Home Forums Discussions General Discussion Hospital follow-up communication

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.

You need to talk to whoever is over the hospitalists, as well as the hospital.

Handoffs are a major issue and should be taken seriously. They should have made sure they contacted you and gave you all the information. The fact that you are out of the loop in any way is NOT acceptable.

My suspicion is the other 6 physicians just looked at the name and said "not my patient" and ignored it. I wonder if they are the hospitalist group or why would they be getting the labs?

Thanks Wendell. I agree. I did talk to the person over Intensive Care and Pediatrics. He was sympathetic, but a bit defensive. Kept saying I need to own part of it.

It's not about blame or taking ownership, etc.; it's about realizing there is a problem and fixing it. Like you said, the handoff needs to be better.

I am big on systems. Telling everyone to do the handoff better is a behavioral change. Just like when we chastise or try to teach the ED physicians to not do a U/A reflex on urines on two-year-olds or younger or especially cathed specimens. Any pending lab result has to get sent to the PCP as well as the hospitalist. Where was the ordering physician? The ED doctor?

I remember with the U/A and cultures (regardless), the head of microbiology and I came up with the perfect solution. But, no one went with it. CPOE has many places where your selection brings up a window to either stop you or educate you. For instance, try ordering IV Vanco. You can but only after your check off a few boxes that tells the pharmacy why you need to use it. Should be the same with ordering a urinalysis on any child under five or whatever cutoff. Either educate them that young children and infants don't localize their infection plus a UTI in a nine-month-old is much worse than in a 16 yo. Maybe make it mandatory unless you give another reason for the U/A and U/A micro such as hematuria or proteinuria. But, no, they just keep ordering U/A reflexes and putting them on amoxicillin and Bactrim so the UTI has a 50% chance or greater of being resistant. Can't use cefprozil, that would make too much sense. But, I digress.

Bert
I feel your pain. Our hospital has had a problem for over 3 years. When a patient of mine goes to the hospital they are supposed to be on a list. My daily routine starts with going over this list to see if I need to "Own it" as they said to you...the hospital misses about 50 percent and they never get on the list. Just another one this A.M.

A recent one was an 18 yr old with a visit at 2 AM, a positive chlamydia at 0730 was released from the lab. I called the pt at 8 and had her on appropriate therapy by 9. The hospital to my knowledge never called her with the positive result. Many doctors don't do this workflow and things fall in cracks....

So I feel your pain and the discharge information I usually get is, lets just say, mostly computerized jargon...

I have talked to 3 Administration personnel, 3 ER dept heads, IT, even the multiple geeks...and they ...you guessed it sent me right back to the same VP where I started over 3 years ago...I feel your pain...it will take a death and maybe that wont even fix the problems..

Thanks Todd. Given, the patient began having some respiratory issues at the referral hospital, I guess it could be life threatening.

I'm in the same position, so this is obviously a systemic problem across the nation. As we've read, there have been major lawsuits involving the "handoff" back to primary care. I have let the CEO and CNO know about this problem, but just this week I'm still struggling with this despite all their promises. They have turfed it down to a nurse who may not be capable of really solving the problem - corporate response in most situation. I sent a sick diabetic into the ER last week. They say to follow up with PMD in 5 days, but send me nothing of value. They have some totally useless piece of paper their EMR coughs up. I told them this was a problem from when they signed up with this vendor years ago. Why do hospitals repeatedly sign up with vendors who know nothing about making an EMR useful to physicians, AND why do they continue to pay through the nose for these lousy products? Is there some kind of kickback involved? I sent a chest pain/MI patient to them (including specifically talking with the ER attending) and they not only sent nothing, but told her to follow up with a different doctor (their outpatient clinic).

The other thing is even if I see the list of 10 pending labs. In order to reconcile them, I have to go in and check PowerChart every day. I have no labs being sent to me. It would seem rather simple to change the Other to PCP on the labs the moment the discharge is done. System, system, system.

Bert,

I commend you for being so thorough in following up this patient and arranging specialty care. It seems more often than not, that just does not happen anymore. Such physician behavior can save lives and lawsuits, but of course it is uncompensated care.

To answer your question about what happens elsewhere, we don't even receive notification when one of our patients winds up in the ER or is admitted to the hospital, despite being listed as the primary care physician. We rarely receive discharge summaries. Even rarer do we get a call from the discharging hospitalist. Patients often show up in my office wondering why I don't know anything about their trip to the hospital. I've talked to various ER docs, hospitalists, IT, etc. to no avail. I have served as chairman of medicine and chief of staff - irrelevant.

To get any information about these patients, I have to go into Cerner (ugh) and suck the information out which takes forever, whereas it should have been automatically pushed out to me. The ER docs tell me that if I really wanted the information, I can go into Cerner and get it. Even if that were the case, the problem is that I don't know that I need to go into Cerner to get it because I don't know the patient was at the hospital in the first place. There are a couple of hospitals in Denver that send me information without asking for it, which is a breath of fresh air. As others have mentioned, there is a lot of potential liability with these poor practices. One of the ironies is that the hospital is reported to have over $150 million in reserves, which I'm guessing is not all that common these days.

There is a lot of talk these days about EMR interoperability. The issue which you raised is so much more basic. It seems that it is just being ignored.

You have spurred me to schedule a call to my malpractice insurance company which insures most of the doctors in the state, as well as the hospitals. They may be able to get someone's attention better than I can. Perhaps a flood of similar calls around the country may get the ball rolling to improve handoffs in patient care.

Hi Norm,

Thanks very much for your informative post. I guess I feel kinda lucky now. I receive a fax on every patient that is admitted, and I thought I was singled out, because I have to rotate it 90 degrees counter-clockwise. It is ironic, because I know when they are in, and I follow their course. When I do get the call from the hospitalist, I have to interrupt just for a second to say I have read the ED report, H & P and discharge, just so they know they can just fill in the blanks.

Our neonatologists NEVER discharge a patient without calling us. The irony there is it is either a premie, a septic workup, or a methadone baby. But, I listen intentively.

One thing I NEVER do it call or email a hospitalist to put in my two cents worth even if I think it would be helpful (unless it relates to knowledge I have of the family or patient). That's the last thing I need and really the last thing they need is to think I am second guessing.

There was a time when I could call the ED attending on call and coordinate care that I could not get done in my office, i.e. an IV bolus or IV Rocephin, etc. Now, they are just as likely to see them and send them home with neither. When I emailed the chief of the ED to tell her I have no issue with their doing what they think needs to be done as long as they honor what I have requested. At the very least call me if they think the patient is now sucking down three Mountain Dews. But, she told me quote, "I spoke with all of the ED docs, and they feel like you (being I) do not trust them. So, now I just admit them. Even more ironic, I sent a kid in with periorbital cellulitis for the hospitalist to look at and see if she felt the child needed a CT. I had asked for at least a shot of Ceftriaxone. Turns out they never called her when the child arrived, and they just sent the patient home on Clinda, ignoring the fact that non-typable H. flu can cause cellulitis of the eye. I emailed the ED doctor and simply asked him if he could contact me next time, and he forwarded my email to the ED chief. So, I received another chastizing email. She told me, I should talk to the ED doctor and let him know what I wanted. Wow. Talk about damned if you do and damned if you don't.

I try very hard after reading the ED reports and seeing glaring issues with the care (but usually not enough to truly affect the outcome) to not call or email the physicians. I just feel as though they are doing me a huge favor (in a way) by seeing my patients and generally do a good job. I also think that ED physicians are and should be trained to handle emergencies and not ear infections at midnight.

Anyway, I am going to try to push the lab to send lab results that are pending after the patient is discharged. And, it would be nice if the pending labs were in bold red at the top of the discharge. But, you are right, then I have to check Cerner every few days. But, I could still see an attorney asking me why I checked on the 4th when I could have checked on the 2nd.

At least I can check daily and see if there are any new CMS mandated Transition of Cares in Cerner. They are the first thing you see when you log in. And, to think there are many private physicians who don't even have a Cerner portal. What are they supposed to do?

I think Norm has the right idea. It's probably worth talking to your malpractice insurance company and having them talk to the hospital. While they may ignore a doctor, they are less likely to ignore a lawyer or malpractice insurance company.

I have the same experience as everyone who commented above, regarding the failure of the hospital to provide timely reports, especially those with abnormal results. As regards the other 6 doctors who received reports, there may be another explanation for the lack of follow-up. I regularly have problems from certain hospitals or physician's offices, in which the initial face sheet or partial page is received by my fax, but never the whole document. Very commonly even large institutions fail to properly configure their fax face sheet, so it is impossible to establish what information on which patient was not received completely. If all the doctors, including Bert, received a partial fax without the critical information, no follow-up would be possible. Trying to troubleshoot this type of problem with the hospital IT person usually gets down to a problem of finger-pointing.

Thanks. I think the liability insurance (especially if the same one for the hospital) is a great way to go. As John was saying and going even further, the fax may not even get to me. At least with the crazy mandated CMS transfer of care document, you have two chances. And, it actually puts the pending labs at the top.

It's crazy, because in 20 years, this is the only time I can remember this happening. I don't mean something like oligoclonal bands or an HSV PCR in the CSF coming back positive. There must be times a patient goes in overnight, and for whatever reason, they don't get the Rotazyme test until the day of discharge. Or a Lyme antibody could take three days. But, I don't remember looking at a discharge about a kid with fever and joint pain going home, and I read the d/c and go, "Oh, there is a Lyme test pending. I better follow that up."