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advice please, CT with contrast orders quandary
My group (large PE group) acquired a new contract several months ago. I have privileges and have worked a few weekend shifts on site. I am now being hassled by medical records for failing to sign orders in a timely manner. Like most diagnostic radiologists, I DON’T write orders. I avoid them all at costs. I told them there must be a mistake. I was informed, that at this hospital, there is a provision in the by laws that the onsite radiologist for the day is responsible for signing ALL orders for that day for CT’s performed with contrast. If not signed in 30 days, you lose your privileges. (I do have privileges at at least 20 other hospitals for this group).
This includes all ER CT’s and inpatients cases as well. Am I crazy, but does not set off alarm bells? If you really think about, the liability issues are huge (contrast reactions and kidney failure), and is it even legal to sign another doctor’s order?
I never saw the patients, examined the patients, ordered the studies or even read the reports that someone else may have read, never mind being responsible for an abnormal or critical finding. I am so far resisting, and trying to get it kicked up the ladder to legal.
Has anyone ever heard of this, and does anyone have any suggestions? I don’t think I can be fired for refusing to do something that seems illegal, but these days you never know.
By the way, I have spoken with a malpractice attorney who is a friend of mine, and in his opinion, signing another doctor’s report is not legal. How can this be the “standard of care”? -
13 Replies
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Sounds like your PE group should have ironed this out before you started reading for them.
I doubt its illegal, but it is stupid. Youre not really signing another doctors orders. They ordered the scan, and apparently you ordered the contrast (at least according to the way they do it).
Id fight it and get the backing of your group.
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Are these orders in Fuji PACS /RIS? If so , I feel your pain. One of the hospitals we cover has these issues. We negotiated that we would cover/sign orders like barium/ gastrograffin for fluoro studies but the orders for contrast for CTs and MRIs must come from the ordering docs. Even so, we said we will try to sign our orders in timely fashion but will not be held to losing priveledges over these inane orders. Stand firm, good luck.
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Do others on your group rotate there? Are they similarly upset?
If neither you nor your colleagues are willing to cover that hospital, then tell them that unless things change to match every other hospital with regard to contrast, starting next week they no longer have a radiology service.
My guess is theyll change their mind.
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I don’t respond to threats
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I don’t think the group knew about the “rule” before they took the contract. Since we have only had the contract for a few months, some of us are just now finding out about it now that the emails and calls from medical records have started to come in. My question for you guys is have you ever heard of anything like this before? I certainly haven’t and I have been doing this for over 20 years. As far as the legal end of it goes, how can I ethically sign an order that I had nothing to do with? “Standard of care” is the supposed to be the measure we are all expected to live up to.. This doesn’t seem to meet that definition. And I also don’t respond to threats, but I am trying to find the most diplomatic way to deal with this.
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Weve recently lost the battle on this after a delay of 4 years or so. Im told its at Joint Commission requirement. IV contrast requires a provider signature and the ordering docs/NPs etc. wont write the order because they arent familiar with IV contrast.
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We ran into the same issue at one of our hospitals.
Definintely a joint commision issue.
We put up a big fight but lost. Doesn’t seem right that the doctor ordering doesn’t sign it but the precedent was established in the health care system long before us and we could either do it or leave basically.-
I think our order set has contrast orders on it so it gets signed when they order the CT.
Medicolegally I think we are responsible for bad outcomes from contrast regardless of whether we sign an order for it. There was a case where a urologist badgered a radiologist into giving contrast unnecessarily and the the patient died. It was ruled to be the rads fault because they are the expert. The er doc and urologist pleaded ignorance at the trial.-
The only environment I’ve seen where the radiologist wasn’t responsible for the contrast order was in a state that required a MD to consent the patient for all contrast, and so that and the contrast was dumped in the ordering/referring
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A non-US perspective:
The clinicians are not “ordering” you to do a CT in a certain way. You’re not junior in their chain of command. They are really asking for your opinion on a clinical problem, so which radiological examination you do and how you do it is up to you. Therefore contrast is your responsibility, although you can ask them to provide information (eg renal function, allergies) with the referral. The radiologist justifying and protocolling the examination is “prescribing” the contrast-
That doesn’t work in the US. We can change the order on inpatients and ER patients but we can’t on outpatients. Tracking them down and changing is literally impossible more than half the time. So you start out on your high horse and quickly learn that it is an impossible fight.
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Its true. In the US, if the clinician ordered the CT with IV contrast, I must sign the contrast order. However, I cannot change to the study to non-contrast if the insurance company has authorized it as with contrast. I also cant change a CT to a CTA or vice versa. I must get a new order which may require a new pre-certification from the insurer. And that may delay the study for days.
Of course the rules vary between insurances. Some may authorize the study with or without contrast, or even with and without. But I never know what is allowed.
If a study isnt ordered correctly, we ask for a new order and reschedule.
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That’s correct Max. In Canada the referring provider is actually requesting a DI referral. Mind you, we still usually call them ‘orders”.
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