I may not leave this up too long even though there will be no identifying information. Just want to get feedback as to how everyone's hospital does things.
Referred a patient to the ED, secondary to signs c/w Guillain Barre Syndrome. An extensive workup was done there including very specific CSF labs. The patient was admitted to the hospital for three days, and had an MRI done from head to toe. Many other labs. Pt was treated with OMT with some help. Patient continued to get weaker but not dramatically so and was discharged with a f/u with OMT and with my office but no appt date was made. Generally, if a patient goes to the ED, I will be listed as PCP for both the ED report and any labs, but if a patient is admitted, I then am listed as PCP for all reports, i.e. ED report, H & P, two discharge summaries and supposedly OMT and other consults but I received none of these. Once the paatient is admitted, the workup in the lab becomes part of the admission, and I am then listed as "Other" for all labs, imaging or other interventions. In other words, I do not receive any labs, imaging or all other intervention results. These results go to the doctors involved in the patient's care including the ED doctor who ordered the original tests.
When the patient was discharged, there were still a multitude of pending test results, which were listed on the discharge summary. There is generally a verbal report from the discharge attending to the PCP. There was. A summary was given, and the diagnosis of conversion disorder secondary to anxiety was made. There was no mention of the pending lab results. To be fair, I did receive the discharge summaries. I sometimes skim through these, but given the complexity of the case, I read through both D/C summaries. I guess the fact that I was told they found nothing and all the labs were listed as normal (every single one), I didn't really pay attention to the three lines of pending labs. I didn't know what most of them were. Generally, when I order a lab, I know why I am ordering it, so I look for the result.
The lab results came back one by one after her discharge, and the lab stated to me later they were sent to six providers, none of which were I. Hospital policy mandates that the PCP is listed as Other for all lab results both during and after the hospitalization. As PCP, I automatically received reports only, mainly ED, H&P, consults and discharge. The discharge summary concluded with the finding that based on the hospital course, physical exam, labs and imaging that it was felt the pateint had no organic reason for the weakness and pain, that nothing was consistent with GB or MS or Transverse Myelitis. The patient had a neurology phone consult, but because there was no consult note, I did not receive information about that either.
The patient went home, had the OMT f/u, was lost to f/u and presented back to me 12 days after discharge. At that point, the patient was unable to walk without assistance, could not attend school and had weakness and tingling in both legs. The patella tendon reflexes were intact, however.
I was completely dumbfounded, but as I often do, I started from the beginning and went to the hospital portal to look up the entire admission from the ED to Discharge. Upon opening the record, the first thing that jumped out was CSF labs with a red result. Red results are abnormal. The result was positive for oligoclonal bands c/w either MS or GB. These results were sent to six physicians with the exception of me. I referred the patient to pediatric neurology the following day, where the pt was diagnosed based on exam and labs with atypical GB and admitted for IVIG and Neurontin. The patient improved dramatically, but is now still in a wheelchair or using a walker.
I do see many ways where this could have been avoided. One is to really make conversion disorders a diagnosis of exclusion. The PCP should at least receive lab results of all pending labs after the hospitalization. The doctors in the hospital should be responsible for lab reconciliation. The verbal discharge should discuss the pending labs and WHY they were done and verify that I know they are out there. This should be noted in the discharge summary. The CMS mandated discharge should either go away or be the only discharge summary. Two are confusing.
Finally, all pending labs should be at the very top of the discharge summary in red, bold letters with some type of wording like, "The labs are pending and should be followed up by the primary provider."
It is just strange that after 20 years, this is the only time this has happened. Probably because Influenza, Rotavirus just don't make the grade as huge things to miss.
I am looking for any feedback. I am certainly open to criticism for not being on top of the pending labs. The last time I read the word oligoclonal bands was in medical school. My FP friends on here probably read them at least monthly. I think also assuring the patient has a f/u appointment scheduled would be helpful. Imagine a verbal discharge stating, the patient has an appointment with you on such and such a date and the discharge summary has a list of labs that are pending. While the ED did CSF for oligoclonal bands to rule out GB, we do not think the patient has that, but you should follow the result as well.
I don't know how six physicians could be sent results stating that that oligoclonal bands are present and not do anything. I also get calls about positive RSV tests and there are cutoffs, obviously, for every lab, say a sodium of 125. I don't know enough about oligoclonal bands, but the comment written in the computer was three paragraphs long. Just saying.
Again, I would like feedback. I will likely delete the thread in a couple of days, so please don't be upset that your time was wasted. Unless anyone thinks I should not have it here now.
