Acebecker Posted January 25, 2014 Share Posted January 25, 2014 All - I had gone to a lecture given by an urgent care MD and we talked about the various resp infections that come with fever. The guideline he used was something along the lines of this: If someone comes in with a cough and a fever (temp >100.4F), they don't leave unless they have a positive flu test or a negative chest xray. What are your thoughts on that? Seems like a lot of flu swabs that may be unnecessary. I like it becuase it's simple, but may be too expensive for the Pts. Not a good use of medical dollars or provider clinical decision making. Andrew Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 25, 2014 Moderator Share Posted January 25, 2014 really depends how sick the pt looks. some of these folks just need a dose of tylenol and should hav stayed at home, others need a septic workup with blood cultures, iv fluids, etc. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 25, 2014 Share Posted January 25, 2014 So what happens to those who have a negative flu and a negative chest x-ray? Too pigeon-holed for my liking. You didn't mention if the sample base was adult only or if this included peds. Nothing is ever this clear cut. Shoot, we can't even agree over strep pharyngitis, and that's when you HAVE a diagnosis (well, allegedly, but I won't go there). Link to comment Share on other sites More sharing options...
Acebecker Posted January 25, 2014 Author Share Posted January 25, 2014 Wholeheartedly agree... What I'm more concerned about is whether or not we need to flu swab everyone with a cough and a fever. If you have a non-septic looking Pt, non-productive cough, no chest pain with good v/s aside from temp and a negative exam aside from the classic flu findings, do we really need to flu swab these people? I am of the opinion that it can be a clinical diagnosis. And often it's not cost effective to swab everyone. Obviously, if the Pt looks sick we're going to do some more looking. Andrew Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 25, 2014 Moderator Share Posted January 25, 2014 agree with above. if I wouldn't tx even if flu swab + I don't check one. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 25, 2014 Share Posted January 25, 2014 Another example of the greatest statement in medicine: "Don't ask the question (or order the test) if you don't care about the answer." Link to comment Share on other sites More sharing options...
AREID Posted January 25, 2014 Share Posted January 25, 2014 I agree with everyone else. That sounds like a waste of time and money. Would you mind expanding the physicians logic? Was it to reduce lawsuits or based on something else? Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 25, 2014 Moderator Share Posted January 25, 2014 I agree with everyone else. That sounds like a waste of time and money. Would you mind expanding the physicians logic? Was it to reduce lawsuits or based on something else? Sent from my iPhone using Tapatalk $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted January 25, 2014 Moderator Share Posted January 25, 2014 Wholeheartedly agree... What I'm more concerned about is whether or not we need to flu swab everyone with a cough and a fever. If you have a non-septic looking Pt, non-productive cough, no chest pain with good v/s aside from temp and a negative exam aside from the classic flu findings, do we really need to flu swab these people? I am of the opinion that it can be a clinical diagnosis. And often it's not cost effective to swab everyone. Andrew It's absolutely a clinical diagnosis, but the real question is, what're you gonna do differently if they test positive for the flu? If they're outside the 48 hour window, and they don't have asthma and/or diabetes, you're not giving any additional medication. Even if it's within the 48 hour window, it really depends on how sick they are- if they need to be admitted, I don't think anyone questions they need a flu swab. But if they're going home...maybe if they have asthma and DM, I'll swab them because it's a CDC recommendation that they should get tamiflu Link to comment Share on other sites More sharing options...
jdumoch Posted January 25, 2014 Share Posted January 25, 2014 I work full time in UC and have seen a ton of people with this same attitude. I basically reserve flu swabs for those patient's who can't get it out of their heads that they need to be tested and I can't convince them otherwise. Considering how many false negatives there are.. my treatment never relies on the outcome of a rapid flu. If it looks like flu and they fit cdc guidelines for treatment... they get treated. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 25, 2014 Moderator Share Posted January 25, 2014 the other issue is that many places can't get a flu-swab result in real time so you need to use your clinical judgement. it's funny that I can get this at both of my rural jobs within 30 min but at my primary job at an inner city trauma center it is a send out lab with a 24-36 hr turn around time. the only time I get it there is if the pt is admitted and is likely to be an inpt for > 24 hrs. Link to comment Share on other sites More sharing options...
AREID Posted January 25, 2014 Share Posted January 25, 2014 $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ But the hospital would lose money wouldn't they? Especially if the patient doesn't have insurance. Sure, the patient will get billed buy they won't pay. Isn't one of the reasons behind ordering fewer tests to save money? I don't work at a hospital so sorry if these are dumb questions lol Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 26, 2014 Share Posted January 26, 2014 It would still be a charge-off on their operation expenses. Link to comment Share on other sites More sharing options...
Guest JMPA Posted January 26, 2014 Share Posted January 26, 2014 I totally agree with the physician IF the patients are from a high risk populations (prison inmates/guards, HIV, imigrants from high risk countries ect.) What type of patients/ field of medicine do you work in? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 26, 2014 Moderator Share Posted January 26, 2014 if it is an urgent care setting everyone has cash or insurance(see post #1). Link to comment Share on other sites More sharing options...
Guest JMPA Posted January 26, 2014 Share Posted January 26, 2014 if it is an urgent care setting everyone has cash or insurance(see post #1). does not change my point. In a high risk UC setting would be an appropriate approach, not money medicine. The op did not clarify if this was to be applied to all or select UC settings. Link to comment Share on other sites More sharing options...
UpRegulated Posted January 26, 2014 Share Posted January 26, 2014 It would still be a charge-off on their operation expenses. A charge-off is still an expense/loss of money. Link to comment Share on other sites More sharing options...
Guest Paula Posted January 26, 2014 Share Posted January 26, 2014 Here is the scenario from this past week when I was responsible for the walk-in patients while the regular provider was on vacation: Reminder.....I work on a reservation....so give me some slack. Mom comes in with 2 kids and all are sick with cough, one kid with fever. The mom tells the nurse she is coming in for antibiotics for their "bronchitis". I do the exam and tell Mom they all have the influenza. She says: but we are not vomiting and don't have diarrhea. I say: I'm talking about the respiratory flu, not the stomach flu. She says: So do we get our Z-Packs? I say: No, this is a viral condition and Z-packs don't treat viruses. She says: We always get a Z-pack when we come in and have bronchitis. I think in my head: Sigh. Then I educate on bronchitis and why it generally is not to be treated with antibiotics....... yadayadayada. Then I offer a flu swab to prove I am right and they all have the "flu". The sickest kid gets the swab and bingo! It is positive A. Mom finally gets it and goes home happy that they really don't NEED antibiotics. None got tamiflu either as all had been sick 4 days. I believe I am following the recommendations the best as possible but it is always the dance of negotiation and education and saying a prayer that the dang flu swab will be positive! Next week the regular walk-in provider will be back and the patients will once again get their "Z-Packs" for every thing that runs, coughs and sneezes. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 26, 2014 Share Posted January 26, 2014 A charge-off is still an expense/loss of money. Sure it is but it is an operational expense that they pass along to their insured clientele (at who knows what "cost") or help to balance the books at the end of the fiscal year if government or non-profit run. They aren't losing that much anyway. Unit cost is low as I recall from when my former government clinic purchased them and we ran them in the exam room with the patient watching. Very little difference from a rapid strep swab. Link to comment Share on other sites More sharing options...
Derbingle Posted January 26, 2014 Share Posted January 26, 2014 Dont we worry about two main things? Lungs and hydration? If they can breath, arent wheezing, crackling, desaturated or working to breath, and if they can drink fluids, and without vomiting. I give tylenol, recheck vitals to see if theyre tachy, give zofran and oral fluid challenge and DC home with OTC meds advice/return precautions, also as you all say, depends on how they look. DX. Viral syndrome if you dont have time to do rapid flu. They want us to do them on kids who are sick tho. Link to comment Share on other sites More sharing options...
Guest Paula Posted January 26, 2014 Share Posted January 26, 2014 Is anyone having trouble getting the suspension form of tamiflu? None of the pharmacies in our area have it in stock. Plus we had problems last year with it not being covered under the medicaid programs for families/kids. I'm not sure if that is an issue this year. Our pharmacy has only the adult dosing available. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 26, 2014 Share Posted January 26, 2014 Dont we worry about two main things? Lungs and hydration? If they can breath, arent wheezing, crackling, desaturated or working to breath, and if they can drink fluids, and without vomiting. I give tylenol, recheck vitals to see if theyre tachy, give zofran and oral fluid challenge and DC home with OTC meds advice/return precautions, also as you all say, depends on how they look. DX. Viral syndrome if you dont have time to do rapid flu. They want us to do them on kids who are sick tho. I was kind of feeling reassured after seeing you in the clinic but now I've made it to the pharmacy and you've given me a prescription for Zofran (which now keeps me from taking my screaming rug rats through the drive-thru at McDonald's when I'm already feeling crappy because of the higher co-pay, or in some cases OOP cost) in lieu of a cheaper promethazine prescription. :-) On a more serious note, I have always been somewhat leery of using not specific, but too specific diagnoses in an urgent/emergent setting such as "viral syndrome" as opposed to LRI (leaves you the option of bronchitis or pneumonia of any etiology since technically the LRT begins below the cricoid cartilage). Same goes for the more financially rewarding "gastroenteritis" based upon nothing more than a Hx/PE as opposed to N/V/D. No, I've never had a bad incident to warrant this degree of paranoia, but I've worked with some physicians who were. Link to comment Share on other sites More sharing options...
Moderator ventana Posted January 26, 2014 Moderator Share Posted January 26, 2014 money money money not enough confidence in people he works with oversimplification of the patient presentation And to top it off - there is now some articles (Which I honestly have not read) that say the rapid flu test is not that good..... if medicine were simply algorithms then a computer would be far better then a PA! I would ask for a meeting to discuss the logic of this, while explaining/education on the negatives cost, radiation, incidentaloma's, bad medicine to take the decision away from the clinician, reliance on a test instead of clinical assessment (false positives and false negatives) Are you going to treat every + flu with tamiflu? what about the issues around that?? No I would not like this... Link to comment Share on other sites More sharing options...
AREID Posted January 27, 2014 Share Posted January 27, 2014 Is anyone having trouble getting the suspension form of tamiflu? None of the pharmacies in our area have it in stock. Plus we had problems last year with it not being covered under the medicaid programs for families/kids. I'm not sure if that is an issue this year. Our pharmacy has only the adult dosing available. Yup. I'm in california. Seems a lot of pharmacies are out of stock here as well for the suspension Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 27, 2014 Share Posted January 27, 2014 Remember that the source for this recommendation was a lecturer, and not necessarily the employer. Link to comment Share on other sites More sharing options...
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