I work as a hospitalist and I got dinged by the QI people because I admitted a patient for TIA work up which I really think he had orthostasis from excessive BP medications. Initial presentation was syncope. But they told me I had not ruled out TIA. How exactly can you rule out TIA??
Got dinged by quality improvement
- Thread starter Cadet133
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What are the presenting symptoms? Any focal neurological deficits?
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You rule out TIA “with your expertise, based on clinical presentation, exam and imaging”. That’s all you need to say.
Just curious, Are these QI people doctors?
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You don't rule out TIA, either the history and exam fits it or it doesn't. Your QI people sound like the kind of knowledgeless parasitic healthcare administrators whose sole function is to create more parasitic healthcare administrators.
He said he had trouble writing down stuff but when he came to ed he had no focal deficits at all
No theyre not which ticks me off
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Not being able to write is vague and further history and exam needs to be done to rule out CVA that may result in agraphia or UE hemiparesis. Depending on your documentation and description of these events, this could warrant TIA/stroke work up.
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1. Seriously consider quitting. This actually sounds so grossly inappropriate that I question the culture of the hospital system. You will be sued if you screw up, not them. You are responsible for your diagnoses, not them. You assume the role of physician, take care of people, not them. They are accusing you of failing to meet the standard of care in this case by not working up TIA (ICA eval with MRA, CTA or CUS) and echo, and starting secondary stroke prevention. But if you thought it was syncope, then no need to do any of that. This is a big call, one clinicians have to make all the time.
2. As below, you cannot "rule out" TIA. You can work it up. You can also diagnose TIA or possible TIA by knowing what a TIA is: decreased localized flow to the brain, creating reversible ischemia. It presents with classic findings, sudden onset of focal neurologic symptoms. Syncope is entirely different, due to blood pressure alterations affecting the global brain. Sometimes the history is crisp, and it is easy to tell these apart, sometimes not. Reasonable people can and do disagree. By second guessing you, they are creating a serious legal issue for you. If this patient has a massive stroke in the next couple of years, and the lawyer gets her hands of their QI report, then you are doomed. This point cannot be over-emphasized. They take NO accountability or responsibility for the patient's care, but have placed you in serious legal jeopardy.
They will say that these QI reports are confidential. Do you think that will pass muster when the hospital is faced with a subpoena?
Also, the fact you framed this as being "dinged" is TOTALLY inappropriate. You are a physician. The very fact you think these parasites can dare level a critique against you is an outrage.
It is even worse when they are doctors. I like to remind them when they introduce themselves as doctors (usually for prior authorizations) that their current role is NOT a physician, but an admin. So their degree is being used as emotional bolstering. This REALLY makes them angry and me happy.
Exactly right on all counts. Screw all parasites.
Unfortunately, this is all BS you need to deal with.
Practically, there is no way to rule out TIA. There are no tests or clinical exam findings that would accomplish this task. Often, by the time you come the symptoms resolve and you need to rely on very vague documentation and patient's subjective experience. TIA in the basilar artery, for example, can be completely non-focal and presents with isolated dizziness.
However, you need to play those games and provide some kind of meaningful explanation in your notes to satisfy the people who have no clue about TIA, but who may ruin your career regardless.
P.S. I have had numerous cases presented with very vague and nonspecific, non-focal (you name it) symptoms and had a stroke on MRI. TIA, by definition, should not show up on MRI. So, good luck with ruling it out lol
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