Dr. Ragland is working hard to improve the quality of our admissions. Because we got cited on the ACGME review about having too much service over education, we are trying to gather info on how to improve this problem. There have been a lot of complaints about admitting too many surgical subspecialty patients (plastics, ent, ortho etc...) or that those services using medicine to "babysit" patients while waiting to go to the OR.
We need to gather a list of solutions for Dr. Ragland by 8/2/2014.
So far this is what we have come up with, mostly Dr. Raglands ideas:
- Surgery is to put in their own post-op orders
- If we are to continue to admit, we want lectures from the attendings, maybe around 4 a year per subspecialty
- Mid level (NP/PA) must stop by the room and round with the primary teams each day and give plan OR have their notes done by 10 AM. I vote for the first option as it will be more educational. No more running around chasing the midlevel for the plan. If a surgery is canceled we need to know about it.
- NO admission without 24/7 coverage from the subspecialty attending. For example. We will not admit patients if ENT is not available that day and the next day to see the patient
- We need to come up with clear indications on when to admit a patient for surgery when the pt has medical problems. Please give clear suggestions.
- ex: HTN if BP is > 160/100
- ex: DM with glucose > 250
These are just a few ideas. Please share your suggestions with us so we can have a draft ready by 8/02/2014.
I don't think it's appropriate for surgical subspecialties to place a consult for patients who are post op and in PACU and half sedated. If they want us to comanage then they need to consult prior to OR so we can conduct a proper HPI and physical.
ReplyDeleteThis is a great suggestion. I'll make sure we include this at the meeting
DeleteWe need an exact elderly age for indication to admit without questions. I have been told by some surgery PA's that it's 80, others say its 65. we need something in writing that we can refer to if we don't admit.
ReplyDeleteWhat age do you propose?
Deletepatients who have medical problems that are chronic and well controlled should not be an excuse for the medicine service to be primary
ReplyDeleteCan you suggest a clear guideline? How about, if the chronic problem can be managed in the outpatient setting then there is no clear indication for medicine to admit?
Deleteharji was telling me about a patient who had rheumatoid arthritis and was on methotrexate. very well controlled and been on that medication for a long time. nothing to do with the planned operation from ortho. just because they're on MTX doesn't automatically make them a medicine primary patient.
DeleteHow about just consult us on stopping and restarting a special medication
Ortho has many delays in surgery, whether it's the initial surgery or for revisions. Too many times the residents are not aware of the delays until late in the evening. These delays in OR end up as our delay for discharge because many of these Ortho patients need placement to SNF or acute rehab, or need for durable medical equipment that can only be assessed by physical therapy. other residents and myself propose that if a patient is on the medicine service and well controlled and there is a delay by a minimum of two days then the patient should be on the Ortho service. Trauma's will probably be used as an excuse to keep patients on our service but we should have Ortho provide proof of these traumas and need for OR time.
ReplyDeleteThat's what the following guideline is for:
DeleteMid level (NP/PA) must stop by the room and round with the primary teams each day and give plan OR have their notes done by 10 AM
all subspecialties need to place immediate post op orders with the plans. Dr Nguyen from podiatry is a perfect example. He always has an immediate post op note that includes dressing changes and recs for follow up as outpatient
ReplyDeletesome suggestions for clear indications from a collection of residents to admit for surgery:
ReplyDelete- age >80
- HgBA1c > 9.0
- Anyone with CHF, pacemaker, CKD stage 4-5, exisiting arrythmia
- SBP> 180
- any post operative severe electrolyte abnormalities, e.g. the parathyroidectomy patient with severe hypocalcemia
Thank you, this helps..
DeleteIf medicine is going to admit for surgery subspecialty service then:
ReplyDelete1. Subspeciality service is call the team on call directly and ask us to admit the patient instead of ER residents calling us telling us to admit, this month I have had at least three consults where ortho has evaluated the patient and tells the ER to call medicine to admit and we are clueless of what the plan is for the patient and we go chasing the subspecialty of what the plan is going to be for the patient, so there needs to be direct communication
2. If the surgery gets delayed longer than 24-48 hours for no reason then they can transfer the patient onto their service and we will co-manage the patient along with them and they can be the primary service
3. I like the idea of mid levels coming to our rooms and notifying us of thier plans for the day
4. For post op patients, mid levels or residnets who assisted with the surgery need to call the primary team or team on call and notify us of any special post op orders or notify us of any complications that happened while the patient was in the OR so we know what to expect when the patient comes back to the floor.
I am 100% on learning about different fractures and management thereafter, we need to be educated on these patients if we are to manage them. I know we can always look things up but it would be nice getting some surgical lectures if we managing so much of this stuff.
ReplyDeleteThese mid levels need to be more honest with us and not lie to us, we all know who we are talking about; when the patient has no htn, they are not to make up these false diagnosis when the patient clearly has no history of htn or other medical conditions.
how about:
ReplyDelete1. new onset medical problems
2. uncontrolled medical problems
3. even given the two previoius criteria i don't understand why sgx cannot remain primary and for us to be consulted