OB vasodilators

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painstop

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Hey guys,

I work at a community hospital and as one of my duties as Quality Chair I am the liaison to the OB department. For years, our hospital has shipped out patients with severe pre-eclampsia requiring greater than a certain dose of labetolol for BP control to a tertiary facility. One of the OBs is frustrated with this because she has to ship out these patients (and subsequently lose the revenue) and wants the anesthesiologists to place arterial lines and manage IV antihypertensives like Nitroprusside or Nicardipine on the OB floor with an ICU nurse coming down to manage the infusion under our care. I am willing to help place the arterial line but I feel managing the infusion would be inappropriate since it is basically making me into an intensivist when I have other responsibilities on OB (epidurals/C-sections/etc.) and I don't want that liability. In my opinion, she is the primary physician for the mother and should be responsible for this, especially since she is also giving other meds which have an effect on the patient's blood pressure like magnesium. When I asked her why she doesn't want to manage the antihypertensive infusion, she said she has not trained in it and would be uncomfortable. That seems like a weak argument. I can give her a 5 minute Powerpoint presentation and "train" her on basic infusion rates. She is hesitant to have these women deliver in the ICU because the infrastructure to monitor the baby is not in place up there but that may be an option if the intensivist is willing to go along (the docs are not in house at night generally so I don't know if they would be willing to as well). I know I can bill for an arterial line (a whopping $60) but can a non-intensivist bill for vasodilator management separate from the primary OB physician? Does anyone have experience with this kind of setup at their COMMUNITY hospital (not some fancy tertiary facility with a dedicated OB ICU)?

Thanks for the responses
 
painstop said:
Hey guys,

I work at a community hospital and as one of my duties as Quality Chair I am the liaison to the OB department. For years, our hospital has shipped out patients with severe pre-eclampsia requiring greater than a certain dose of labetolol for BP control to a tertiary facility. One of the OBs is frustrated with this because she has to ship out these patients (and subsequently lose the revenue) and wants the anesthesiologists to place arterial lines and manage IV antihypertensives like Nitroprusside or Nicardipine on the OB floor with an ICU nurse coming down to manage the infusion under our care. I am willing to help place the arterial line but I feel managing the infusion would be inappropriate since it is basically making me into an intensivist when I have other responsibilities on OB (epidurals/C-sections/etc.) and I don't want that liability. In my opinion, she is the primary physician for the mother and should be responsible for this, especially since she is also giving other meds which have an effect on the patient's blood pressure like magnesium. When I asked her why she doesn't want to manage the antihypertensive infusion, she said she has not trained in it and would be uncomfortable. That seems like a weak argument. I can give her a 5 minute Powerpoint presentation and "train" her on basic infusion rates. She is hesitant to have these women deliver in the ICU because the infrastructure to monitor the baby is not in place up there but that may be an option if the intensivist is willing to go along (the docs are not in house at night generally so I don't know if they would be willing to as well). I know I can bill for an arterial line (a whopping $60) but can a non-intensivist bill for vasodilator management separate from the primary OB physician? Does anyone have experience with this kind of setup at their COMMUNITY hospital (not some fancy tertiary facility with a dedicated OB ICU)?

Thanks for the responses
Click to expand...

if you are providing care for a patient in the OR concurrent with that patient on the floor, I'm fairly certain you are violating CMS rules for the things you are allowed to do while providing anesthetic care. You can still medically direct a CRNA and leave to do an emergency airway or a labor epidural, but continuous management of a vasoactive drug for a floor patient cannot be allowed (I'm pretty sure).

What you can probably do is provide a consultation outlining what you think the primary OB should do, but it has to be on them to be responsible for it.
 
You probably need two physicians available if you're in engaged in active OB anesthesia care elsewhere (either another anesthesiologist or an OB willing to manage the drip). As far as billing, you can discuss this with your hospital coders, but you should be able to bill this as critical care time assuming you put in the proper documentation in an H&P, and then continue putting in daily progress notes delineating how much critical care time is accumulated throughout the day (e.g., 30-45 minutes).

http://www.sccm.org/Communications/...Billing-Basics-Billing-for-Critical-Care.aspx
 
painstop said:
Hey guys,

I work at a community hospital and as one of my duties as Quality Chair I am the liaison to the OB department. For years, our hospital has shipped out patients with severe pre-eclampsia requiring greater than a certain dose of labetolol for BP control to a tertiary facility. One of the OBs is frustrated with this because she has to ship out these patients (and subsequently lose the revenue) and wants the anesthesiologists to place arterial lines and manage IV antihypertensives like Nitroprusside or Nicardipine on the OB floor with an ICU nurse coming down to manage the infusion under our care. I am willing to help place the arterial line but I feel managing the infusion would be inappropriate since it is basically making me into an intensivist when I have other responsibilities on OB (epidurals/C-sections/etc.) and I don't want that liability. In my opinion, she is the primary physician for the mother and should be responsible for this, especially since she is also giving other meds which have an effect on the patient's blood pressure like magnesium. When I asked her why she doesn't want to manage the antihypertensive infusion, she said she has not trained in it and would be uncomfortable. That seems like a weak argument. I can give her a 5 minute Powerpoint presentation and "train" her on basic infusion rates. She is hesitant to have these women deliver in the ICU because the infrastructure to monitor the baby is not in place up there but that may be an option if the intensivist is willing to go along (the docs are not in house at night generally so I don't know if they would be willing to as well). I know I can bill for an arterial line (a whopping $60) but can a non-intensivist bill for vasodilator management separate from the primary OB physician? Does anyone have experience with this kind of setup at their COMMUNITY hospital (not some fancy tertiary facility with a dedicated OB ICU)?

Thanks for the responses
Click to expand...
When a patient needs ICU level care that patient should be in the ICU not in a makeshift ICU for someone's convenience!
The OB floor is nothing more than a regular floor and that's what would be my argument with the administration and the nursing managers who will probably back you up on this.
Also is your call in house???
 
Planktonmd said:
When a patient needs ICU level care that patient should be in the ICU not in a makeshift ICU for someone's convenience!
The OB floor is nothing more than a regular floor and that's what would be my argument with the administration and the nursing managers who will probably back you up on this.
Also is your call in house???
Click to expand...

We do in-house call for OB but since it is a relatively low volume OB service if there are no epidurals running some of my colleagues that live nearby go home. As a corrolary, our ICU docs manage pressors/dilators in the ICU from home with the assistance of the ICU nurse and protocols but I agree with your sentiment that we shouldn't make the OB floor a makeshift ICU.
 
I would not trust OB nurses monitoring and titration of any vasoactive medication, plain and simple.

I do question, though, whether you could bill critical care time and still be the in-house anesthesiologist. When you bill critical care, you are billing discrete visits...like a 45 minute critical care time versus the continuous anesthesia care you provide in the OR. Why can't you bill a critical care visit, so long as the time doesn't overlap with your anesthetic time? But again, this is all assuming the patient is in an intensive care unit, which the OB floor is not.
 
painstop said:
We do in-house call for OB but since it is a relatively low volume OB service if there are no epidurals running some of my colleagues that live nearby go home. As a corrolary, our ICU docs manage pressors/dilators in the ICU from home with the assistance of the ICU nurse and protocols but I agree with your sentiment that we shouldn't make the OB floor a makeshift ICU.
Click to expand...
So if the ICU patients are managed by ICU physicians on the phone, and if this is your hospital policy, then the OB physician who is asking you to become her private intensivist should comply with the hospital's policy and arrange for these patients to get admitted to ICU.
 
painstop said:
Hey guys,

I work at a community hospital and as one of my duties as Quality Chair I am the liaison to the OB department. For years, our hospital has shipped out patients with severe pre-eclampsia requiring greater than a certain dose of labetolol for BP control to a tertiary facility. One of the OBs is frustrated with this because she has to ship out these patients (and subsequently lose the revenue) and wants the anesthesiologists to place arterial lines and manage IV antihypertensives like Nitroprusside or Nicardipine on the OB floor with an ICU nurse coming down to manage the infusion under our care. I am willing to help place the arterial line but I feel managing the infusion would be inappropriate since it is basically making me into an intensivist when I have other responsibilities on OB (epidurals/C-sections/etc.) and I don't want that liability. In my opinion, she is the primary physician for the mother and should be responsible for this, especially since she is also giving other meds which have an effect on the patient's blood pressure like magnesium. When I asked her why she doesn't want to manage the antihypertensive infusion, she said she has not trained in it and would be uncomfortable. That seems like a weak argument. I can give her a 5 minute Powerpoint presentation and "train" her on basic infusion rates. She is hesitant to have these women deliver in the ICU because the infrastructure to monitor the baby is not in place up there but that may be an option if the intensivist is willing to go along (the docs are not in house at night generally so I don't know if they would be willing to as well). I know I can bill for an arterial line (a whopping $60) but can a non-intensivist bill for vasodilator management separate from the primary OB physician? Does anyone have experience with this kind of setup at their COMMUNITY hospital (not some fancy tertiary facility with a dedicated OB ICU)?

Thanks for the responses
Click to expand...
I'm sorry but a loss of revenue is not a good enough reason to keep those patients in-house. If your OB for whatever reason is not comfortable taking care of these patients then they should be shipped out. Every hospital I have worked at, the OB's took care of the pre-eclamptic and eclamptic patients and whatever they could not handle would be consulted out to the appropriate service.
 
Greed gets people in trouble. There's a really good show called American Greed on one of the NBC channels. Of course it usually doesn't feature about doctors although there was this one episode about an ENT doc. Hmm.

Save yourself and she the trouble and ship them out. I can only imagine if one of those preeclamptics becomes eclamptic. And the possible outcome one for mom and baby. And the possible lawsuits.

There's a good thing about working in smaller hospitals. You don't have to deal with much complex ****. That's what the Meccas are for.
 
Planktonmd said:
When a patient needs ICU level care that patient should be in the ICU not in a makeshift ICU for someone's convenience!
The OB floor is nothing more than a regular floor and that's what would be my argument with the administration and the nursing managers who will probably back you up on this.
Also is your call in house???
Click to expand...

When I was at my little community hospital they could barely manage a patient with O2 on the floor. I was a DH and at the leadership meeting one day they said that they wanted to start caring for kids. I laughed out loud. It's comical to think that OB nurses, who are usually more worthless, I mean siloed, than most could manage complex patients on dangerous vasoactive infusions. That OB is hitting the pipe hard. What happens when they seize, have a cerebral hemorrhage, etc. anyone at the community hospital managing those things or is helicopter time? Do you even have a helipad? An ICU that is much more than a pre morgue care?


--
Il Destriero
 
I work at a community hospital too and we do bread and butter OB. I've seen maybe 2 preeclamptics in the past year. If they expect me to put a-lines and manage vasoactive drugs for their patients, I'd say f*** no! Not only is there no appropriate way to bill for it, it probably violate cms rules as someone above mentioned, and it puts too much liability on you for really no return.
 
Would not touch this scenario with a 100ft pole. The OB wants you to do ICU-level monitoring with ICU-level infusions using ICU-level staff, without being in an actual ICU. All so they don't lose out on the billing. This is not looking out for the patient's best interest in any way, shape, or form.
 
painstop said:
Hey guys,

I work at a community hospital and as one of my duties as Quality Chair I am the liaison to the OB department. For years, our hospital has shipped out patients with severe pre-eclampsia requiring greater than a certain dose of labetolol for BP control to a tertiary facility. One of the OBs is frustrated with this because she has to ship out these patients (and subsequently lose the revenue) and wants the anesthesiologists to place arterial lines and manage IV antihypertensives like Nitroprusside or Nicardipine on the OB floor with an ICU nurse coming down to manage the infusion under our care. I am willing to help place the arterial line but I feel managing the infusion would be inappropriate since it is basically making me into an intensivist when I have other responsibilities on OB (epidurals/C-sections/etc.) and I don't want that liability. In my opinion, she is the primary physician for the mother and should be responsible for this, especially since she is also giving other meds which have an effect on the patient's blood pressure like magnesium. When I asked her why she doesn't want to manage the antihypertensive infusion, she said she has not trained in it and would be uncomfortable. That seems like a weak argument. I can give her a 5 minute Powerpoint presentation and "train" her on basic infusion rates. She is hesitant to have these women deliver in the ICU because the infrastructure to monitor the baby is not in place up there but that may be an option if the intensivist is willing to go along (the docs are not in house at night generally so I don't know if they would be willing to as well). I know I can bill for an arterial line (a whopping $60) but can a non-intensivist bill for vasodilator management separate from the primary OB physician? Does anyone have experience with this kind of setup at their COMMUNITY hospital (not some fancy tertiary facility with a dedicated OB ICU)?

Thanks for the responses
Click to expand...
If your OB doc can't handle a severely pre-eclamptic patient, they get shipped out. Simple. End of story. It shouldn't be a billing question. Your hospital clearly is not set up to handle these types of patients and shouldn't really try to unless they want to invest the resources to do it properly. I'm not sure how many deliveries you do a year, but if you're doing OB call from home, your volume is nowhere near high enough to deal with this.
 
chocomorsel said:
There's a good thing about working in smaller hospitals. You don't have to deal with much complex ****. That's what the Meccas are for.
Click to expand...

Depends on how small the hospital is. Plenty of community hospitals get sick and/or complicated patients all the time.
 
I just find it hilarious that this OB is lobbying to take care of these pts and then turns around and admits to you that they don't have the training or comfort level to do what is needed to take care of these pts. 😵🤣
 
We had this sort of arrangement in one of the places I worked.
I got a phone call from one of the OB nurses asking if they could put the antibiotics through the arterial line as the peripheral IV had tissued.
 
Dude, I couldn't trust fair-to-good CTICU nurses with an art line and nitroprusside. That drug is too potent. If they titrate up too fast you'll have 40/20 before you know it.

OB nurses doing that? On a labor floor? SHEEEEEEIT YGBFKM
 
I agree with all of this. The hospital I train at does a huge volume of OB and even here I don't trust the OB floor nurses. They are trained to be protocol puppets to the OBs, not the Anesthesia service. If they are going to default to OB thinking and calling the OB (who we all know even before their admitting it that they have no idea how to manage vasoactives) it has the potential to create disastrous scenarios. Do you really want to be in the OR getting a call from an OB nurse saying they titrated the nipride up, got a ****ty tracing on the FHR monitor so they turned it off and now the BP is >200? Not to mention how the OB and/or hospital is asking you to do high risk medicine without the appropriate tools just because they think they can pressure the anesthesia Dept into assuming risk so they don't lose the billing revenue on patients their own OB is afraid of.
 
I think it has already been said, but if the OB isn't comfortable taking care of these patients, then he has no business taking care of these patients. Farming out pre-eclampsia management just so he can perform the delivery (whether for monetary or social reasons) is extremely unethical. I wouldn't touch it with a ten foot pole.

It's not an issue of being worried about billing or whatever. I would have no issue managing drips on a post-cardiac surgery patient from the OR. Sure, if I was doing this de novo, I would spend a few days getting comfortable with the system and the nurses before I felt comfortable doing it while in the OR, but remote physician management of ICU nurse titration of vasoactive/ inotropic meds is standard. Typically, an intensivist doing this is taking care of multiple patients, performing procedures etc. Same thing as managing from the OR.

The issue is assuming management of a pre-eclamptic patient. That is within the scope of practice if the OB or MFM specialist, and is well outside my scope of practice. I would be willing to place the arterial line but otherwise the OB can GTFOOH
 
I agree with everyone's comments above. I'm just wondering what this OB's partners think of all this?
 
jwk said:
If your OB doc can't handle a severely pre-eclamptic patient, they get shipped out. Simple. End of story. It shouldn't be a billing question. Your hospital clearly is not set up to handle these types of patients and shouldn't really try to unless they want to invest the resources to do it properly. I'm not sure how many deliveries you do a year, but if you're doing OB call from home, your volume is nowhere near high enough to deal with this.
Click to expand...

100% agree. This patient needs an MFM and anesthesiologist skilled in OB. Not a general OB who can't manage hypertension.
 
Random Resident said:
100% agree. This patient needs an MFM and anesthesiologist skilled in OB. Not a general OB who can't manage hypertension.
Click to expand...
That anesthesiologist is called an intensivist. If the patient needs an ICU nurse, the patient also needs an ICU doctor, most likely.

The way to do it is to reserve two adjacent ICU rooms: one for the patient, with an OB nurse and continuous fetal monitoring, and the second one for a makeshift OR, in case of emergent CS. Or to have an ICU doc follow the patient on the OB floor, if the former is too complicated.
 
Last edited by a moderator:
FFP said:
That anesthesiologist is called an intensivist. If the patient needs an ICU nurse, the patient also needs an ICU doctor, most likely.

The way to do it is to reserve two adjacent ICU rooms: one for the patient, with an OB nurse and continuous fetal monitoring, and the second one for a makeshift OR, in case of emergent CS.
Click to expand...

Needs an MFM and tertiary level care. Intensivist, maybe. Probably. But the thing that sticks out most is an OB over his/her head. I'd be very concerned if I were the pregnant one stuck with a surgeon who didn't know how to handle my fairly common comorbidity.
 
Random Resident said:
Needs an MFM and tertiary level care. Intensivist, maybe. Probably. But the thing that sticks out most is an OB over his/her head. I'd be very concerned if I were the pregnant one stuck with a surgeon who didn't know how to handle my fairly common comorbidity.
Click to expand...
Obviously not just for BP management, but for the "severe" part. If the guy can't manage a BP, he should not take complicated patients.
 
FFP said:
Obviously not just for BP management. If the guy can't manage a BP, he should not take complicated patients.
Click to expand...

Agree. And we both know the cure for pre-eclampsia is delivery. I'm not sure how much faith I would have in the end game if they can't even manage BP issues, or even HELLP/eclampsia if we are truly talking severe.
 
FFP said:
That anesthesiologist is called an intensivist. If the patient needs an ICU nurse, the patient also needs an ICU doctor, most likely.

The way to do it is to reserve two adjacent ICU rooms: one for the patient, with an OB nurse and continuous fetal monitoring, and the second one for a makeshift OR, in case of emergent CS. Or to have an ICU doc follow the patient on the OB floor, if the former is too complicated.
Click to expand...
I think this is a bit over kill.
In a community hospital this is unheard of even. And if they can't handle this type of case in the usual manner then ship it.
But in a "regular" hospital, this is too much. Really? 2 ICU rooms? Come on man!!!!!!
I've done plenty of these cases. First get BP under control and next deliver the f'n critter. 😉
 
Noyac said:
I think this is a bit over kill.
In a community hospital this is unheard of even. And if they can't handle this type of case in the usual manner then ship it.
But in a "regular" hospital, this is too much. Really? 2 ICU rooms? Come on man!!!!!!
I've done plenty of these cases. First get BP under control and next deliver the f'n critter. 😉
Click to expand...
I was assuming the patient can't deliver yet for some reason (immature fetal lungs), and one cannot expect an intensivist to manage a severe preeclampsia on the OB floor for days. And if the patient is in the ICU, far from an OR, then there should be a backup plan for CS.

In cases where a similar patient is admitted to the ICU for other pertinent reasons, not just preeclampsia (e.g. severe DKA), the setup I described is needed, unless there is an OR in the immediate vicinity.

Otherwise, you are perfectly right. Fix the BP on the OB floor and section her.
 
Last edited by a moderator:
painstop said:
Hey guys,
...wants the anesthesiologists to place arterial lines and manage IV antihypertensives like Nitroprusside or Nicardipine on the OB floor with an ICU nurse coming down to manage the infusion under our care.
Click to expand...

This isn't the most ******ed thing I have ever heard, but it is DEFINITELY in the top 10.
 
And @painstop, no offense, but how long have you been an attending? I'm guessing <5 years....the reason I say this is because any experienced anesthesiologist would not even consider this OB's assinine request.
 
Consigliere said:
And @painstop, no offense, but how long have you been an attending? I'm guessing <5 years....the reason I say this is because any experienced anesthesiologist would not even consider this OB's assinine request.
Click to expand...

No offense taken...I've been an attending close to a decade now. I can only listen to the stupidity as it comes my way and give it some thought before rejecting it. With experience comes the ability to be political and not insult everyone...remember you need to work with these people and make cogent arguments, not just "wow you're an idiot!" Most of the other OBs don't want this headache nor does administration seem particularly keen on this so I doubt it will go very far.
 
Don't
painstop said:
No offense taken...I've been an attending close to a decade now. I can only listen to the stupidity as it comes my way and give it some thought before rejecting it. With experience comes the ability to be political and not insult everyone...remember you need to work with these people and make cogent arguments, not just "wow you're an idiot!" Most of the other OBs don't want this headache nor does administration seem particularly keen on this so I doubt it will go very far.
Click to expand...
dont be the one that says "no" if you can help it. Make administration do it.
 
Consigliere said:
This isn't the most ******ed thing I have ever heard, but it is DEFINITELY in the top 10.
Click to expand...

This idea lends further support to my theory that OB decision making is guided at least in part by sorcery or witchcraft. In residency I was convinced that one of the L&D rooms actually had a necromancer stirring a cauldron with newt gizzard, etc., who advised the residents on their plan.
 
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