Unnecessary testing

papawjohn · Oct 6, 2005

Hey Question

As I said above, I often question the ER. You gotta get the picture. I'm the ICU RN and here's the 'question' I/WE have about ER....

First, I've been to the ER myself, of course, with specific problems and had good and appropriate treatment/work-up.

I've taken my (slightlly hysterical) daughters to ERs and been thankful for realisitic and skeptical ER MDs'/RN's. ("Daddy, I can't tilt my head forward to touch my chin against my chest!!!!") (Until the ER Doc tells them put your chin on your chest; which they do immediately.)

But there are still issues with the ER that we in the ICU have. Like why do the ER folks have to transfer the Pt at 0600? (Maybe because they were stable as rocks, and if they 'admitted' them before 0600 they'd get another Pt in their 'ER' bed?)

And why do the admits to the ICU need a Nuc-Med scan "in AM" or CT Scan in AM Stat?

Hummm....

Just the truth about the murmur in the ICU after we look at the ER record...

Papaw John

(Never to forget the report I got...ER Nurse says, 'he was still having chest pain so we gave him another Nitro' So I asked, 'did that relieve the chest pain?' And the ER Nurse says (very grieved, angry tone on voice) 'well, I don't know---I'm just GIVING REPORT!!' Have never asked any questions of ER nurses since---they aren't likely to know any answers.

P- J-

babynurselsa, RN · Oct 6, 2005

My experience over the last few years has been an increase in testing. They feel like they have to rule out everything for the liablity factor. I see complete work ups done over and over again on the same frequent flier for fear that just this once it will be something real and if they sent them out and they died family will sue.

One in particular I can think of... He gets drunk and his wife won't let him come home so he calls an ambulance c/o chest pain. He will openly smirk at us, never had an abnormal ecg, nor any elavations of enzymes but gets admitted to tele every time.

PapawJohn, I have admitted pts at shift change because my charge nurse is screaming at me to get that pt upstairs so one of the 25 angry folks in the waiting room that has been waiting for hours can come back. I never hold a pt till shift change to keep a bed occupied. I won't say no one does this since I can't answer for what others do.

I do know things like Nuc Med are unavailable on NOC. We always had CT done before going up, unless a brilliant resident orders it differently.

Sometimes I have been unable to answer some questions when I am calling report for another nurse who is tied up and we need to get the pt upstairs, again to let someone else get back for tx.

I know we all have wonderings about why other departments do some of the things that they do. I try to give them the benefit of the doubt since I don't know how things operate where they are.

I have often wondered why I get a room number at 2030 and am told I can't call report until after 2300. I try to assume it is due to staffing.

papawjohn · Oct 6, 2005

Hey sla

I don't wanna make anyone feel like they're being attacked. It's just that we in ICU are accustomed to a particular kind of 'knowledge' and 'background' on our pts. In the ER, that's not a reasonable expectation. If you're doing your job thoroughtly, we might STILL find fault. But that's OK, the Pt still got served well and all that's left is mumbling in the ER and the ICU about each other's units--and the Pt is well served--so what's the deal, eh?

I would not want to do your job---and prob'ly you don't wanna do mine. If we have 'issues' and the Pt is well served---we just have to forgive each other and be understanding of each other.

I've never been a PT in ER (myself or family) and felt that a bad job was done. It's pretty easy to be in the ICU and be critical. I am aware of the difference.

But if you give the ICU nurse report tomorrow and think of this just a little bit, they might be favorably impressed with your ER.

Papaw John

**canoehead, BSN, RN** · Oct 6, 2005

I worked for an ER that openly said that they get reimbursed for x test for this diagnosis and they wanted to maximize their revenue to pay for the tests they need that aren't reimbursed.

I've worked in 3 ER's and never seen an ER nurse hold off an admission to shift change to minimize workload. I saw almost every day the docs coming in the AM or after office hours to write the admitting orders we'd been waiting for and then the floor gets slammed at shift change. Also the doc said to each family in turn "the nurse will get you right up" and then takes an hour or two to do dictation and orders, while family gets progressively more irate, and we are SO ready to send them up...and they've been lying on the stretcher for 6 hours waiting anyway.

Seriously, the three hospitals I've been an ER nurse at, there was no change of shift conspiracy.

mommatrauma, RN · Oct 6, 2005

I've run into overtesting...but not for the reasons you suggest...I've run into it because of inexperienced docs, or patients that are poor historians that need everything worked up just because we really have no stinkin idea what is wrong with them...despite the fact that we think there is nothing at all wrong with them....There have been plenty of patients in my 10 year nursing career where I thought were being over tested...and some I've questioned and others I have not...but I can tell you that I've been surprised on more than one occasion where I think a test may have been a little over the top and something shows up on it...and if I ask the rationale for why it was ordered, it makes sense....part of it is probably a liability thing...and part of it may be over-ordering...but I've never run into a problem where tests are ordered simply for the reimbursement...because honestly...an insurance company can refuse to pay for certain things if they feel they were unecessary...so its possible that it will never get paid for....and personally I'd rather have a doctor that over orders then someone who constantly blows things off and under orders....and as for the ER and your feelings about it PJ....don't generalize...not all nurses or ERs are created equal...are there times where I don't know the answer to every question...absolutely....I try to find it out if I don't...but in the ER...I'm worried about the things that are going to kill you...ABCs...everything else is kinda secondary...so if I don't know how well someone ambulates because I haven't had the occasion to take them for a stroll and there is issue found with it...so be it...mumble away...and as for change of shift...we have no control over when our patients come into our ER...we don't round them up and say hurry up and lets get you in before the shift ends....a lot of factors effect when our patients can go up...if it happens to be right at change of shift...sorry...next time I'll ask grandmom to be more kind about picking the time when she decides to have her MI....

papawjohn · Oct 6, 2005

Hey Y'all

Please, don't misunderstand me. I'm just telling you ER types what us ICU nurses think when we admit a completely OK person into the ICU at 0630 after the ER has "played with" them all night. (2 CTs, 3 sets of blood labs with chemistries, cbcs, etc) and the 'attending' has a set of complex f/u studies for the AM on the ER orders (?Nuc Med for PE) when all labs point the other way.

Yeah, I guess that there is a sub-set of Pts who can pass thru the ER and XRay and CT and STILL turn up with a PE in Nuc Med in the AM.

You tell me how many of them there are and how many need ICU at 0600

am.

Grumble Grumble

Papaw John

carachel2 · Oct 6, 2005

Hey Question
As I said above, I often question the ER. You gotta get the picture. I'm the ICU RN and here's the 'question' I/WE have about ER....
First, I've been to the ER myself, of course, with specific problems and had good and appropriate treatment/work-up.
I've taken my (slightlly hysterical) daughters to ERs and been thankful for realisitic and skeptical ER MDs'/RN's. ("Daddy, I can't tilt my head forward to touch my chin against my chest!!!!") (Until the ER Doc tells them put your chin on your chest; which they do immediately.)
But there are still issues with the ER that we in the ICU have. Like why do the ER folks have to transfer the Pt at 0600? (Maybe because they were stable as rocks, and if they 'admitted' them before 0600 they'd get another Pt in their 'ER' bed?)
And why do the admits to the ICU need a Nuc-Med scan "in AM" or CT Scan in AM Stat?
Hummm....
Just the truth about the murmur in the ICU after we look at the ER record...
Papaw John
(Never to forget the report I got...ER Nurse says, 'he was still having chest pain so we gave him another Nitro' So I asked, 'did that relieve the chest pain?' And the ER Nurse says (very grieved, angry tone on voice) 'well, I don't know---I'm just GIVING REPORT!!' Have never asked any questions of ER nurses since---they aren't likely to know any answers.
P- J-

pj: Before I worked ER (when I worked CCU ten years ago) I used to think the ER nurses deliberately kept the patients until shift change. It was a plot they all had and employed specifically at US so they could get a patient, hold them and then have an easy afternoon.

Ha ! Now that I am working ER I know that is THE furthest thing from the truth. I SO do not want to hold a patient after we've received a bed assignment. They start wanting things and needing things that are VERY incovenient in the ER and for the ER staff. The females need to use the bathroom; they want to eat; they want more family back with them and if you keep them there too long you need to start in with routine meds and re-draws on their next set of troponins,etc. Trust me, as soon as a bed assignment is given I want them GONE. But sometimes they bring in a *fresh* chest pain *just* as I'm calling report...so the immediate transfer doesn't happen.

And then your # 2 complaint about ER nurses not knowing the answer...sometimes we are forced to call report on patients we ourselves have not been taking care of. I'm sure there are some not so bright bulbs out there, but sometimes we are just reading from an assessment sheet as we go along and we don't know all of the details. I've had CCU nurses ask me a gazillion questions about their admit orders...which drives *me* insane too, but I remember how important it was as a CCU nurse to be able to plan when my next labs were due, what drips needed to be hung,etc.etc. so I humor them and give them all I know.

Trauma Columnist · Oct 6, 2005

Whew - okay, my perspective is as both an ER RN (currently) and ICU RN (used to be).

1. The over-testing...I don't see this happening. However, what I do see happening is that our providers are called into court much more often then they would like, so they must protect themselves. Plus, few of our patients come in with a diagnosis tattooed on their chests. When you add drugs/ETOH/psych illness to your medical problems, you have pea-soup and it is necessary to rule out a lot more things. (From my ER perspective).

2. Let's not make this another us versus them (ER versus ICU) thread. We've BTDT too many times to count and that's productive.

RainbowSkye · Oct 6, 2005

I've been working in various ERs since 1979, and yup, there is a lot more testing. But golly, back in 1979 we didn't have: ct scans, mri scans, we didn't even have an ultrasound in our hospital at that time. We didn't have ck-mbs, troponines, bnps, d-dimers, or even bedside glucose testing. So, sure we do a lot more testing today. Because it's available.

ER patients are totally different that patients who present to physicians' offices. Of course, the same thing may be true at the office, but we have one chance to determine what's going on with the patient so we do and should utilize everything within our means to do it (well, within reason). Which is the point of what we do, really.

So far, I haven't worked at a facility that said, go do that ____ test so we can make _____ bucks. Wouldn't really work as such a huge amount of our patient population is indigent and can't/won't pay anyway.

As far as sending patients to the unit or the floor at inopportune times, well, welcome to my world. I swear we don't do it on purpose to wreck your day. Really.

One hospital had a great solution for all the patients waiting for beds in the ER. They decided to utilize all the patient care units to hold patients until the actual bed was ready. They would take turns - one patient to a hall bed on the medical floor, one to a hall bed on the surgical floor, one to a hall bed on the whatever floor, one to a hall bed in the ER (they checked this out with OSHA and HIPAA etc before initiating this). Worked great, and amazingly, patients got an actual bed in a much timely manner. Food for thought.

wooh, BSN, RN · Oct 6, 2005

It's just that we in ICU are accustomed to a particular kind of 'knowledge' and 'background' on our pts.

:angryfire Well I'll defend ER on that one. As a M/S nurse, I get so annoyed when I'm having to transfer a pt to the unit and after giving report get the "You must be an idiot" look from the ICU nurse and a "Is that all you know?" Well, yep, about this patient, but if you'd like, I can give you info on my other 7 patients that are waiting on me. When you've got more than 2 patients, it's tough to keep a life history on all of them.

As for the OP, it's called covering your behind in case of a lawsuit. And it's not just the ER, it's everywhere in healthcare. What kills me is you get a pancreatitis patient on the floor that decides "Well since I'm here, can you call the doctor and tell him my knee hurts?" "How long has it been hurting?" "Oh, off and on for the last 5 years." And then the doc orders an ortho consult.....:uhoh21:

Altra, BSN, RN · Oct 6, 2005

As far as testing in the ER, as others have said ... it's a combination of CYA and vague symptoms reported/presented by the patient. I suppose it happens - testing for the dollar reimbursement - but so many ER patients are there because they have no insurance to seek health care other than the ER that it would be financially shooting yourself in the foot to order unnecessary testing and then gamble that you're actually going to get paid for the services.

As far as getting patients out of the ER and up to the critical care units ... as a new grad in my hospital I've spent a fair amount of orientation time w/the new grad ICU nurses. We have some opportunity to "feel each other's pain." :chuckle One thing I'd like to make clear (again) is that we have almost NO control over when a patient goes upstairs. And there is absolutely no incentive for me to hold a patient, because if I did that I would be moving that pt. out into the hallway so that another can be put in that room - I'd be increasing my pt. assignment, not decreasing it.