Agree totally ! Very kind to share his expertise and his time William E. Haik, M.D., F.C.C.P., C.D.I.P. AHIMA Approved ICD-10-CM/PCS Trainer Office: (850) 863-2110 Cell: (850) 803-5854 Fax: (850) 864-4438
> On Sep 23, 2015, at 2:23 PM, William S Demaray <[email protected]> > wrote: > > 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
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