I would just like to take this time to thank Dr. Townsend for all of his recent responses to not uncommon questions. They are always cogent, measured and backed by the most recent evidence. I have shared many with my colleagues to aid in explaining the reasoning to the doubters and naysayers. Thanks again Sean, Bill
William S Demaray BS RRT Sepsis Coordinator University Hospitals Albuquerque, NM 505-925-7370 Desk 505-480-4716 Cell -----Original Message----- From: Sepsisgroups [mailto:[email protected]] On Behalf Of Townsend, Sean, M.D. Sent: Wednesday, September 23, 2015 9:11 AM To: [email protected] Cc: [email protected] Subject: Re: [Sepsis Groups] Physician/ANP/PA Assessment Gayle, my comments are not directed at just your situation, but at this issue in general. So here it goes: Please don't take this the wrong way, but ask those docs who protest if at their next full check-up if it would be okay if the nurse in the office did the exam, instead of their internist. Or, you might ask them if they feel the bedside nurse would see significance to even report the finding of a fixed split S2 (if he noticed it) in the setting of new mild upper extremity swelling (if he noticed it) after IJ central line placement (on the same side) just a few hours earlier. <<possible acute thrombosis with associated pulmonary embolism inducing acute pulmonary hypertension>> These guys and gals went to med school and did residency and fellowship for a reason. We do not always need to resort to the lowest common denominator in care -- i.e. if there's no evidence that a doc does an exam in a critically ill person better than a nurse, use a nurse. Why not frame it the other way -- if there's no evidence a nurse can do it as well as a doctor, use a doctor until such evidence emerges. It's extraordinarily hard to have sympathy for docs who hitherto would have had to place central lines in patients and who are now only being asked to re-examine their patient. I'll make them a deal -- I'll push for a change in the rules so that a nurse can do the exam if the doc is brave enough to tell the family and document that, "I will not be coming back in the first few hours of your mother's critical illness to see her. The nurse will do everything and call me if there's a problem she detects and I'll fix by phone unless there's an emergency." Isn't critical illness an emergency for every patient and family? Finally, if they want evidence that high levels of MD care are essential evidence based elements for septic shock patients in the first 6 hours of care, I recommend they review the ProCESS trial where 31 academic medical centers with 24 hour intensivists and ED attending a managed these patients in house for the first 6 hours of care (and beyond). If you can't meet the standard of that trial for direct care by physician teams in the first 6 hours, then arguably you should not reap the benefits of that new trial which permits non-invasive monitoring via usual care. In other words, they are welcome to not see their patients and place central lines and have nurse driven protocols execute EGDT instead. Truthfully, these docs are asking for their cake (no lines to monitor and direct goal driven care) and to eat it too (no constant direct MD observation in the first 6 hours of care as in the new trials ProCESS, ProMISE, ARISE). There's no evidence basis to draw the line where they'd prefer, and so they are willing to err on the side of less safety. Doesn't seem like excellent practice to me. CMS (and you as taxpayers) pay for the value you get by such lax standards in critical care. CMS doesn't just measure evidence based care -- consider HCAHPS -- patient satisfaction is not evidence based, it's the right thing to do. Here the right thing to do is both evidence based and upstanding. It's about making healthcare better in every way not just what can be proven with big trials or what can be asserted as maybe true when big trials don't fill in the gaps. Sean On Sep 23, 2015, at 7:27 AM, "[email protected]" <[email protected]> wrote: Dr. Townsend, Thank you for your response. While I understand the rationale of providing the best care for every patient every time, I am really looking for clinical evidence to defend that bedside physician assessments correlate with measureable, superior care; my physicians are asking for a reason besides, the opinion of CMS is that “it’s just better this way.” Thank you for discussing this issue with me. Respectfully, Gayle -----Original Message----- From: Townsend, Sean, M.D. [mailto:[email protected]] Sent: Tuesday, September 22, 2015 5:45 PM To: Porter Gayle Cc: [email protected] Subject: [EXTERNAL] Re: [Sepsis Groups] Physician/ANP/PA Assessment The reason is that these patients are critically ill and the expectation of CMS is that patients accessing critical care services should be seen by a licensed provider skilled in assessing volume status and adequacy of perfusion. The expectation as well is that only a licensed provider can issue orders to react to inadequate perfusion. Relying on telephone communication and time delays associated with nursing report of information gathered second hand dilutes the information. In essence, "seeing is believing" and direct observation is more likely to result in well considered orders to correct underlying hypoperfusion. This is especially true in the early phases of a patient's critical illness where it is eminently reasonable that a patient be re-evaluated by trained eyes and hands. Imagine families' expectations as well that a loved one in the ICU needs to be seen only once, if at all, to be properly cared for? Not to put too much shame into the matter, but this is actually an instance where our habitual care patterns are exposed to reality and look pretty flimsy. Finally, it's worth remembering that rather than placing central lines and assessing cvp and scvo2 as a mandatory approach, providers are merely being asked to examine their patients. All that said, yes, many nurses are skilled and capable of assisting in this regard. Unfortunately, there are those who are not as well, and there is no way to eliminate the vagaries of second hand communication and delays in order writing with a nurse directed approach. Hope that helps a little bit. On Sep 22, 2015, at 3:31 PM, "[email protected]<mailto:[email protected]>" <[email protected]<mailto:[email protected]>> wrote: Hello, I am writing to query if there is any evidence-based reason why CMS is requiring a bedside physician assessment for septic shock patients, when the standard for other critically ill patients is typically based on a bedside nursing assessment that is reported to the physician by telephone. I work in an underserved minority population where physician access is challenging without the bedside assessment requirement, and I am curious if there is a rationale for this deviation from the norm. Thanks for your input, Gayle Porter, RN BSN Sepsis Program Coordinator Brownsville, TX _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
