Sun Oct 21, 12:48:00 PM, Anonymous Anonymous said...

The problem I have with the cocept of "if you don't hear from us in 5 days, you can assume the results are negative" is that you really never know if the test came back negative (or as expected).

- Maybe they came back negative.
- Maybe they came back positive, but as expected.
- Maybe thay got stuck to the bottom of someone else's results and your doctor never saw them.
- Maybe your phone number is wrong and some stranger is listening to his voice mail and going "but I didn't go to the ER".
- Maybe your doctor was kidnapped by aliens and is being forced to do Elvis impressions for little green men.

OK, probably not the last one. :-)

The point is that until the loop is closed (via phone or email or postal maill or smoke signals), the test is not done and the patient doesn't really know the results.


At Sun Oct 21, 02:33:00 PM, Anonymous Anonymous said...

If you were the patient, would you be content in "no news is good news?"

At Tue Oct 23, 10:15:00 PM, Anonymous Anonymous said...

What people like nurse K will never understand is that if you order a test, it is your responsibility (medically AND legally). If an ER wants to promptly mail negative results fine. But not giving some type of notification of test results is unacceptable. It may be hard for people like nurse K to understand this, but the simple fact is the responsibility in the end is not her's, it is the doctor watching her.

At Wed Oct 24, 06:52:00 PM, Blogger janemariemd said...

Pretty much everyone is right; it is the ordering doctor's responsibility to check for final results on all tests; it's too time consuming to call everyone with a negative test so a notice in the mail is reasonable; and not letting someone know anything about a negative test isn't good, for the reason noted above. One of my former colleagues (in the VA) used to tell patients who had chest x-rays to call in a month if they hadn't heard any the result; this is appealing because it shares some responsibility with the patient. I tell my patients we will call in a couple of days if there is an abnormality that needs to be addressed, otherwise I will send them the test results in 2-3 weeks, but sometimes it takes me a month to get through all of the reports. I like the approach of some practices, which is to have a website patients can log into to get their results.

At Thu Oct 25, 11:37:00 AM, Anonymous Anonymous said...

The point is people in the ER should not use "we are too busy" as carte blanche to not do their jobs. We are ALL busy in medicine. The ER in general has a large propensity to forget anything exists outside that bubble called the ER. A prompt lettter notifying of negative results is acceptable. A mealy mouth excuse of "we are to busy" is not. This will not even take the RN's/MD's time it could be completed durin the day. We are too buysy is not an excuse for bad medicine.

At Thu Oct 25, 04:22:00 PM, Anonymous Anonymous said...

For all the $$$ that doctors make off of a single consultation visit or a test the very least that they can do is let the patient know either way whether the result is negative or positive. I couldn't agree more with what "JK" said above. If it's a negative result, the doctor him/herself doesn't have to do it, but they should have one of their receptionists call the patient. To a doctor a negative result may seem like nothing, but to that patient it can mean finally moving on and putting the given issue/concern to rest.


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