Recently, policy for call for one of the surgical subspecialities at my shop has changed in that the service refuses calls for nonemergent patients (ie, need to go to the OR RIGHT NOW) in the early evening and overnight hours. The operator has been instructed that he/she is not allowed to page the consultant outside of the 3-4 specified emergent indications. This policy has been accepted by the administration. The service has even had post op patients from surgery that day upstairs with no one to call overnight for patient issues. This policy change is leaving the ED docs and hospitalists in a sticky position. I have spoken with my director without any real response. Any suggestions on how to address this patient safety and liability issue?
Consultant misadventures
- Thread starter katmandu
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Pretty typical example of surgeons pressuring administration to cave to a "convenience policy" that clearly is not in the pt's best interest. You have to tread lightly as you and your director are much more replaceable than the $urgeon$ who likely bring big bucks to the hospital. I'd pen an email addressing your concerns in the context of "pt safety" and send it to your director so that you have a paper trail. No "off line" discussions. If your director calls you to take your concerns I'd email him after the call summarizing your conversation and/or write a memo memorializing your conversation. After that, it's his/her problem and likely he/she is not going to fight this if they value their job and the surgeons are entrenched on this policy change. Medicolegally, I'd document every time you have a surgical patient requiring an urgent consult that you attempted to consult the surgeon but that the answering service/hospital policy will not allow them to be called after hours therefore you are admitting them and placing a consult order. Most of the time, there are bylaws that dictate a time period where the surgeon must be alerted of the consult and they usually call them shortly after you place the consult in the computer. At least they do at my current hospital. If it's something that's truly emergent then I'd raise hell until I got them on the phone including a call to administration. If it's urgent but not emergent, then just document as above and admit. If there's one positive to all of this...it certainly makes admissions easy.
I mean, I have no problem admitting patients overnight for non emergent surgical issues that require hospitalization and then just putting a routine order for consult without waking up the surgeon. It just depends on the case. Most of the time, it's common sense. You just don't want to delay consulting them for appropriate cases that require an ED consult such as appendicitis, or diverticular abscess, SBO, etc.. You don't want to find yourself in a situation where the pt decompensated overnight and you never attempted to place a consult. I'd much rather be in a position where I attempted to consult the surgeon but was refused by hospital/surgeon policy and made every attempt to speak with the surgical specialist.
It's a dumb policy and is going to burn them eventually. You'll have an emergent case that's not on their list and multiple personnel refusing to put you in contact with the surgeon forcing you to wake up administration and threaten to transfer the pt inferring an EMTALA violation unless they help you get in contact with the surgeon. Do that a few times and things will quickly come to a head. Either that or you'll be replaced for not playing along.
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First, it depends a bit on which one surgical specialty this is. Note that the original post mentions "one of the ...." Plastics is different from vascular. The key to resolving this is pressure from the other surgeons. They would generally not be happy that one sub-specialty is getting special treatment; unless of course this is some bizarre situation where "sub-specialty" means podiatry.
Second, as in most things in life and everything in medicine, the key is to document. The administrators are usually smart enough to know when this is repeated in an email that the intent is to ensure that they are on the hook for the decision. The same with medical records, "operator refused to call Dr. X per hospital policy."
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If I were a hospital...why pay these people to take call 24/7 when they want to take call 16/7?
(That’s a rhetorical question)
im dying to know the surgical subspecialty.
(That’s a rhetorical question)
im dying to know the surgical subspecialty.
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Alex, I'll take "this is a urology move" for $500.
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If it's Urology I'm OK with that....there are few true emergency Urological diagnoses that require them to do something "right now". They would be
- testicular torsion
- priapism
- AUR of whatever etiology and everybody has had problems passing a foley
- septic kidney stone
- perineal necrotizing fascitis
Am I missing any? Probably some random things here and there that are quite rare: upper obstruction with pt with one kidney and anuria (seen that once)
Where I work GI has told us that, actually has told our hospitalists not to call them for stable things stable UGIB, LGIB, inflammatory colitis, gallstone pancreatitis. And then they proceed to say if they are really unstable they need to be resuscitated first before they do the procedure. In general it makes sense to me. What they don't understand though is if I have a pt on pressors for obstructive gallstone cholangitis at 0100, I or anybody else are calling them. Why wait 8 hours to do the ERCP while you are adding on pressors?
- testicular torsion
- priapism
- AUR of whatever etiology and everybody has had problems passing a foley
- septic kidney stone
- perineal necrotizing fascitis
Am I missing any? Probably some random things here and there that are quite rare: upper obstruction with pt with one kidney and anuria (seen that once)
Where I work GI has told us that, actually has told our hospitalists not to call them for stable things stable UGIB, LGIB, inflammatory colitis, gallstone pancreatitis. And then they proceed to say if they are really unstable they need to be resuscitated first before they do the procedure. In general it makes sense to me. What they don't understand though is if I have a pt on pressors for obstructive gallstone cholangitis at 0100, I or anybody else are calling them. Why wait 8 hours to do the ERCP while you are adding on pressors?
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Agreed. I used to work at a busy rural place where we had 1 urologist on call...24/7/365. While on the one hand the guy loved being a workhorse, he was a human who needed to sleep sometimes. As a group we always tried to not call him overnight except for the things on your list.
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As far as liability with individual patients, I'd just put it right in your note if it is a case you strongly feel needs a subspecialist's input. "Transferred pt to outside hospital due to the lack of ability to consult specialist due to hospital policy regarding after hours consults and my opinion that this patient requires emergent specialist evaluation." "Pt was admitted to hospitalist with presumption that specialist service would be consulted in the AM. Attempted numerous times to get ahold of specialist; however, given hospital policy, I am unable to reach specialist after hours except for a very limited scope of diagnoses." Obviously don't do this except in the most extreme cases.
This is the nuclear option, but if you are truly justified it will get the hospital administration's attention quickly because the specialists in question have committed an EMTALA violation.
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What a bunch of freaking prima donnas.
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I agree Mr. Hat
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Except that this is not the norm. I hope that no ABEM doc is consulting ENT for a PTA at 0200.
If I have to wake up a consultant for guidance on an unusual patient or urgent follow-up (that leads to the patient being discharged from the ED) or add them to the list for early AM rounding, I will. They don't have to come in. I feel zero remorse about a phone call to get help and advice, but this happens maybe once a month total on my end.
If I have to wake up a consultant for guidance on an unusual patient or urgent follow-up (that leads to the patient being discharged from the ED) or add them to the list for early AM rounding, I will. They don't have to come in. I feel zero remorse about a phone call to get help and advice, but this happens maybe once a month total on my end.
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Surgeon to administration, "If it's an emergency, they can call me. If not, they can send them home and follow up in the office."
Admin, "Okay, that seems reasonable. There's no problem, then. We'll make it policy."
EM doc: "There's a lot of middle ground between 'needs surgery right now to live' and 'well enough to go home, call the office and possibly not be seen for many days.' Those patients can be sick and still need a surgeon, to prevent decompensation. This policy is a set up for disaster."
Admin, "That's why you and the hospitalists are here, to check the patient and if they decompensate and need surgery, to call the surgeon."
EM doc, "HOW THE HELL ARE WE SUPPOSED TO CALL THE SURGEON IF THE RULE IS WE CAN'T CALL THE SURGEON?"
Admin, "You can call them, but they have to be dying, and need surgery."
EM, "So the policy is literally designed to make patients progress towards death and needing surgery, without any middle ground to prevent that?"
Admin, "Uh...Surgery and ICU care equal money, so....I guess so. Yeah."
Because the proceduralist is too lazy to get out of bed?
Enough Levophed squeezes the smooth muscle and squeezes the stone out right?
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Don't hate the player, hate the game. Anyone with the power to squeeze The Man to not have to come in nights or weekend (or extract anything else of benefit) would be a fool not to.
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Ugghhhh...ortho, is that you?
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I try not to consult the specialists, but the lazy night hospitalist always insist. "Can you please call cardiology on-call for this new-onset A-fib RVR?" Sure, they'd love to hear about that at 2AM just because you are too lazy to call them at 6 or 7AM.
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It's almost the same at every ED I work at: if a consultant is helpful and friendly we don't want to wake them up and will do everything within reason to avoid doing so. If it's a consultant who chooses to be a jerk and act like a pgy-14 resident and routinely punt/draw things out as long as possible every time they're called...their sleeping habits are viewed with apathy.
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I always say no to that. My response is something to the extent of "yeah, they probably need an inpatient consult. I have literally no question for them regarding their emergency management though, so it doesn't make sense for me to call them."
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Agreed. If it's not going to change ED management I'm not calling them. I'm not playing secretary and things get lost by playing telephone from one consultant to another.
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If you're getting pressured to place a lot of non emergent consults from the ED, one way you can fight it is to communicate directly to the hospitalist director or through your medical director and mention that you're getting a lot of requests for non emergent consults from the ED. Inform them that if you consult a specialist from the ED, you are required to place an order for a formal consult in the EMR and that you're worried about excessive consults delaying overall LOS on patients who otherwise could be solely managed by the hospitalist. This lengthens hospital stays and prolongs timely discharges which have a trickle down effect of bed holds in the ED. Recommend that the hospitalist evaluate the pt in person first before requesting a non emergent consult as a strategy for reducing overall consults per pt in the hopes of reduced inpatient LOS.
Trust me, if you get something to that effect to the hospitalist director and/or c-suite, you'll stop getting all these requests to consult x,y,z from the ED. Our guys are the complete opposite because they've been sensitized to LOS and inpatient metrics. They don't want to consult anybody if they can help it because they know if they consult cards, regardless of what they do, the pt will be in the hospital for 3 days for blood pressure control alone.
Our hospitalist director occasionally likes to poke his chest out and mention that "a real hospitalist doesn't need to consult....". To which I quietly smile underneath my surgical mask....
Trust me, if you get something to that effect to the hospitalist director and/or c-suite, you'll stop getting all these requests to consult x,y,z from the ED. Our guys are the complete opposite because they've been sensitized to LOS and inpatient metrics. They don't want to consult anybody if they can help it because they know if they consult cards, regardless of what they do, the pt will be in the hospital for 3 days for blood pressure control alone.
Our hospitalist director occasionally likes to poke his chest out and mention that "a real hospitalist doesn't need to consult....". To which I quietly smile underneath my surgical mask....
D
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This is something that is hard to learn at academic residencies with 24/7 subspecialty availability. I admit I am struggling a bit straight out of residency with knowing what is and isn’t an ‘emergent’ consult. Hopefully nobody is consulting for hematuria but is an infected stone in a septic but totally stable patient (ie leukocytes is and HR 92) a truly emergent consult in the middle of the night? I know that I had attendings who would slice it both ways. It makes me nervous not to call the urologist for those cases even though I know plenty of people admit them to the hospitalist with the expectation that it’ll be seen in the morning.
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Always call. Infected stone with obstructive uropathy and hydro = badness. I don’t care how well they look. Some of my most impressive and rapid decompensations have been in this pt population. They have potential for the most epic crashes on the floor.
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I hate both. I have an immense yet finely honed capacity for hate.
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Do we know the other side? If I were a surgical subspecialist (I am), I might ask why take call 24/7 if I wasn't being paid to?
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umm....hospitals are paying you to take call 24/7. I don’t follow you.
The problem is you guys get paid 24/7 to take call, but only really want to be bothered at night for “real” emergencies. I get that.
Maybe you guys should negotiate only taking call from 7a-10p.
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all of our private groups get some coin for taking call. I think the range is $500-1000 per day or so.
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Ours do not, its part of the deal to use the ORs. Or at least they didn't 5 years ago, that might have changed.
If you get paid for call beyond what you bill, then you absolutely should be available 24/7.
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You're Ophtho. You don't count. We wake you guys up...what, once a month? 2 months? No offense.
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That's a very unorthodox arrangement in my experience. Everywhere I've worked, virtually all surgical sub specialists on call are paid. There are frequent negotiations for MORE pay. In fact, our ENT and OMFS groups bluffed for more pay and our hospital simply dropped them much to the ED's dismay. I can live without OMFS but the lack of ENT has been frustrating.
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It helps being the only game in town
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Offense not taken. Every situation is different. There was enough call during residency to occupy a resident full time during the day. I take call for a large health system and hear from them 1-2 times every night I'm on call. The calls are usually triagable but every once in awhile, we're put in an impossible situation of telling them there's nobody to see the patient until after clinic/surgery the next day or cancelling clinic/surgery. Why do I do it? Great question...other, older colleagues, who don't take call or won't be taking call much longer feel it's an obligation to the community/society.
Same deal for us. Except the vast majority of the time we use our own ORs. We only use the hospital OR's to take care of the emergencies...which are generated from the ED. Circular logic?
Patients go where their insurance plan requires them to go. New patients from the ED are typically medicaid/uninsured.
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It is true...at my hospital there are "tiers" of consultants. We have a specialty group of on-call consultants who I believe are paid. I once heard (although haven't verified) that Neurosurgery makes $3K/24 hr call cycle. However there was a time ENT did not make money for being on-call, it was just one or two docs, and they would occasionally not see consults (especially from inpatients) when it was stupid stuff like relatively benign ear complaints, reduced hearing, and sometimes even epistaxis.
They probably wouldn't mind if it was a psych patient.
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They probably wouldn't but these situations expose the transferring facility to a lot of EMTALA risk. The danger is when a consultant recommends transfer because they don't feel comfortable taking care of something but they are privileged to treat that condition. That's a big mess.
For example if ortho wants to transfer an acetabular fracture but they didn't exclude them from their privileges it's really risky.
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Battle that happens all the time.
Admin wants 24/hr call. Admin doesn't want to pay for 24/hr call
Specialist doesn't get the call $$ and tells admin they will not take call overnight.
Admin rather have limited rather than no coverage
So EM doc stuck in the middle.
This is what I do.
If someone can wait, I call next day.
If someone admitted, then hospitalist can deal with it.
If someone can't wait and specialist wont' take my call, then I call hospital admin and let them decide what to do.
After awhile admin gets sick of being called and problem will be fixed with either increased stipend or they will find someone hungry to take call.
This will get played all over again once the specialist stops taking call and they start the negotiating all over again.
Admin wants 24/hr call. Admin doesn't want to pay for 24/hr call
Specialist doesn't get the call $$ and tells admin they will not take call overnight.
Admin rather have limited rather than no coverage
So EM doc stuck in the middle.
This is what I do.
If someone can wait, I call next day.
If someone admitted, then hospitalist can deal with it.
If someone can't wait and specialist wont' take my call, then I call hospital admin and let them decide what to do.
After awhile admin gets sick of being called and problem will be fixed with either increased stipend or they will find someone hungry to take call.
This will get played all over again once the specialist stops taking call and they start the negotiating all over again.
As a resident going into community wanting to learn more, how often do you all in community see a patient overnight, discharge them and call the specialist in the morning as you are leaving your shift to help arrange outpatient follow up. Is this a common thing?
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Never done this. Although to be honest, I rarely call consultants just to schedule an outpatient appt. I just don't see what playing secretary does. If I'm concerned enough to call, I probably wouldn't be sending the patient w/o having already talked to the consultant. I could see doing this if you had that type of relationship with an orthopod or something, or if they had a policy that they had to be called on every ED referral.
Never. Should. Happen.
If this is what you do at your residency program, they are teaching you wrong and this needs to stop.
They dont teach this, thats why Im asking.
EmergentMD above said
" If someone can wait, I call next day."
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Meh. After you practice long enough you know what you can do. After working long enough and knowing most of the consultants well, I send them home and text the specialist the next day if they are safe to go home.
3am fracture that needs surgical repair and eval the next day, why am I going to page them to ask them this? Text in the am, thank you, and everyone is happy.
I have done this many times b/c the specialist and I have a good relationship who would gladly see them in clinic in the early am rather than having to come to the ER to see the pt at 3am.
3am fracture that needs surgical repair and eval the next day, why am I going to page them to ask them this? Text in the am, thank you, and everyone is happy.
I have done this many times b/c the specialist and I have a good relationship who would gladly see them in clinic in the early am rather than having to come to the ER to see the pt at 3am.
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As other's have alluded...this is unorthodox. You either need to call them to assist with disposition and/or "buff the chart" i.e. spread/shift liability, or you don't.
Common sense stuff. If it's a boxer's fracture, I don't need to discuss it with the orthopedist although I send the pt for f/u. If it's a bimalleolar/trimalleolar ankle fx then I call. That's an unstable fx and even if you reduce adequately and get the mortise perfect, the longer it waits for surgery, the more at risk for disarticulation/diastasis and chronic pain syndromes impairing ability to ambulate even after surgery. For those, I want to document a discussion with the orhopod. (Most don't want to admit these unless you work in academics.)
The timing of ankle fracture surgery and the effect on infectious complications; A case series and systematic review of the literature
Information about the influence of delayed surgery on infectious wound complications is ambiguous. A clinical audit was performed to test the hypothesis that early surgery lowers the rate of infectious wound complications. Secondly we looked at the influence ...
www.ncbi.nlm.nih.gov
Nobody spends the end of their shift arranging f/u appts. You've got better things to do. The last thing I want to do is call a consultant hours after I've discharged the pt and risk him instructing me to do something else entirely. I mean, what are you going to document exactly if he recommends admission and you already discharged them? If I need their input to disposition the pt, I want to be able to document that discussion prior to discharge. Anything else is foolhardy. I stopped feeling bad for these guys long ago. They get paid good money (most of the time) to be on call and if they don't want to take call at 2a.m. they can go work somewhere else. If I don't need to talk to them, then I don't and I still arrange f/u.
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Sounds reasonable. Here's a tip. Always prepare for poor interactions and "pimp" sessions when you call an ornery specialist about a case that you're not 100% sure about. Many times, your gut instinct is correct but there was not enough cognitive processing and analysis (due to the fast pace of a shift) and you didn't stop to really think about "why" your gut instinct is concerned. Then you can't articulate your concerns well enough to the specialist. Meanwhile, he/she is getting woken up and they are processing about 45 seconds of your case before you lose their attention. If you haven't adequately and succinctly communicated your concerns and/or questions in that timeframe...they get (understandably?) pissed.
If it's a case that's not straightforward or common, I spend a minute analyzing why I'm concerned and how to articulate it properly to the consultant. I even search uptodate or pubmed to see if my concerns are validated. I anticipate resistance from the consultant before I call...assuming that this might not be something they see too often either and when I get them on the phone...I'm ready for either scenario. 100% support and assistance or 100% resistance. Don't get discouraged by a crotchety surgeon, etc.. Most of the time, your intuition was right on the money...but you did a piss poor job articulating those concerns to the specialist because you didn't anticipate them to really push you on the case.
For instance, with the humerus... I think that's a reasonable call. I'd probably say something to the effect that although the extremity is neurovscularly intact, it's a really messy fracture pattern with several large comminuted and distracted humeral fragments and although you anticipate being able to reduce, splint and stabilize, you could use their assistance on whether the pt is safe to be discharged given the complicated nature of the fracture pattern and whether delayed operation would have any deleterious effect on extremity function and/or is there any increased risk of nerve injury (increased swelling and/or hematoma formation, etc..). If he/she still yells at you, just shrug it off...your concerns are valid. If it makes you feel any better, I had this exact case and articulated it just as above. I was told to send the pt out and they had a hematoma form and came back in 24 hours later with nerve palsy and had to go to OR to suction out the hematoma and decompress the nerve, at which point the orthropod thought it best to perform ORIF in a more expedient manner.
Also, for those messy humerus fx's, I like to have them give me a green light on reduction if at all possible. Iatrogenic radial nerve palsy is a common complication from an overenthusiastic complicated humeral reduction. (I didn't cause one in my case but got blamed for it until the orthopod realized the nerve palsy came from hematoma formation.)
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And sometimes the bad interactions are just unavoidable, lol. Reminds me of this high risk, morbidly obese, 39.9 week pregger pt I had one time that had a bimal ankle fx. I refused to sedate for reduction in the ER and told the orthopod that I was recommending anesthesia to sedate in the OR with OB available under a more controlled environment. We yelled at each other for a few minutes. I hung up and admitted to FM/OB and when I woke up, read all the consultant notes where everyone was playing hot potato for the most of the day until they finally took her to the OR with anesthesia with OB on stand by.
