Critical lab value? Gotta page the doc

by Walter Olson on October 13, 2008

We’ve often touched on the subject of lab testing and defensive medicine, but as Happy Hospitalist points out [Oct. 11], ordering needless testing is by no means the only way the various parties endeavor to avoid liability. Another is the superfluous communication of not-really-urgent abnormal test results, sometimes on a doctor’s pager at 4 a.m.:

Unfortunately, patient safety is rarely an issue. It’s a giant game of shifting liability. The lab documents they notified the nurse–>lab off the hook if something bad happens. The nurse notifies the doctor —> nurse off the hook if something bad happens. Doctor is left with a critical value called 10 or 20 times a day, interrupting the entire flow of patient evaluations and discharges. Every time, I must stop what I’m doing and answer a page for a critical lab value, I lose valuable face time with patients. And it all adds up over the course of a day. I wouldn’t have a problem with the system, except that critical thinking has been removed from the equation. The nurse is not allowed to make judgments as to whether a phone call is warranted or not.

As a default protocol of calling all critical lab values, the liability is shifted up the educational food chain, landing ultimately on the physician’s lap. Often times a nurse is not allowed to not call a critical lab value. The problem is, what the hospital has defined as critical, does not apply to the vast majority of critical lab values reported. What’s considered critical by hospital standards, is a normal or chronic value for [that particular] patient.

Whole thing here.

{ 26 comments }

1 Ron Miller 10.13.08 at 11:56 am

We need to break these issues down with a little more critical analysis. Do you really think hospital nurses have a great fear of medical malpractice? Is that their concern? Ask nurses where medical malpractice ranks on these list of concerns about their profession.

As it turns out, people pass the buck to others in virtually every employment context, from the construction worker to the bioloigst to the mailman to the engineer to the salesman for reasons that have abvolutely nothing to do with malpractice.

We can’t bundle everything bad that happens in a health care environment and deliver it to the door step of medical malpractice.

Now, this post does not reference medical malpractice. But the name of the blog is Overlawyered so I’m assuming there is an implication of a link or this is completely off topic.

2 nevins 10.13.08 at 12:05 pm

The nurse likely fears the most imminent possible outcome of not following policy, loosing her job or a lesser disciplinary action. But at the core of the policy created by the lab director (a physician overseeing a legion of techs) and the nursing administration is the liability bugaboo. Now everyone can respond to ‘the policy’ and the inherent threats therein if ‘the policy’ is not followed. But it goes unstated and unthought that ‘the policy’ is merely liability control formalized.

3 T. Bruce McNeely 10.13.08 at 12:38 pm

I was a lab director when we brought in a critical values policy. I can assure you, Ron, that it was in direct response to a lawsuit in Canada where a clinician claimed that he wasn’t phoned about a life-threatening lab value.
The lab disputed this,but unfortunately did not have a record of the call. Now it’s considered standard practice here. It sounds like the critical values that the Happy Hospitalist is complaining about are set too cautiously. Well, maybe in a medical sense. In a liability sense, maybe not…

4 Ron Miller 10.13.08 at 12:51 pm

Here is the thing: we cannot pretend that something is useless for patient safety yet health care providers are compelled to provide it because they fear malpractice lawsuits. Virtually everyone has (or should) have malpractice insurance right? So everyone is going to jump up and down to avoid the unlikely event of the incredibly unlikely happening coupled with the data that shows most malpractice does not result in a lawsuit? To overuse the word, not likely.

It would be insane to deny that there is some unnecessary defensive medicine as the result of fear of malpractice suits. Okay. But people have been covering their own butts from blame since the caveman. It is in practice today in even the most evolved of us. To pretend that all of that is out of fear of malpractice is just not sensible.

5 Mark 10.13.08 at 1:42 pm

I am a physician and agree that it is a nuisance. But what other way is there to handle it? A patient comes to the office; I order a chemistry, and the blood sugar is 570. Who can make the determination that this is significant or not? A lab tech? Or in the event of a in hospital patient does this become a nurse responsibility?
Aren’t doctors paid the big bucks because they take responsibility outside of a nine-to-five workday?

6 Deoxy 10.13.08 at 2:22 pm

Ron Miller:

Here is the thing: we cannot pretend that something is useless for patient safety yet health care providers are compelled to provide it because they fear malpractice lawsuits.

We don’t have to pretend such – we have multiple documented instances.

Easiest example: caesarian section births. The rate on these things has SKYROCKETED in response to lawsuits against OBs regarding cerebral palsy, but the evidence is quite thoroughly in (and has been for years) that CP is not caused in the method these lawsuits claim (that is, it happens far earlier than birth, and the OB has nothing to do with it). CP rates haven’t declined, but C-sections are still performed to prevent these lawsuits.

Virtually everyone has (or should) have malpractice insurance right? So everyone is going to jump up and down to avoid the unlikely event of the incredibly unlikely happening coupled with the data that shows most malpractice does not result in a lawsuit?

If you bothered to look into it at all, you would see that doctors will go to great length to avoid the suit itself, even when they are blameless. “The process is the punishment,” as the old saying goes. Go read a few accounts of actual doctors going through it.

Not to mention that suits can exceed the limits on malpractice insurance, so it’s not exactly risk-free.

In short, you are imagining a more reasonable world than the one we live in, and then arguing against real-world policies and actions based on those imaginings. That’s not helpful.

7 Jim Collins 10.13.08 at 3:45 pm

Ron,
In most hospitals the nurse is an employee of the hospital, while the doctor is an outside contractor. The nurses have little or no say so in these matters. If policy dictates that they call the doctor, they call the doctor. Why should the nurse risk his or her job?

8 Ron Miller 10.13.08 at 4:09 pm

Deoxy, the suggestion CP can’t be caused by medical malpractice is simply not supported by the scientific literature. The notion that C-sections are non indicated to avoid birth injuries in many cases is a premise with which you could not find a single medical doctor to agree with you on. Your suggestion that people just need to “look into it” and then they would agree with you is just anti-intellectual. This absence of critical thinking is not consistent with the tenor of this blog. (The upside of your post: I still love the block quotes, they look great in the comment section here.)

I agree with Mark, the doctor who commented above.

As for Jim, I appreciate your comment. I would reference Mark’s comment and the comments to the underlying post that most nurses use their judgment on these things for things that could actually implicate patient safety.

9 throckmorton 10.13.08 at 4:11 pm

The issue of critical lab values is part of medicine. The definition of a critical lab result is that if something is not done as a result of that information, the patient may have an adverse event. One of the problems though is that we have the staff nurses of the hospitals so busy taking care of the paperwork that they can not care for the patients. A classic example is when you are called because a patient has a low potassium. You immediately ask the nurse calling if the patient is having any rhythm problems. The answer will be “I don’t know”. This is because they are all tied up making sure the paperwork is done instead of seeing that the lab value is low and checking the patient as they are trained to do.

So in short, call me with critical values but free the nurses to take care of the patients instead of being glorified stenographers.

10 Ron Miller 10.13.08 at 4:23 pm

One more thing… are any of us feeling a little funny discussing a blog post that has at the top a “survey” on the question of whether women hate sex? Did anyone see that and ask themselves why we are taking anything this person says seriously? Going out on a limb here, I question whether this is actually a medical doctor or someone who works with one (the description of the blog does not commmit on this point).

11 Deoxy 10.13.08 at 4:56 pm

Ron Miller:

Deoxy, the suggestion CP can’t be caused by medical malpractice is simply not supported by the scientific literature. The notion that C-sections are non indicated to avoid birth injuries in many cases is a premise with which you could not find a single medical doctor to agree with you on.

1) you avoided the very specific case I was making about C-sections. Of course they are indicated in some cases (I was born by C-section).

2) your point about CP is a bald assertion on your part, and it is wrong.

If medical malpractice during birth were the cause of CP in any statistically significant way ,the massive increase in C-section births would have reduced the prevalence of CP. That has not happened.

Your suggestion that people just need to “look into it” and then they would agree with you is just anti-intellectual.

No, “just agree with me” is anti-intellectual. “I’m a doctor, so you should just believe me” is largely anti-intellectual. “Go check real data to verify my claims” is essentially the opposite – I’m NOT asking you to take my word for it.

But, just to get the point home (and with less than 2 minutes spent), I give you this:

Recent research has demonstrated that intrapartum asphyxia is not the most important cause, probably accounting for no more than 10 percent of all cases; rather, infections in the mother, even infections that are not easily detected, may triple the risk of the child developing the disorder, mainly as the result of the toxicity to the fetal brain of cytokines that are produced as part of the inflammatory response.[22]

That’s from the Wikipedia entry on cerebral palsy. Blaming doctors for CP at birth was essentially routine for quite some time (ask John Edwards), and no other evidence was necessary save the CP itself, despite the fact that the birth itself likely had nothing to do with it.

So, as I said, we have a well-documented case where doctors are doing more and more C-sections to remedy their liability, not a problem with the patient.

You want more opinions than just mine? Google “therpeutic radiation” (one deragotory catch-phrase I happen to remember seeing) for doctors talking about giving unnecessary scans of different types to cover their liability, even though the chances of it being medically useful are easily outweighed by the extra radiation exposure to the patient.

12 The Happy Hospitalist 10.13.08 at 5:17 pm

Hi Ron. I am the author. I can assure you I am a physician. I’ve been practicing for five years, so you needn’t let that part worry you too much. The survey you seem all riled up about was the result of a reader who commented, in response to another post of mine. She said women hate sex. I disagree with that assertion and am taking a poll of my readers to prove my point. Women don’t hate sex.

You don’t have to take me seriously, but my experiences on the front lines of medicine provide a lot of useful information from real world examples and experiences. I’m not going to write a stuffy and boring blog, but I will write my slant and experiences in an educational and humorous way. If you want stuffy and serious, you’ll be disappointed. You’ll likely be offended by a lot of what I write.

In case you missed the point of this post which appears to be causing you a lot of unnecessary stress, it was not simply about me not wanting to be called critical lab values. It was intended to show that the system of shifting liability is set up so all critical lab values are treated the same in terms of the documentation and the legal paper trail. Nurses have been removed from their role in critical thinking by not allowing them to make determinations as to whether a lab value, while defined as critical by hospital standards, is in fact not critical and represents a normal value for the patients. By not allowing the nurse to do the job they were trained for, it adds a whole lot of unnecessary work for the nurse and doctor and interrupts patient flow and care to the detriment of other patients. If she has to make a call, then wait for the response from me, document she waited for me, then document that she talked to me, then I must be pulled away from other patient care to answer the page that was not necessary in the first place and interrupt other patient encounters, it is the result of shifting responsibility, not patient safety. If it was patient safety, the nurse could make determinations that she is not allowed to make.

Next week I may have a poll about lawyers. You’ll need to stop by and see for yourself.

13 Ron Miller 10.13.08 at 5:31 pm

Deoxy, I can go in and edit Wikipedia. Do me a favor, don’t site Wikipedia in a Dalbert motion. But of course Wikipedia does not say that anyway. One big cause of CP is hypoxia which can be caused by negligence. The debate is over what percentage can be caused by negligence. Your 10% number is disputed by most everyone but let’s pretend it is true. It still makes your original comment false.

Speaking of Dalbert, is there a single case in the country where a court has found that there is not science to support a relionship between CP and malpractice? Has there been a single decision that says that?

Again, we all agree that it happens. The question is one of degree.

14 Ron Miller 10.13.08 at 5:45 pm

Happy Hosptialist, I was not riled up about the survey or the ads. It just makes you less credible unless you read your blog further (I initially just read the one post). I was just mocking you for fun and I should not have done that. Obviously, you just wrote a thoughtful comment here and I appreciate what you are saying. And you have sold me: you are a doctor.

Look, I don’t necessarily disagree with you. I think you very well would know better than I would on this nuanced issue. My point is that when your blog is linked to by Overlawyered, the very title of the blog suggests the implicatation that this is the fault of “overlawyering” and that medical malpractice claims are the root of this evil. My original post was directly on point to this: that you can’t bundle every problem of blame shifting and defensive medicine at the doorstep of malpractice claims. You can dump some problems, I’ll grant you. But we have to be careful which choose to place on that doorstep. One reader, Deoxy, blames the sub prime housing market crisis and the kidnapping of Patty Hearst on tort lawyers. Walter Olsen and, I suspect, you, take a little more discerning view which is why I made the original comment.

This is the longest comment of my life!

15 Nurse K 10.14.08 at 12:08 am

When I worked on the floors on straight nights, I’d get abnormal labs called to me at like 0700 or whatever. I’m not a robot, and only called those that I felt couldn’t wait until am rounds. Sometimes, of course, “am rounds” didn’t happen until like 3pm, so it’s not like there was a delay of only an hour…sometimes it was a shift or more before a “critical” lab was addressed. I’d oftentimes just call the night dood for the hospitalist service and just have them tell the patient’s specific hospitalist that was rounding on them there was a critical/unexpected lab and to see them sooner. They all carry around a sheet and jot down notes t/o the night if someone calls them about one of the hospitalist patients.

HH: If you don’t want people calling critical labs, you need to write an order saying ‘Call hospitalist immediately only if K < 2.8′ or something. Otherwise, you’re leaving it up to the nurses’ judgment.

16 jb 10.14.08 at 8:15 am

Ron Miller,
Your arguments may be right here, but the fact that you can’t see that hospitals create these policies as part of defensive medicine practices (i.e, to avoid lawsuits) raises significant doubts as to your credibility, as does the fact that you don’t recognize that, as has been said here, the process is the punishment.

17 Melvin H. 10.14.08 at 10:02 am

Um, Ron Miller—Do you mean a “Daubert” motion, instead of a “Dalbert” motion”?

18 Deoxy 10.14.08 at 10:08 am

Ron MIller:

1) This isn’t a Dalbert motion, it’s a blog comment, and (as I mentioned), that was simply the fastest thing. I’m not going to sit around and do your research for you, when it’s clear you haven’t done any.

2) For sake of argument, let’s say it’s 25% of cases. It’s STILL unreasonable that the only evidence needed to get money from the doctor is that the kid has CP, as it’s still only a 1 in 4 chance. Other evidence should be required to rule out the other 3 out of 4 chance that it was something else. To say that this doesn’t pressure doctors to perform unnecessary C-sections is the equivalent of holding your hands on your ears and screaming, “LA LA LA I CAN’T HEAR YOU!”

3) You ignored the rest of my arguments.

4) “One reader, Deoxy, blames the sub prime housing market crisis and the kidnapping of Patty Hearst on tort lawyers.” OK, now you’re just resorting to ad hominem. The only “lawyers” I blame the subprime mess on is the ones in Congress (and actually, they only bear some of the blame – complete idiots that ran some of the large investment banks are the primary culprits). I am quite open to the possibility of blame in other places besides lawyers, but I do ask for evidence. I’ve placed blame on them based on the evidence as best I can find it, and I’ll be glad to change my mind if that evidence is wrong.

19 Ron Miller 10.14.08 at 2:10 pm

Deoxy, I’m bringing this to a close but the notion that the evidence in a CP case is “Gee, 10% or 25% or whatever is the case, therefore we win” is insane. Each case is decided on its individual facts. There are injuries where the cause is malpractice 1% of the time and there is malpractice and their are injuries were the cause 99% of the time is malpractice and it is not a malpractice claim.

Okay, Deoxy. Tell me what you think of doctors who risk injury to a mother and a unborn child to avoid medical malpractice claims that are covered by insurance by giving them a c-section that is harmful to the baby or child? What percentage of doctors do you think fall into this category? Delivering babies is a really tough job on a thousand levels, one of the least of which is malpractice worries. I don’t think the fast majority of OB/GYNs make calls based on malpractice because they are too concerned with the welfare of their patients.

Sorry Melvin. We use the old Frye test still in Maryland.

20 MF 10.14.08 at 7:42 pm

I don’t think the fast majority of OB/GYNs make calls based on malpractice because they are too concerned with the welfare of their patients.

(I’m assuming you meant vast majority…)

I suspect a large percentage of OB/GYNs make their calls based at least in part by directives from their superiors, whether those superiors are hospital executives, insurance company orders, or from whomever. That statement is not meant in any way to denigrate the doctors. It’s simply a statement that doctors do not have nearly as much freedom to do whatever they think is right, and not do whatever is not necessary, as you might think.

21 Deoxy 10.15.08 at 10:56 am

Tell me what you think of doctors who risk injury to a mother and a unborn child to avoid medical malpractice claims that are covered by insurance by giving them a c-section that is harmful to the baby or child?

“Normal.”

Risks from C-section are small. Malpractice risk for not performing a C-section in some cases, even if the medical risk is low or non-existent, is high. Outcome: C-section. Duh.

It’s really a very simple issue: C-sections have gone WAY up, CP has not gone significantly down. If birthing issues were a significant cause of CP, CP would have gone down.

It’s like the issue with Thimerosal. It has been repeatedly shown to not cause autism (by many different methods of proof), but it has been eliminated anyway, simply to get the liability issue to go away.

Let’s pretend I’m a doctor. There are certain readings on certain sensors that make a CP case against a doctor very easy. If I get those readings, the only reasonable thing for me to do is to perform a C-section ASAP.

That is what has happened, but CP hasn’t gone down. If those readings had ANYTHING to do with CP, CP would have gone down.

How hard is that to understand?

As a side note: “that are covered by insurance”. Congratulations, you have successfully ignored the entire point made by me and other posters about BEING SUED being punishment in and of itself, regardless of monetary issues.

22 Walter Olson 10.15.08 at 11:12 am

Special aside to Deoxy: You will make it easier to get typos in your posts checked and fixed if you **include a non-fictional email address**. Remember that this address does not show up in the comment itself, it just allows the comment-editor-wallah, namely me, to reach you if needed.

23 ERP 10.15.08 at 11:51 am

In my ER, the secretary has to tell EITHER the RN or the doc on the case. Often, the RN does not rush over to tell me the Hgb is 8.0 in a stable patient since he or she knows it is not of immediate consequence. I find out on my own when the value gets into the documentation system. I rely on the RN to tell me when a value IS critically important – and they are usually right on. The old system was terrible where the lab just told me directly, causing me to waste my time running to the phone and thus take me away from patient care.

24 james kontak 10.15.08 at 1:02 pm

In response to comment # 5 “aren’t doctors paid the big bucks outside 9 to 5 job”—this is the problem. Doctors are not being paid big bucks relative to lawyers, MBA’s and accountants these days (maybe MBA’s have come back down to earth as of late). The insurers pay us sometimes as little as $50 for an admission and $20/day for follow-up. This supposedly covers the entire time component, liability, etc.. Obviously $50 should pay for about 1/10th of an hour or 6 minutes of time if we, as physicians, are to be fairly valued. In reality, this $50 buys a patient unlimited access/time. This is not an acceptable financial model that medicine is based. It would be much better if physicians could simply bill for time as do lawyers, accountants and even plumbers and roofers.

25 Ron Miller 10.15.08 at 2:14 pm

Deoxy, moderation is not your strong suit. The fact that doctors abhor the litigation process and that this is certainly I agree a punishment in and of itself. This does not change the fact that these claims are covered by insurance has to make an doctor less fearful of medical malpractice claims, all things being equal.

This is not a reasonable minds could differ point.

But Dexoy, please do start reading my Maryland Injury Lawyer Blog. I don’t get 50 comments on a post the way Walter does so I’d be particularly glad to argue with you over there.

26 Deoxy 10.16.08 at 11:45 am

This does not change the fact that these claims are covered by insurance has to make an doctor less fearful of medical malpractice claims, all things being equal.

“less fearful” I certainly agree with, but you’re using it to mean “not fearful”. The enormity of the difference would be difficult to overstate.

Without med-mal insurance, the feal level would be so high that many doctors would simply leave practice (we’ve seen the beginnings of such things in many areas). Certainly, med-mal makes them “less fearful”. I would never say otherwise.

But “less fearful” than “completely fearful to the point of not participating” still leaves room for lots of fear.

Let’s say that I have a gun, and I threaten two people with it (this would be the lawsuit). One of them has a bullet-proof vest, and the other doesn’t (this would represent medmal insurance). Certainly, the one with the vest should be “less fearful” than the other, but to claim that the behaviour of the one with the vest should be unaffected by my threats is still quite ridiculous.

“Months-long bureaucratic torture with a side of ongoing slander to my reputation” is quite sufficient to alter behaviour even without adding “followed by possible financial ruin” on the end.

As to moderation, it really depends on the topic. In my opinon, “painfully obvious injustice” and “moderation” don’t play well together.

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