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Never seen?

September 2014

Published in the September 2014 issue of Today’s Hospitalist

WHAT HAPPENS to test results pending at discharge “particularly those that are “jamais vu,” or never seen?

This scenario played out several years ago: A 25year old man was admitted for cellulitis of the left arm related to IV drug use. He responded to treatment with parenteral antibiotics and was screened for syphilis, hepatitis B and C, and HIV.

No results were available at discharge. Moreover, the discharging doctor, who took over the case on the patient’s final hospital day, hadn’t ordered the tests and failed to mention them in the discharge summary. The local free clinic did receive a copy of that summary. But the patient didn’t keep his appointment there and was lost to follow-up.

Nine months later, he presented to the same hospital ED with fever and a dry cough. A review of his labs from the prior admission found that both the hepatitis C and HIV antibody were positive.

Full-blown AIDS was confirmed. The patient sued both the admitting and discharging physicians from the original hospitalization and received an out-of-court settlement based on the “failure to diagnose and treat HIV.”

Chasing discharged patients
I was not involved in that case, but I recently had a similar experience. I was asked to perform a routine H&P on a patient admitted to our hospital’s behavioral health unit. She used heroin intravenously, and I ordered exactly the same tests noted in the previous case.

While she was entirely asymptomatic, I checked her lab results daily in the computer. Her HIV 1 and 2 rapid screening tests returned negative within 24 hours, as did the hepatitis B and C serologies. But the RPR for syphilis came back positive with a 1:8 titer three days after being drawn.

I immediately contacted the behavioral health unit, but the patient had already been discharged. The discharge summary did not mention any of the tests I’d ordered.

The confirmatory treponemal test came back negative, indicating a biological false positive (BFP). Nonetheless, I contacted the infection prevention nurse to notify the patient for further evaluation of the BFP. Had the latter test been positive, the patient could have had latent syphilis and been at risk for tertiary disease if untreated. As the ordering physician, I would have been liable for not arranging adequate follow-up.

The “Blue Book”
Both cases illustrate the medicolegal danger we face with patients we do not follow after discharge. The take-home message is simple: If you order a test, you are responsible for acting on an abnormal result unless you clearly “pass the baton” to the follow-up physician.

Before I closed my primary care practice in 2008 and began my encore career as a locum hospitalist, I performed an annual physical on an otherwise healthy 55-year old woman. As I opened the paper chart, I discovered her year-old mammogram report, which read: “Impression: Cluster of calcifications upper outer quadrant left breast suspicious for malignancy.”

My heart sank. I immediately told the patient of the result, performed a careful breast examination (which was negative), and ordered follow-up studies and a surgical consult. The work-up was negative, so I dodged that bullet.

I also established some new rules and started what we called the “Blue Book.” We began recording any lab or diagnostic study with abnormal results that could lead to death or serious illness in a blue notebook with the patient’s name, date and contact information. Patients with a Blue Book entry were told to follow up on results by phone in case they did not hear from me.

Any report flagged in the Blue Book required my initials and date, so no results could go to the chart unless I had actually seen them. Once all criteria were met, the Blue Book entry would be marked as resolved. The Blue Book was our safeguard, one I have carried forward to my hospital practice.

Tips for TIPs
I have worked at many hospitals around the country. So far, I have not found one with an organized system for dealing with tests in progress (“TIPs”) or an administrator charged with tracking pending results. Here are my recommendations:

1. Always communicate about TIPs with the follow-up physician, whether that is a hospitalist or outpatient physician. A phone call, in-person discussion or sign-out sheet is fine, as long as you note it in the hospital chart.

2. When referring a patient to a free clinic, send the discharge summary to the clinic.

3. Tell patients in-person at discharge that certain key tests are in progress or that repeat tests will be needed. Give them a written copy of those instructions and have a nurse witness your discussion, documenting the encounter in the chart and including the nurse’s name.

4. As discharging physician, review all consults, unresulted lab and pathology reports, and radiological reports. Note unresolved results or recommendations in the discharge summary in CAPITAL LETTERS. When concerned about potentially critical results, call the follow-up physician and note the conversation in the summary.

5. Start your own Blue Book “a small pocket notebook or pad or a tab in the electronic health record “with the name, date, medical record number and the potentially life-threatening test in question. Check the hospital computer until results are available, then act on any abnormal or potentially serious results.

6. When ordering tests, even if seeing the patient only once as a consult, do not assume the attending physician will see results or follow up. Use your own Blue Book for follow-up.

7. Encourage your hospital to start a discharge Blue Book program, or have a clerical person in the hospitalist program keep a TIPs log. Remember, even if you use an EHR to capture these tests, someone must be responsible for entering and retrieving results, and acting on them.

This means recording the TIPs when notified by the ordering physician and communicating final results to the ordering and follow-up physicians, and the patient. Once you’ve successfully passed the results along, write “resolved” in the book, spreadsheet or EHR.

If you cannot contact the follow-up physician and/or patient, note that in the book or spreadsheet and send a registered letter to each if there is a known address.

To make the process simpler, forward a copy of the discharge summary to the Blue Book administrator, clearly identifying TIPs in the body of the document to make it easy for the clerk to record.

Unfortunately, hospitalists have many tasks besides “doctoring.” Often, we are also unit secretaries in charge of entering orders and billing clerks coding patient services.

I’m urging us to take on one more role: risk manager. Until all potentially lethal results are automatically recorded and flagged for action, we must take a personal, proactive approach to protect our patients and ourselves.

Stephen L. Green, MD, is a locum hospitalist who also maintains a telemedicine infectious disease consulting practice. He previously practiced for more than 30 years as a primary care internist and infectious diseases specialist.