Unnecessary testing

Specialties Emergency

Published

Hello,

I was wondering if it is common practice for doctors to over utilize test when people come to the ER? My friend works in the ER and he said that the doctors would order whatever they can to charge the patient and only the older nurses or x-ray tech will question him. My friend is new and is afraid to get fired but said that it is a common practice there. I was wondering if this is a universal problem or just a few places. From my own experiences it seems that they are very eager to do a lot of expensive and more invasive tests.

I know a lot of people go because they are scared and want to know what is wrong with them and if is not serious some would be happy to be sent home and told to go to their family doc. At least the people I know would.

The reason I am asking is because ER interests me but I do not want to be in an area that puts people through unnecessary testing.

Specializes in ER/ICU/STICU.

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?)

In our ED we get harped on about keeping patients. We get pressure for our manager that once the bed is available, report is called and the patient is taken up. I don't know about anyplace else, but we get in trouble for sitting on patients. I personally don't like to do it because the patient has been trough enough by that point and the ED beds are soooo uncomfortable. Just another perspective of why this happens.

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Specializes in ER.
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

PJ, just so you know in my ER and I'm sure as other ERs...The ER docs are done with the patient from the minute the patient is signed out to the admitting team...I have a bed, I call report, and now..in most cases I am waiting for the ICU team to finish my orders...and low and behold they decide the patient needs another test before the patient leaves the ER...trust me...I'd much rather send my patient up to the ICU and let the patient finish their work-up up there so I can move and get my next patient....Its very easy to monday morning quarterback care patients receive in other departments when you don't work in them...As a flight nurse I get to receive report from many different types of units, OR, ER, PACU, ICU, Cath lab...and every unit has their good and bad...

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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?)

Okay, if you really want to know why we would admit a patient (stable or unstable) at 0600:

-we have completed the ER evaluation and treatment and have admission orders (this means the IV or IVs have been started, the foley and NG tubes placed, lab, x-ray, EKG and other diagnostic tests done, first dose of antibiotics given, heparin, nitro, whatever drip started....)

-the patient is very uncomfortable on the 3 inch thick stretcher mattress

-the family is interrupting the ER nurse every 3-5 minutes asking when the bed will be ready because the patient is very uncomfortable (see above)

-the ICU bed is empty

-I finally have a minute to transport the patient between the five other people I'm taking care of (chest pain, vag bleeder, puking baby, psychotic patient who has been hearing voices telling her to cut herself, rape victim, kid with the broken arm - you get the picture)

-we have ___ (fill in the number; at the trauma center I worked at it would be about 20 or 30) patients who are waiting in the waiting room for a stetcher so they can be evaluated and treated

-we just got a call from EMS and they're bringing in two trauma patients (that happened this morning) or a patient who is seizing, has hypoglycemia, chest pain, resp distress, or whatever who will trump the patients in the waiting room for the bed (as soon as I get it cleaned after taking the patient to the ICU at 0600)

That's all I can think of right now. Oh, wait, because the ER nurses just kind of want to sit around until the end of the shift and drink coffee and play on the internet (I wish).

Please, lets stop the blame game. We all work incredibly hard in a very difficult profession. We all have patient care as the focus of our work. We need to think of new ways to deal with this problem as it's been with us for a long time (I know I've been dealing with it for over 30 years - both as an ICU nurse and as an ER nurse). I think it's time to come up with solutions that will work for all of us (patients and nurses). Anyone have any ideas?

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Specializes in Emergency, Trauma.

Okay, not to get off topic here, but just gotta respond to a few comments that are rubbing me the wrong way!

As to these "stable as rocks" pts, if you don't feel they warrant ICU placement, perhaps you should ask your ICU docs why they are accepting them. It's not up to the ER docs to place the pts, and the intensivists certainly have the right to say when the pt does not need ICU. If a pt is kinda borderline, our ER docs will call the ICU doc and run it past them- there are times when they say no, the pt needs to go to medical or tele or whatever.

Same for the "stat a.m." tests; I don't understand how this is an ER issue? Our ER docs don't order any further testing on pts for after they've left the ER, that's up to the admitting doc. Is this different in other hospitals?

I'm an ER nurse and I know my pts; you can ask me all the questions you'd like. I seldom have a problem giving report to the unit nurses- I can say that when I was a new nurse and had a lot less knowledge, I hated it and felt like I was getting grilled. Now I know that that's just part of the ICU nurse's mindset to want the details; so it doesn't bother me, I've got the answers to the important questions. But don't expect me to know their psychosocial issues or the measurements of their decub, because I really don't care; ER has different priorities and while these things certainly are important, they are not important in the ER setting. In the ER, we need to deal with each pt's emergency and stabilize, not delve into the pt's history.

Re: pts sent up at shift change; I want my pts out of the ER as soon as possible. What people who do not work in the ER do not understand is this: IT DOESN'T MATTER WHETHER I SEND MY PT UPSTAIRS OR HOLD ON TO THEM BECAUSE I WILL GET ANOTHER PT ANYWAY. THE ONLY DIFFERENCE IF I HOLD ON TO A PT IS THAT MY NEW PT WILL BE TREATED ON A STRETCHER IN THE HALLWAY INSTEAD OF IN THE ROOM. THIS MEANS THAT IF I AM HOLDING ON TO MY ADMITTED PTS, THEN I WLL HAVE MORE PTS THAN IF I SENT THEM UPSTAIRS. With my ICU pts, the ICU doc usually comes down to the ER fairly quickly and writes his 3 pages of orders, which are now MY responsibility to initiate while I wait for an ICU bed. Please explain to me why anyone would believe that I would rather do the ICU's electrolyte protocol/rapid gastric feeding protocol/new hourly acucheck with sliding scale protocol/CVP monitoring/multiple gtt titration/sedation protocol,and on and on...when all I might have to do for a new ER pt is drop a line, do an EKG, give a few meds? Seems a pretty simple choice that a new ER pt is usually an easier gig than holding on to my ICU pt just to spite the ICU nurses.

When I'm doing charge, there are many times when I will call report for one of the nurses so the admitted pt can get out of the ER and make room for a new pt. As charge, I am glued to a desk so I can watch the monitors and take EMS calls. Chances are that I haven't seen the pt since I eyeballed tham as they wheeled into the ER hours ago. Yeah, in that instance I probably can't answer all your questions, but I'm trusting that you plan to assess the pt yourself shortly when you receive them. I'm also trusting that you can read the chart in case I don't know that the pt's great grandmother twice removed was a diabetic.

Sorry for the rambling, back to the original question- the longer I'm in the ER, the less I believe pts are overtested. I find it hard to believe that the ER docs overtest for the money, not because I think they don't care about the money, but because, as other posters have said, insurance won't reimburse uneccessary tests, and those without insurance don't pay anyway.

Tests that may seem silly are flat out CYA. There are the pts who will surprise you, and these are the ones that will come back to bite you. Case in point, a few weeks ago one of our frequent fliers, an ETOH psych pt who comes to the ER weekly came in last week; someone "stole" his meds and his pressure was high. Only this time when the ER doc ordered the all the tests, the pt was having an MI and ended up getting cathed. Who's fault do you suppose it would have been if the pt had went home, coded and died as a result of his MI if the ER doc had just done the minimal and sent him home with a new Rx for his HTN meds?

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Specializes in Emergency, Trauma.

Another thought, I have a book written by an ER doc (Kevin Pezzi), I think he has almost a whole chapter on this topic. Anyway, he brings up the point that the ER doc can be sued for not ordering enough tests, even if the pt is fine. His example is something along the line of this scenerio: suppose you have a young girl, in her twenties, come in complaining of chest pain. She denies any medical Hx. She was lifting some heavy boxes and than developed the pain. You think chest wall tenderness, just do the minimum and send her on her way with a script for some pain meds and instruction to rest. Easy, right? Except maybe this pt is obese, sedentary lifestyle, smokes, and is on birth control pills. She has a work excuse for a few days and decides to take a nice 6 hour drive to see some friends the next day. Maybe she develops a huge PE during her roadtrip, has more chest pain, but just continues to take her Rx pain meds, maybe she dies from her massive PE. Her family is furious because that ER doctor sent her home without doing any tests and look what happened. How is that doctor going to prove that she didn't have the PE when he saw her the day earlier? Worst case scenerio of course, but possible.

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Several years ago, I worked as a phlebotomist in a large "not for profit" hospital in Florida. There was a staff meeting called for all phlebs. and the Director of Lab and VP of Ancillary Services (Dir. boss). We were informed of some "Minor Changes": 1. A new $5.00 per stick drawing fee 2. We were not to draw more than 3 vials of blood- if we needed more than 3 vials we were to come back at least 30mins later for a 2nd stick and charge. 3. We were to discourage Dx. from ordering "Group Testing" (ie, request an H&H instead of CBC, because it was twice as expensive). When we all complained that this was dishonest to our pts. the hospital immediately terminated ALL of us and had the Lab Techs and Nurses draw blood until we were replaced. :angryfire

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unfortunately this can mostly be blamed on our "litigation nation". doc's just trying to cover theirs. Some docs have been burned before so now order everything on everybody. We've all heard the hoofbeat story - "if you hear hoofbeats, think horses, not zebras" -but I work with a doc that if we hear hoofbeats you can beat it's zebras. I stopped questioning him about all the extra tests after noticing all the zebras wandering around!:rotfl: :p

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unfortunately this can mostly be blamed on our "litigation nation". doc's just trying to cover theirs. Some docs have been burned before so now order everything on everybody. We've all heard the hoofbeat story - "if you hear hoofbeats, think horses, not zebras" -but I work with a doc that if we hear hoofbeats you can beat it's zebras. I stopped questioning him about all the extra tests after noticing all the zebras wandering around!:rotfl: :p

So, I guess that if you think you can make it until the next day just wait and see your family doc, right ? I mean someone that is not going to the er to get unnessecary meds or trying to screw the system but someone who is wanting quality care.

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in my experiency a lot of the visits to the er can wait till tomorrow, but i don't understand what that has to do with what I wrote. If you feel you need emergency servies come on in, but the most frequent comment I get when I ask a patient why they came to the emergency room instead of visiting a doctor is "I can't afford to go to the doctors office so I have to come to the ER" Somehow I missed the memo that stated the ER was free.

If you read my original post, all I said was that many docs order test to cover ther posterior.

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Funny how many posts (out of 3 pages...so far) have little or nothing to do with the original. My opinion (and we all know about those) is that tests will be ordered and done...some are necessary, some are not. The majority of the un-necessary ones are probably because of CYA. Some are only deemed un-necessary by us "monday morning doctors" ...after we see that is was negative ( or normal or whatever.)

As far as the ICU vs ER...that is a whole other topic and will probably never be resolved.

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Specializes in Cath Lab, OR, CPHN/SN, ER.

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.

.

EXACTLY! Not like a lot of these folks have the money to cover these bills anyways.

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Specializes in ER, ICU, L&D, OR.

Welcome to the wonderfull world of ER Nursing

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