Monthly Journal Discussion

[Groove]

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So, what does everyone think of a monthly discussion on one of two journal articles that are interesting and ripe for some disagreement?

As an example, I was thinking of starting one on the 2h Troponin study from JACC. (Or one from Annals, etc..) We could probably find a way to distribute the entire article within the post and then go from there. Perhaps have some suggestions, vote on it, discuss?

Just an idea.

 

[Interpolfanclub]

Are you talking about the ADAPT trial from Than? I just did a review of that one and some others for my group. Our hospital wants us to send more "low-risk" chest pain patients home. Our hospitalists refer a lot to the TIMI risk factors but I try and tell them it doesn't apply to the ED. Also reviewed some articles on that.

 

[Birdstrike]

. Our hospital wants us to send more "low-risk" chest pain patients home.

Then they can send a hospital employed nurse practitioner down to the ED to assume liability and discharge these patients. Or they can buy you a secondary med-mal policy, out of their pocket with no limit and no risk of ever dropping your coverage and no risk of ever raising your rates.

What's the number one greatest liability for an EP, by award amount amount paid out?

Missed MI.

Which ones are the ones you miss?

The exact ones you are talking about: The "low risk" ones no one thought would really rule in.

Think about it....Which scares you more medical-legally? 1) The 75 year old male with a history of coronary disease and high cholesterol that you are going to admit every time, or 2) the 42 year old male with reflux that just seems a little weird that everyone is trying to convince you to blow off?

#1 Has a much greater medical risk. #2 Has a far and away much greater medical-legal risk to you if he drops dead leaving a wife and three kids behind, and 30 years of lost wages after you told him and his wife "it's nothing" and sent him home to clear out a bed for hospital admin.

Think about it.

 

[la gringa]

Then they can send a hospital employed nurse practitioner down to the ED to assume liability and discharge these patients. Or they can buy you a secondary med-mal policy, out of their pocket with no limit and no risk of ever dropping your coverage and no risk of ever raising your rates.

What's the number one greatest liability for an EP, by award amount amount paid out?

Missed MI.

Which ones are the ones you miss?

The exact ones you are talking about: The "low risk" ones no one thought would really rule in.

Think about it....Which scares you more medical-legally? 1) The 75 year old male with a history of coronary disease and high cholesterol that you are going to admit every time, or 2) the 42 year old male with reflux that just seems a little weird that everyone is trying to convince you to blow off?

#1 Has a much greater medical risk. #2 Has a far and away much greater medical-legal risk to you if he drops dead leaving a wife and three kids behind, and 30 years of lost wages after you told him and his wife "it's nothing" and sent him home to clear out a bed for hospital admin.

Think about it.

EXACTLY, and that's how i explain it to patients when i want them admitted. risk tolerance. unfortunately, i have to sell their "CAD risk factors" to the hospitalist to get them admitted b/c usually they come in w/ hours of pain, negative trop, and normal ekg...

 

[gman33]

The Vancouver CP rule may work great in that malpractice environment. I use the "terrible big city" CP rule. You have CP you get admitted. A little exaggeration, but not by much.

I agree more with some of the docs that think you can't ignore national guidelines even if they aren't based on EBM.

 

[Groove]

Are you talking about the ADAPT trial from Than? I just did a review of that one and some others for my group. Our hospital wants us to send more "low-risk" chest pain patients home. Our hospitalists refer a lot to the TIMI risk factors but I try and tell them it doesn't apply to the ED. Also reviewed some articles on that.

Exactly. ADAPT. Would be interested in hearing your thoughts.

For those of you that haven't read it..

http://content.onlinejacc.org/article.aspx?articleid=1216447

Read the whole thing. Let's talk about it.

 

[Birdstrike]

Exactly. ADAPT. Would be interested in hearing your thoughts.

For those of you that haven't read it..

http://content.onlinejacc.org/article.aspx?articleid=1216447

Read the whole thing. Let's talk about it.

Interesting. Concerns:

1-The study includes primarily Caucasians in a different hemisphere and altogether different healthcare system and medical-legal climate than the USA. Does this mimic your patient population, practice setting, and medical malpractice environment?

2-They excluded "atypical" presentations which is the exact patients one needs such a decision rule for. Are you comfortable with that?

3- Out of 392 patient called "low risk" by the rule, 1 had a major cardiac adverse event. How long does it take you to see 392 low risk chest pains, and are you okay missing a major adverse cardiac event for every 392 "low risk" chest pains you see and send home using this rule?

4- The entire underpinning of this proposed rule is "close follow up" which they stated occurred "approximately within 7 days." Can you guarantee that your discharged patients will get investigative-study quality cardiac follow-up within 7 days once you click the eject button?

 

[DeadCactus]

While nothing can completely protect you from anything, I have to think that if a hospital has written a specific policy with clear criteria then it provides a lot of protection to the individual practitioner working in that institution. For all the bitching about lawyers, the willingness of physicians to drown each other to protect themselves probably does much more medico-legal harm than anything else and these sort of consensus statements and policies protect from that...