"I went to Urgent Care and they didn't give me anything"

[MT2PA]

We do 48 hour f/u calls on our clientele (all employees/dependents of same employer) and I've had them ask my folks and we found that over a two week random period that ~60% never filled the prescription and actually followed the instructions.  As others have beat to death, including myself, some folks just don't get it regardless of what is said.  Heck, they even complain about TOO much information.

 

I"m not disagreeing!  Just giving some evidence to your point.

 

It's certainly not something to be implemented as a blanket policy but it has it's merits in appropriate situations.

[GetMeOuttaThisMess]

I"m not disagreeing!  Just giving some evidence to your point.

 

It's certainly not something to be implemented as a blanket policy but it has it's merits in appropriate situations.

 

 

This wasn't directed to your post.  I was just imparting information on what we've observed with regard to rescue prescriptions.  I'd like to see what additional insight could be provided by others who might have followed up on same.

 

An example of how general questions like this evolve into standard of care, I've commented previously on the EMS Med Directors conference in Dallas annually called "A Gathering of Eagles".  Contrary to what many I suspect believe, standard of care in EMS is primarily determined by what these EMS directors garner from each other.  Examples would be calling out of hospital arrests w/o transport, use of hard boards for spine injuries and are they actually beneficial or even risk further harm, and the usage of "Super Paramedics" to do home visits on frequent 911 callers to diminish calls and tying up of EMS vehicles.

 

BTW, for those of you in EM, especially at level one centers, see if you can get approval for attending one of these events.  It is broken down into quick 10-15" topic snippets and they have multiple round tables during the days to cover topics of interest from the attendees.

[sas5814]

http://jamanetwork.com/journals/jama/fullarticle/203330

 

That link is specific to AOM but I think you can make an argument for other commonly seen "want an abx but don't need it".

 

I'd also love to know what percent of those that actually fill WASP scrips use them (sometimes you pass the pharmacy on the way home and it's easier to fill it and still wait and see to use it instead of making a trip back out with a sick kid).

That was an interesting read. At first I was concerned they study relied on honest answers from the patients as to whether or not they filled the prescription. I saw they call the pharmacy to confirm. There are still a couple of potential holes in the methodology. Did the pt get a paper prescription? If so they could have gone anywhere to fill their prescription. Did they check to see if an escript was transferred to another pharmacy? It was still good info and different from what I was expecting and may spark some conversation at work.

[Guest Paula]

I've learned how to be an actress.  I listen to the UC patient sympathetically and look them straight in the eyes, nod my head, murmur my sympathies of how bad they must feel.  Then I do the exam and at the end I let out a huge sigh of relief and say:  I am so relieved that you have a condition called the rhinovirus/adenovirus/RSV and do not need antibiotics.  Your lungs are completely clear and you do not have pneumonia.  You do  not have a fever.  You are not wheezing.  Your cough is keeping you up at night.  Your nasal secretions are clear, your ears are without fluid, you feel crappy, and I have a great solution for you:

 

Tessalon perles (and for those who insist I will give Cherutussin AC).  Acetaminophen, ibuprofen, saline wash and an offer to give them a work excuse for a day off  so they don't blow snot all over their coworkers or  my lunch (if they are the hospital cafeteria employee). Then I recommend rest, chicken soup for the soul and to call Mom. 

 

Works like a charm.  

[Katera]

I've learned how to be an actress.  I listen to the UC patient sympathetically and look them straight in the eyes, nod my head, murmur my sympathies of how bad they must feel.  Then I do the exam and at the end I let out a huge sigh of relief and say:  I am so relieved that you have a condition called the rhinovirus/adenovirus/RSV and do not need antibiotics.  Your lungs are completely clear and you do not have pneumonia.  You do  not have a fever.  You are not wheezing.  Your cough is keeping you up at night.  Your nasal secretions are clear, your ears are without fluid, you feel crappy, and I have a great solution for you:

 

Tessalon perles (and for those who insist I will give Cherutussin AC).  Acetaminophen, ibuprofen, saline wash and an offer to give them a work excuse for a day off  so they don't blow snot all over their coworkers or  my lunch (if they are the hospital cafeteria employee). Then I recommend rest, chicken soup for the soul and to call Mom. 

 

Works like a charm.  

 

 

LOL I think you and I went to the same acting school ;)

[ventana]

(and for those who insist I will give Cherutussin AC).  

 

 

 

 

 

NO no and NO

 

 

Do not give narcotics out for the complainer.. cough

 

 

I have a jail full of addicts that know this and demand them all the time.....

[RuralER/Ortho]

NO no and NO

 

 

Do not give narcotics out for the complainer.. cough

 

 

I have a jail full of addicts that know this and demand them all the time.....

I don't think that we should be using narcotics for cough regardless. Just looking at the risk to reward, I can't see that it's worth it.

[mmiller3]

If we all practice the same way - then there is no one to hire, and the bean counters will actually have to let the medical professionals dictate the medical treatments....

 

As well I have to go to sleep every night knowing that i did the right thing.... I have no desire to work at a place that knowingly practices bad medicine.....

 

Let teh UC bean counters have to tell the family of an elderly person who had a cold and got ABX and then C Diff and now has failed so badly that they are goin on hospice that this all started with an ABX..... and see how they feel...

 

 

 

 

A final note - being let go is usually more about personality then just a script - you can't cop an attribute or yell at patients.... you need to have an alternative offering for treatment as listed above and even a hand out to explain when you would treat. Empower the patient with knowledge, but hold your ground....

 

While this sounds great in theory, in practice it is likely never going to to happen. I couldn't show you consistent antibiotic writing in my office of 8 providers, much less across an entire city.

 

I say you reach those you can, but never let the good fight interfere with your employment. When proper antibiotic use becomes tied to reimbursement, then we might see organizations change their tunes. Until then, Press-Ganey is king.

[sk732]

If I had my druthers, I'd put signs up beside the "we will not refill narcotic Rx's here" poster that says "You're not getting an ABx Rx for a cold or flu here"...but since we can't kick people out of our ER if they show up with even a hang nail (we have managed to with people coming in for physicals and other mentally challenged things, though I'm sure if someone make a court challenge under the Canada Health Act we'd lose),   If I'm going to do a WASP, I post date them and highlight the date for the patient and the pharmacist to see.  I have a pad of sticky notes amongst my little pocket cards with my name and credentials and Rx pads for OTC Rx's...I used to have in my primary care office some pads much like the CDC "Viral Illness Rx" that I'd use as well.  I still retain the nickname of "Antibiotic Nazi" from primary care days for good reason...goes back to a time when I did a presentation at a National PA conference up here that someone had already titled for me "CAP - Old Bugs, New Drugs"...well under the list of culprits of offending agents, I put, besides the usual bacterial agents, I put "us and our Rx pads", since I opened the presentation as "I really wanted to change this to CAP - Same Sh&t, Different Day" , since we aren't making that many new antibiotics and the ones we're using are increasing useless."

 

We're getting to the point that antibiotics will have to be controlled the same way narcotics are if people give them out for every little owee that shows up in our increasingly wimpy society.  I was told when I started working outside the military that if I wasn't getting complaints, I wasn't doing my job...I got 2 in my first week, both for refusing inappropriate prescriptions.  I also do take the time to explain why I'm doing what I'm doing and make sure that the person at least heard me - if we agree to disagree, well so be it, they're still getting the OTC Rx and tincture of time...if they feel they can afford to wait for  6 hours in another ER, well so be it - I refuse to be part of the problem.  I tell people that part of my job is to tell them things they don't want to hear, not to give them whatever they want - that's what Danny the Drug Dealer on the street corner does.  I've had (and continue to have) more than my fair share of issues with pan-resistant organisms in my life and would like to diminish that...but with non-medical (and even medical) retards running clinics like they're McDonald's Drive Thru's, I think I'm soon flying to Fantasy Island myself.

 

$0.02 CDN

 

SK

[BruceBanner]

This is a non stop never ending issue in UC. During cold and flu season we would see 60-70 people a day with colds. My organization doesn't have a policy. It is clinicians call. I would say 97% don't get an antibiotic and some have symptoms or history good enough to justify it. We also all have days where we are just tired of having the same argument over and over so we give it to them to avoid the argument and complaint. As for "wait and see" prescriptions we have disagreements. I don't because I assume the patient will just start taking it right away. Others have more faith than I do (but I think it is a lazy way to avoid doing what you should have done in the first place). Opinions vary... 

 

Never-ending issue in primary care as well. Never ceases to amaze me how many people think we can cure them of a URI.

 

I've tried almost every angle there is and patients just dont want to hear it. I think MOST of the population has this deeply-held, almost emotional belief that abx are what they ultimately need when they have a cold. Even reasonable people who give it 5-7 days.

 

They always walk out with this disappointed look on their face like you gave them a consolation prize. Then, they call another clinic in our organization or call the RN line a day later saying they are not better they need abx.

 

My personal rule is ~10 days of symptoms WITH a worsening course or other clinical features of bacterial sinusitis or bronchitis that I can document. Some special cases like old folks with COPD or those prone to PNA.

[BruceBanner]

I've got a question for you guys and gals in settings where you're not the PCP.  Do you have to deal with any satisfaction ratings such as the private practices? I honestly don't know because for the last 10 plus years in my settings I haven't had to deal with same, other than do we keep the clinic open or not?

 

Yep, and they are demoralizing. Every 4th or 5th patient gets a phone survey. They ask these patients so many questions it almost invites dissatisfaction.

 

"Did you get the appointment you wanted, in the location you wanted?? How long did you have to wait? Were you happy (happy!?) with your treatment plan? Was the provider super nice? Did they answer every question? Were they compassionate? Would you go back to them?"

 

It's fooking ridiculous and has no place in medicine.

[Katera]

Yep, and they are demoralizing. Every 4th or 5th patient gets a phone survey. They ask these patients so many questions it almost invites dissatisfaction.

 

"Did you get the appointment you wanted, in the location you wanted?? How long did you have to wait? Were you happy (happy!?) with your treatment plan? Was the provider super nice? Did they answer every question? Were they compassionate? Would you go back to them?"

 

It's fooking ridiculous and has no place in medicine.

 

 

ve

Every single pt I see gets a survey.   Every one...

[DogLovingPA]

I agree with Bruce.... people just think they need an abx and there is no way they are going to get better without one.  Even people who check in for a "cold" still look at me crazy when I tell them they don't need a zpack.  Everyone thinks that anything that lasts over 3 days and has green sputum can't possibly be viral......  

[Reality Check 2]

This is an ongoing and almost unsolvable problem in FP too.

 

My doc is too generous and expects us to be as well. The retired docs handed out oodles of abx to make folks happy and feel good about themselves.

 

Patients DO think they are owed something because they took time off, paid a copay and came in. Afebrile, breathing regularly, sats at 98% with clear ears and no redness in throat. 

 

Honestly, I am usually WAY more congested than any patient thanks to our cleaning service and whatever the hell they clean with that burns my nasal mucosa to a crisp. 

 

I get worn out - I print the CDC and WHO discussion of what a sinus infection REALLY is and I print out Mayo Clinic patient ed on allergic rhinitis and - hey, just for kicks - WHY DON'T YOU STOP SMOKING.........

 

Even a clean set of Water's X-rays or a sinus CT and they are still convinced they are DYING. 

 

We don't do surveys and I guarantee that 99.9% of our "just in case" Rxs get filled and either taken by the patient or inappropriately by someone in their household. 

 

I don't know exactly how we take this back over as the ART of medicine. I try everyday to do just one more thing to lessen the unnecessary rx'ing and then the doc/owner calls me in to say that Mrs. X is unhappy because she has always been able to come in for Kenalog shot twice a year since WWII or Mr. Y "knows" he needs the abx - (he has his spleen and doesn't need meds....)

 

I feel like I can't win most days.

 

Looking to get out of FP is about my only salvation right now.

[Guest Paula]

NO no and NO

 

 

Do not give narcotics out for the complainer.. cough

 

 

I have a jail full of addicts that know this and demand them all the time.....

 

 

I get it and have been changing my prescribing of this medication.  It is rare now but I admitted my sin on the Forum!  Please forgive me!!

 

What do you all think of Robitussion DM?  That can be abused as well.  I also haven't prescribed the Hydrocodone cough syrup and   can't remember the name of that one !!!!

[sk732]

The amount of DM in those cough syrups is actually homeopathic/sub-therapeutic in dose...what used to really work inthose cough syrups was the alcohol that used to be in them.  Apparently it's now frowned upon to give kidlettes a shot of whiskey so that they and the parents can sleep at night though.  A lot of how those cough meds work is coating the throat - something you can do with candy or honey (honey and hot buttered rum - even better, but see above...).  My mother was a base brat in Germany in the 50's and had a very bad case of pertussis - the old guy they were billeted with used to sneak her shots of schnapps at night to shut her up.

 

SK

[Reality Check 2]

Nyquil is 17% alcohol and some of my old hardliners drank pure vanilla, listerine or the like.

 

There are online calculators for dextromethorphan highs - call RoboParties - for Robitussin. The online party site calculates your weight and tells you how much DM to drink for a buzz and what to mix it with for fun - booze, benadryl, etc.

 

Astounding use of the internet.....

[sas5814]

"Astounding use of the internet....."

 

 

Indeed. :-)

To round out the subject this morning I got screamed at and threatened, not because I wouldn't give an antibiotic, but because I wouldn't give the (wrong) one she wanted. Actually said "I know my body" as her criteria for picking her antibiotic. Screamed at me. Screamed at the front desk and demanded another opinion from another provider. My medical director was here, heard the story and the patient, and basically told her no...what she was given was correct. After she screamed all over the clinic for 15 minutes then she started screaming (again) about US committing some kind of HIPAA violation. Sheesh...what a way to start a 12 hour shift.

[GetMeOuttaThisMess]

Two years, only two more years...

[ventana]

"Astounding use of the internet....."

 

 

Indeed. :-)

To round out the subject this morning I got screamed at and threatened, not because I wouldn't give an antibiotic, but because I wouldn't give the (wrong) one she wanted. Actually said "I know my body" as her criteria for picking her antibiotic. Screamed at me. Screamed at the front desk and demanded another opinion from another provider. My medical director was here, heard the story and the patient, and basically told her no...what she was given was correct. After she screamed all over the clinic for 15 minutes then she started screaming (again) about US committing some kind of HIPAA violation. Sheesh...what a way to start a 12 hour shift.

 

I would be asking her to find another PCP  

[mmiller3]

I would be asking her to find another PCP  

 

Sounds like an UC/ER position, if I am reading it correctly. Unfortunately, you can't fire those patients...

[sas5814]

I would be asking her to find another PCP  

I work for a faith based huge organization. They are all about forgiving. We are an urgent care and not her PCP. I suspect short of a physical assault (and that is iffy) they wouldn't fire a patient.

[Reality Check 2]

I work for a faith based huge organization. They are all about forgiving. We are an urgent care and not her PCP. I suspect short of a physical assault (and that is iffy) they wouldn't fire a patient.

 

 

My corp behemoth was "faith based" but forgiveness is only for the patients, not the employees.  A giant ruse of standing behind a religion and pretending to be pious. 

[EMSGuy1982]

Sums up my work week in UC this week.... I am polite and stand my ground. Usually when I tell them " I don't want to give you a medicine that is MORE likely to give you diarrhea than make you feel better. We can treat your symptoms though with OTC medications." Most get the point. Some patient populations do understand the purpose of avoiding abx and resistance which is refreshing..

 

 

 

Stand your ground and practice good medicine...

[jwells78]

LOL!! ^^^