Such a difference in culture!

[BigNavyPedsGuy]

Hi guys,

I'm not quite 5 months into my new practice as pediatrician at a rural community hospital. Yesterday I get a call from an ED doc. They had a suicidal teen that had been sitting in the ED for ~30hrs waiting for psych placement. They spoke with the administrator on call (who this weekend is the equivalent to the DNS) and she OKed them admitting her onto my peds service awaiting placement. I said that I understand they were stuck, but I really didn't feel comfortable with it: we're not a psych facility, we have no psych techs, there's no endpoint in therapy, etc. It was an amicable disagreement between me and the ED doc. He didn't push, wasn't upset with me, and I understood his situation.

I called the administrator on call (DNS) and discussed with her that it seemed like we were cutting corners and opening ourselves to liability. She said, "I was OK with it if the providers were comfortable with it. If you're not, then I agree, we need to wait for proper placement."

What!?!? They listen to and value provider input? They have a culture where what's best for the patient comes first!? They didn't tell me to suck it up and do it because I was in the Navy?

So awesome to be out of that environment.

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[Perrotfish]

Could you describe your job a little more? Hours, inpatient responsibilities, outpatient responsibilities, call, holidays, ancillary staff support, etc? I'm just curious what's out there when I'm done with my obligation.

 

[bobbyseal]

BNPG,
I know exactly what you're talking about. Since I've gotten out of the Navy, I have found administration to be very supportive of me. I am trying to expand services at an affiliated hospital, and everyone is very reasonable about it. There doesn't seem to be a constant amount of negativity. I'm certainly a lot busy and the acuity of care is much higher. But, I am much more happy. I work many more hours, but I am getting paid commensurate with my experience and I feel like a valued member. The Navy had a tendency to talk a lot about how it valued it's member; every time the CO addressed the command it was a constant line of BS. His actions were always contrary to what his public oration described. Enjoy it.

 

[Gastrapathy]

Before my parole, countless senior types kept telling me how the grass wasn't really greener. They were wrong.

 

[DrMetal]

Hi guys,

I'm not quite 5 months into my new practice as pediatrician at a rural community hospital. Yesterday I get a call from an ED doc. They had a suicidal teen that had been sitting in the ED for ~30hrs waiting for psych placement. They spoke with the administrator on call (who this weekend is the equivalent to the DNS) and she OKed them admitting her onto my peds service awaiting placement. I said that I understand they were stuck, but I really didn't feel comfortable with it: we're not a psych facility, we have no psych techs, there's no endpoint in therapy, etc. It was an amicable disagreement between me and the ED doc. He didn't push, wasn't upset with me, and I understood his situation.

I called the administrator on call (DNS) and discussed with her that it seemed like we were cutting corners and opening ourselves to liability. She said, "I was OK with it if the providers were comfortable with it. If you're not, then I agree, we need to wait for proper placement."

What!?!? They listen to and value provider input? They have a culture where what's best for the patient comes first!? They didn't tell me to suck it up and do it because I was in the Navy?

So awesome to be out of that environment.

So, just out of curiosity, what if said teenager went home and offed herself. You'd be involved in the ensuing investigation, I'm sure plenty would question why you blocked admission. You'd argue that you don't have adequate peds-psych support, but the vultures coming after you would argue that you should have admitted, "stabilized" the patient (as least place her on 1:1), then transfer her to a Peds-Psych service when available. That's what we do at Navy. It seems like it's a reasonable thing to do (it's what I'd want for my kid), vice letting her hang out in the ED >30 hours.

 

[Perrotfish]

So, just out of curiosity, what if said teenager went home and offed herself. You'd be involved in the ensuing investigation, I'm sure plenty would question why you blocked admission. You'd argue that you don't have adequate peds-psych support, but the vultures coming after you would argue that you should have admitted, "stabilized" the patient (as least place her on 1:1), then transfer her to a Peds-Psych service when available. That's what we do at Navy. It seems like it's a reasonable thing to do (it's what I'd want for my kid), vice letting her hang out in the ED >30 hours.

I don't think liability works that way. When a doctor asks you to assume care of a patient, and you say that you're not comfortable managing them and refuse, then they're not your patient. You can't be forced to accept responsibility for a patient that you don't feel comfortable managing.

 

[SuperSoccer19]

So, just out of curiosity, what if said teenager went home and offed herself. You'd be involved in the ensuing investigation, I'm sure plenty would question why you blocked admission. You'd argue that you don't have adequate peds-psych support, but the vultures coming after you would argue that you should have admitted, "stabilized" the patient (as least place her on 1:1), then transfer her to a Peds-Psych service when available. That's what we do at Navy. It seems like it's a reasonable thing to do (it's what I'd want for my kid), vice letting her hang out in the ED >30 hours.

What if you had a patient who needed an ICU bed/ventilator, but no such beds were available. Should you maintain him in the ER where there at least is a precedence to do and unfortunitely the standard of care Or, should you admit him to the Med-Surg ward where nurses do not have this training to manage this patient until an ICU bed opens?

 

[DrMetal]

What if you had a patient who needed an ICU bed/ventilator, but no such beds were available. Should you maintain him in the ER where there at least is a precedence to do and unfortunitely the standard of care Or, should you admit him to the Med-Surg ward where nurses do not have this training to manage this patient until an ICU bed opens?

I dunno. You kick em to the curb, they're gonna die. If you're the only hospital in a 50 mile radius, you just might have to do the latter. A med/surg nurse is better than no nurse at all. This is what they do in trauma situations: stabilize, then transfer, right?

The difficulty with peds-psych is that there are so few peds-psych wards (I think we have 2 in San Diego county), and they're constantly full (it took me 2 to 3 days sometimes to get a bed and coordinate such a transfer). A general pediatric hospitalist and a peds nursing team should be adept at admitting a psych patient, watching her, providing basic treatments, and then transferring when a bed opens up. (I would say the same for an adult medicine team, if the nearest psych service was 60 miles away with a similar 2- to 3- day wait). I'm glad the Navy does it this way.

 

[colbgw02]

So, just out of curiosity, what if said teenager went home and offed herself. You'd be involved in the ensuing investigation, I'm sure plenty would question why you blocked admission. You'd argue that you don't have adequate peds-psych support, but the vultures coming after you would argue that you should have admitted, "stabilized" the patient (as least place her on 1:1), then transfer her to a Peds-Psych service when available. That's what we do at Navy. It seems like it's a reasonable thing to do (it's what I'd want for my kid), vice letting her hang out in the ED >30 hours.

Isn't the choice in the OP between admitting to the floor vs. staying in the ED? I didn't read it as floor vs. discharging to home.

 

[DrMetal]

Isn't the choice in the OP between admitting to the floor vs. staying in the ED? I didn't read it as floor vs. discharging to home.

Perhaps . . . in any case: Stay in the ED vs. Admit to Peds vs DischargeHome , I go for option #2 (she would be better taken care of)

 

[met19]

I understand the situation. I just wonder was it best for the SI teen to be in the ED for another 30 plus hours versus a peds floor.

Sucks to be EP: multiple borders is the new norm in the civilian world. Sucks to the peds attending: nothing to do but watch. really what is best is due to a combo of factors: how loud/invasive/annoying the ED can be towards this patient how much attention will this patient get vs need in the ED. Does the floor not know how to sedate/retrain/etc.

This issue brought up could go either way and it is something the large EM organizations are increasingly concerned about (boarding and specifically psych boarding)

 

[colbgw02]

Perhaps . . . in any case: Stay in the ED vs. Admit to Peds vs DischargeHome , I go for option #2 (she would be better taken care of)

I don't know enough about the topic to say where the patient would get better care, so maybe admitting to the floor is the right answer morally. But regarding liability and the hypothetical investigation you mentioned, the pediatrician is in the clear here unless there is a duty to treat, which - as far as I can tell - only exists in this scenario for the EP, which is why it's relevant that the patient stayed in the ED.

 

[Gastrapathy]

Not a medical admission so not a medical bed. Ask neurosurgery to board the patient, at least they take care of brains .

 

[Perrotfish]

Perhaps . . . in any case: Stay in the ED vs. Admit to Peds vs DischargeHome , I go for option #2 (she would be better taken care of)

She would only be better taken care of if there is an experienced sitter on the Peds floor and a security team in place to back up the sitter. EDs are almost always equipped with sitters/security because they all take psych patients and hold them while they're waiting for a bed. Also since EDs are usually designed with open layouts (no rooms/walls) its also easy to have everyone else half-watching the psych patient from the nurses station. If you're in a children's hospital, or a big military MTF with a lot of Hulking HNs on the floor, then you probably also has someone who can act as a sitter and some kind of security team to back them up, so in that case maybe the floor is a better (more comfortable) option. Most smaller Peds wards, though, don't have either capability. You'd have to pull a nurse from the floor to act as a 1:1 sitter for that patient. So you're creating an ICU level cost of care (1:1 nursing to patient ratio) without being sure that you're meeting the standard of care at all. Do you really trust a Peds nurse with no psych training to NEVER leave the room? What if the patient becomes physically aggressive, do you really think the response time from the one hospital security guard sitting wandering around the building is going to be sufficient? No way that I would accept that patient.

 

[BigNavyPedsGuy]

She stayed in the ED longer waiting for placement. The only way she'd be sent home was if mental health cleared her for discharge.

When you cut corners on care by treating what's outside your scope, you run the risk of getting burned and having a bad outcome. Whether that's keeping too sick of a patient without ICU care or ignoring the need for psych care.

We don't have a "Peds Ward" we have a general ward that we admit peds to- they often are very uncomfortable with pediatric patients. This patient has had multiple admissions to psych facilities in the past, which made me even less comfortable not having any trained psych techs around for observation. I'm pretty sure she knew the tricks to harm herself.

Also, the argument "this is what we do at Navy" is exactly the point. I'm not in the Navy anymore, and I can do it the right way now. That's the whole point of this post. Administration listened and I was able to make a decision without non-clinical types steamrolling me.

The grass is much much greener on this side.

I should change my handle to BigPedsGuy

 

[Chonal Atresia]

She stayed in the ED longer waiting for placement. The only way she'd be sent home was if mental health cleared her for discharge.

When you cut corners on care by treating what's outside your scope, you run the risk of getting burned and having a bad outcome. Whether that's keeping too sick of a patient without ICU care or ignoring the need for psych care.

We don't have a "Peds Ward" we have a general ward that we admit peds to- they often are very uncomfortable with pediatric patients. This patient has had multiple admissions to psych facilities in the past, which made me even less comfortable not having any trained psych techs around for observation. I'm pretty sure she knew the tricks to harm herself.

Also, the argument "this is what we do at Navy" is exactly the point. I'm not in the Navy anymore, and I can do it the right way now. That's the whole point of this post. Administration listened and I was able to make a decision without non-clinical types steamrolling me.

The grass is much much greener on this side.

I should change my handle to BigPedsGuy

Trying to provide care outside the scope of what is SAFE and IN THE BEST INTEREST OF THE PATIENT is one of the many reasons why military medicine has been the subject of 2 scathing NY Times artciles. I guess they are trying to fill the wards in these community hospitals in order to justify their existence/budgets to "big Army" and "big Navy." Add to that very good but young physicians having to take care of these patients (because >95% of more experienced physicians leave at the end of their initial ADSO) and it's a recipe for disaster.

BTW, there will soon be a 3rd article published by the NY Times. I spoke with a reporter for over 45 minutes (on the record) 2 months ago. She contacted me last week and asked for my email address in preparation for the next article.

 

[met19]

Trying to provide care outside the scope of what is SAFE and IN THE BEST INTEREST OF THE PATIENT is one of the many reasons why military medicine has been the subject of 2 scathing NY Times artciles. I guess they are trying to fill the wards in these community hospitals in order to justify their existence/budgets to "big Army" and "big Navy." Add to that very good but young physicians having to take care of these patients (because >95% of more experienced physicians leave at the end of their initial ADSO) and it's a recipe for disaster.

BTW, there will soon be a 3rd article published by the NY Times. I spoke with a reporter for over 45 minutes (on the record) 2 months ago. She contacted me last week and asked for my email address in preparation for the next article.

will wait for this 3rd article but hope it causes some change at the top though I doubt it and am not holding my breath.

In the case above, the best thing for the psych patient was neither the ED nor the ward- it was a psych facility. Either of the former are substandard care. The peds ward in this case is clear- psych patients belong in an area dedicated to their specific needs which is not a normal floor. While the ED can handle the acute case- its not meant for long term psych care. Example: ED's often do not have dedicated tech's and SW for psych patients which are needed for their care.

 

[Gastrapathy]

The subtle indoctrination of good doctors is on display in this thread. The AD physicians just assume that the system will fail the patient and try to find the best possible outcome for the patient in a broken system. The parolees assume that the system can be forced to do the right thing despite an initial failure. It took me a solid year to unlearn the flawed expectations that had woven their way through the fabric of my practice. I still catch myself sometimes and it's vaguely embarrassing.

 

[jabreal00]

So, just out of curiosity, what if said teenager went home and offed herself. You'd be involved in the ensuing investigation, I'm sure plenty would question why you blocked admission. You'd argue that you don't have adequate peds-psych support, but the vultures coming after you would argue that you should have admitted, "stabilized" the patient (as least place her on 1:1), then transfer her to a Peds-Psych service when available. That's what we do at Navy. It seems like it's a reasonable thing to do (it's what I'd want for my kid), vice letting her hang out in the ED >30 hours.

Come on this is not reasonable. To admit someone to the floor without any medical indication just so a bed at an inpatient facility can open? Back in my internal medicine days, I'd refuse to admit a suicidal/homicidal adult patient just so they don't have to wait in the ER for a psychiatric bed. If that patient harms themselves on the medical ward, then guess who assumes the liability. That lawyer will ask are you board certified or residency trained psychiatrist? Oh, your not, then why did you accept the patient to your service? It is the ERs job to disposition patients to the appropriate care area. Surgical patients go to surgical services. Medical patients go to medical services. Psychiatric patients go to psychiatric services. I get that the patient may be more comfortable on the floor but that is not necessarily the right thing to do for the patient, especially if the attending is unfamiliar on the treatment protocols to keep the patient safe.

 

[bustbones26]

The difficulty with peds-psych is that there are so few peds-psych wards (I think we have 2 in San Diego county).

And so you're on staff at a major naval medical center? How are they doing this say at Oak Harbor? Bremerton? (if those places have not closed by now that is)

 

[bustbones26]

Overall, I think we have detracted from the OP. I believe that he was commenting that he enjoys the fact that his leadership at a hospital had taken the time to listen to his point of view?

We can argue whether the above case is right, wrong, or somewhere in between but how many times in our military careers have we been forced to so something that made us uncomfortable and placed a patient at risk?

 

[BigNavyPedsGuy]

And so you're on staff at a major naval medical center? How are they doing this say at Oak Harbor? Bremerton? (if those places have not closed by now that is)

Overall, I think we have detracted from the OP. I believe that he was commenting that he enjoys the fact that his leadership at a hospital had taken the time to listen to his point of view?

We can argue whether the above case is right, wrong, or somewhere in between but how many times in our military careers have we been forced to so something that made us uncomfortable and placed a patient at risk?

I was at Oak Harbor until June. For kids they went via ambulance to Seattle Children's ED. For AD they actually tried to force a plan to have them sit on the ward with a corpsman watching them overnight (not a psych tech, just the duty HM)!? The psychiatrist was thankfully able to fight it only because the terrible CO happened to be a psychiatrist and was well versed in the liability issues around it.

I saw that administrator (DNS equivalent) and thanked her for listening to me. She again re-iterated that we need to have the provider as the bottom line in comfort level. If someone one the team isn't comfortable, we need to address it. I described the culture I came from and she looked alarmed.

**exhales with relief**

 

[pgg]

I guess they are trying to fill the wards in these community hospitals in order to justify their existence/budgets to "big Army" and "big Navy."

I'm back at one of the big 3 now but my last (small) Navy hospital closed the inpatient wards in July. Prior to that there was no pressure (none ... at all) from administration to admit patients who exceeded the facility's capabilities or the physicians' scope, despite the TREMENDOUSLY underutilized ward. Everyone just understood and accepted the fact that there were a handful of patients per month suitable for admission, and when BUMED and NMW came around to talk about the small hospital initiative no one was the least bit surprised that the inpatient ward was to be closed.

It's odd to read posts here describing such pressure at other hospitals. I believe it happened, I have no reason not to believe it, it's just weirdly foreign and alien to my own experience. If there was any tragedy at my last command it was that the low case load and low acuity was bad for the physicians who couldn't practice their full scope ... not that they were pressured into practicing outside it.


BNPG, glad to hear you're loving life on the other side.

 

[DrMetal]

Come on this is not reasonable. .

I dont know what the right answer is, I was asking about it bc Ive been in the same situ, I thought I was doing a reasonable thing in admitting the kid. In any case: I dont think anyone is wrong here (not the EP, the Ped, not the ped psych folks who are overtasked...we're all trying to do the right thing). Its just more evidence that the mental health situation in this country is broke as a joke.

It's odd to read posts here describing such pressure at other hospitals. I

Im glad that you mentioned this, its good to hear it from someone more senior. Ive garnered the same from my experience, though that experience is very limited (in both time and geography, namely the last few years and primarily in SoCal). Ive seen several providers refuse admission (hell Ive seen psych refuse admission for clear psych cases) and refuse to treat in other ways.....Iv never seen anyone disciplined for it. Hell, even as a rinky dink GMO Ive refused to do things bc I wasnt comfortable...my Medical boss let it go, no questions asked.

 

[Perrotfish]

I was at Oak Harbor until June. For kids they went via ambulance to Seattle Children's ED. For AD they actually tried to force a plan to have them sit on the ward with a corpsman watching them overnight (not a psych tech, just the duty HM)!? The psychiatrist was thankfully able to fight it only because the terrible CO happened to be a psychiatrist and was well versed in the liability issues around it.

I have seen multiple civilian hospitals use non-psych techs as sitters, both in the ED and on the floor. Is that beneath the standard of care? What was the concern for liability?

 

[BigNavyPedsGuy]

I have seen multiple civilian hospitals use non-psych techs as sitters, both in the ED and on the floor. Is that beneath the standard of care? What was the concern for liability?

Yes, a corpsman unsupervised, watching a psych patient with no doctor in the building to supervise is below the standard of care.

To the other posters, in Oak Harbor, every time I sent a kid to another facility I had to account for it. The CO and XO would review the ambulance logs each morning at morning report and make the DMS answer why they were sent somewhere else. Every. Single. Transfer. I had to find the DMS and explain my justification or he would get grilled by the CO/XO. They were trying to fill our ward and decrease funds to the network. The CO was a psychiatrist, the XO a nurse and they would literally second guess my decisions every single morning.

That CO and XO are gone and Oak Harbor closed most of it's inpatient services (thankfully).

 

[denali]

To the other posters, in Oak Harbor, every time I sent a kid to another facility I had to account for it. The CO and XO would review the ambulance logs each morning at morning report and make the DMS answer why they were sent somewhere else. Every. Single. Transfer. I had to find the DMS and explain my justification or he would get grilled by the CO/XO. They were trying to fill our ward and decrease funds to the network. The CO was a psychiatrist, the XO a nurse and they would literally second guess my decisions every single morning.

Not unique. CO wants cuts in his/her supplemental care budget, so this is still the current SOP at my hospital for all transfers I either initiate from the floor or consults that I see in the ED.

 

[Perrotfish]

Not unique. CO wants cuts in his/her supplemental care budget, so this is still the current SOP at my hospital for all transfers I either initiate from the floor or consults that I see in the ED.

I've always wondered how the budget works here. Is my department/hospital actually paying for the patients that get seen in town? If they capture more of those patients, do they then have that money available to buy equipment and hire staff, or does the money just return to the federal budget from whence it came?

 

[pgg]

To the other posters, in Oak Harbor, every time I sent a kid to another facility I had to account for it. The CO and XO would review the ambulance logs each morning at morning report and make the DMS answer why they were sent somewhere else. Every. Single. Transfer. I had to find the DMS and explain my justification or he would get grilled by the CO/XO. They were trying to fill our ward and decrease funds to the network.

We did the same, but the tone of it all seems very different. When I was the DSS we had the same conversation every morning (daily board of directors meeting with the XO & CO) about the precious day's admissions and transfers. It was usually obvious why a patient was transferred. Occasionally a surgical patient we could've taken care of was sent out because a 1-of-1 surgeon couldn't be on call 24/7/365 and it was accepted without drama. The only time our XO or CO seemed to get annoyed was when a transfer was a result of something preventable - eg a piece of lab equipment was down so we couldn't do necessary labs. I don't think our surgeons felt pressured to do things they felt were inappropriate for the facility (and as an anesthesiologist I would've put the brakes on it anyway). Our CO was a NP and always deferred to the physicians' judgement about what was appropriate for care at our hospital vs deferral to the network.

There was, for better or worse, pressure on our surgeons to increase case numbers in order to justify the existence of their departments, and the anesthesia dept, and the ORs. The ORs spent by far the most money in the hospital, far more than the outpatient clinics. Someone did some math and decided that 100 cases/month was the break even point. I know our general surgeon did an awful lot of colonoscopies in part because they counted the same as anything else he did. When I left we were pushing hard to get more complex cases done via external resource sharing agreement at the nearby civilian hospital (our patients, our surgeons, their ORs, their inpatient care) and to get some of the nearby VA hospital's outpatient surgical backlog referred to us. But there was NO pressure to push the envelope of complexity and risk at our hospital.

 

[BigNavyPedsGuy]

I've always wondered how the budget works here. Is my department/hospital actually paying for the patients that get seen in town? If they capture more of those patients, do they then have that money available to buy equipment and hire staff, or does the money just return to the federal budget from whence it came?

So it comes from a different pot of money, but all within DOD's health budget. COs get a breakdown of how much out of MTF money is spent on the network and they get dinged for it.

When I was in I had senior folks tell me that on the outside it's all about money and it's not the same. That is total Bulls$@#. It's all about money on the inside too, just different people get it.

 

[BigNavyPedsGuy]

Trying to provide care outside the scope of what is SAFE and IN THE BEST INTEREST OF THE PATIENT is one of the many reasons why military medicine has been the subject of 2 scathing NY Times artciles. I guess they are trying to fill the wards in these community hospitals in order to justify their existence/budgets to "big Army" and "big Navy." Add to that very good but young physicians having to take care of these patients (because >95% of more experienced physicians leave at the end of their initial ADSO) and it's a recipe for disaster.

BTW, there will soon be a 3rd article published by the NY Times. I spoke with a reporter for over 45 minutes (on the record) 2 months ago. She contacted me last week and asked for my email address in preparation for the next article.

I spoke to her for about 45 minutes as well. I'm technically still on IRR until next summer so I stayed off the record.

 

[pgg]

I've always wondered how the budget works here. Is my department/hospital actually paying for the patients that get seen in town? If they capture more of those patients, do they then have that money available to buy equipment and hire staff, or does the money just return to the federal budget from whence it came?

It's complicated but while the individual hospital doesn't directly write the checks, they absolutely do get to-the-cent reports on exactly how much its beneficiary population is costing out in town ... and more importantly, for exactly what kind of care. If that purchased care was something we offered, we wanted to know why. For example, we'd might look over the reports and see "aneurysm coiling" or some other CPT code for a procedure that of course was way beyond our capabilities, and that was easily accepted. Inshallah. What was less fun to see was the 35 year old who got an inguinal hernia repair out in town ... because that was something we probably could've done, if only the patient had seen us first.

When non-AD patients are seen at a military hospital, if they have secondary insurance (eg, if a dependent spouse has a job and private insurance) then that insurance is supposed to be billed. Historically the military has been kind of spotty if not lazy about doing that, but in recent years it has become a priority. As an incentive for hospitals to get their billing departments in order, some fraction of that collected external billing is awarded to the hospital. IIRC it was 5% of the amount collected. I think part of the reason big navy decided to do that was to overcome the "it's not coming out of my optar" indifference some small hospitals had toward outsourced care.

 

[Chonal Atresia]

I spoke to her for about 45 minutes as well. I'm technically still on IRR until next summer so I stayed off the record.

I hammered the military on issues like the army's "brigade surgeon initiative," UAs taking precedence over patient care, computer training taking precedence over patient care, loss of GME funding, nurse as surgeon general of the army, etc, but actually refuted the poor care. Civilian hospitals can (and almost always do) settle out-of-court and part of that settlement is that no one can talk about the case at hand. Military hospitals do not have that option so all of the sob stories make mass media. I can only speak for ENT at my particular former hospital, but I would put our complication rates and surgical "success" with any hospital in the country.