As in the recent Lovenox thread, I agree with you that many studies
ordered from the ED are unnecessary and not well thought out. Many
times this is because of protocol driven medicine instituted to
"speed" up the process when in reality it often slows things down.
When these protocols are driven from ill-defined symptomotology at
triage the ball is already rolling before the patient is seen be
someone other than the triage nurse that is looking out in the waiting
room at all the peeps waiting to be seen. I think this is directly
related to ED overcrowding and an attempt to cya in and overtaxed
To stop these protocol machine in midtracks is asking for trouble
should there be a bad outcome. If patients were seen by a ED provider
(physician, PA, or NP) and actually examined many of these studies
would never be ordered. Picture this. It's a busy night and there are
20 people piled up on the triage screen and all the beds are full. You
quickly browse through the charts looking for anything you can order
in advance so that you can expedite the already slow process. Ah ha!
Here's one! CC:Lower extremity pain and swelling x 2 days. You notice
the patient lists a history of ovarian CA and the only doctor you see
on the triage sheet you know is an oncologist so you assume this is a
recent or ongoing diagnosis. You order the venous study of that
extremity. 90 minutes late, the RVT finds you and quizzes you about
why you thought it appropriate to wake them up at 0200 for a person
with a sprained ankle.
I realize not all calls you get after hours are this obvious. Do I
think that half the studies I see ordered are pushing the limits of
appropriateness? Yes. Do I think many studies that the RVT complains
of as inappropriate are necessary? Yes. Should an RVT be available to
do studies at night. I think so. You are a valuable part of the team.
Other STAT studies could include neck trauma as well. And, when it
comes to arterial studies and you are not counting minutes, you will
lose out to the interventional radiologist every time. The key is
everybody needs to work together to get the best possible outcome for
the patient. Take the time (if they will listen) to educate (nicely)
whenever you can those folks ordering the test. I've learned a lot
Kevin Wilson, PA-C
On Apr 13, 2009, at 1611, Kathy Munson wrote:
> I can understand your dilema. However a way to better your condition
> be for your hospital to implement evidence based medical protocols
> for exam
> work up. For instance before a venous study is sent to the Vascular
> Lab or
> Radiology, D-dimer and other tests may be run, and considered with
> clinical assessment of the patient. The percentage of true clots
> will be higher
> and over utilization will be lower.
> Carotid ultrasound patients should have a CT versus a carotid
> ultrasound as
> the STAT choice. The stroke is in the head, not the neck. Most
> CEA's are
> not performed stat so the need for a CU STAT becomes less likely.
> Pulmonary embolisms need to be diagnosed. A spiral CT will
> diagnose. If there
> is no PE there is no need for the venous ultrasound. A lot of this
> is common
> sense but there is a profitable money trail defining how medicine is
> Suspected arterial graft occlusions could have angios to determine
> where or
> how many places grafts are stenosed or occluded. If a patient is at
> risk of
> losing their leg, no one should wait 30 to 45 min for a sonographer
> to drive in
> and get the machine to the ER and crank it up for an ultrasound.
> The patient
> should have an emergent angio procedure. We find that most clinical
> assessments performed in the ER by MD's or PA's do not reflect
> of vascular pathology and they order everything in the book to CYA.
> based medical protocols would help minimize willy nilly orders,
> especially in the
> middle of the night.
> Our hospital's Vascular Lab does not take call. Radiology is here
> 24/7 and will
> not turn over the vascular testing (carotids and venous duplex) to the
> Vascular Lab. Therefore, since they are here anyway, there is no
> need to
> have two departments doing double duty. We backed away from call
> successfully and Radiology is performing vascular exams after hours.
> The only real STAT vascular exam that a Vascular Lab would perform
> is an
> assessment for DVT, or a TCD in the case of an acute stroke
> confirmed with
> CT. Unless your hospital is a certified Stroke Center with a team
> of trained
> physicians and sonographers performing TCD's, there is no need for a
> or radiology ultrasound sonographer to come in STAT for a carotid
> Some may disagree with this but Neurologists and research on the web
> support this statement.
> Your thoughts?
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