[HSF] ICU Management Systems

Wed Apr 9 17:49:25 EDT 2008

There are several protocols or ideas that are mixed together in this question and responses.

First is the confusion that in order to have good care doctors need to direct every decision. This is an implied inefficiency reenforced by training programs and doctor advocate groups that can become a huge problem in practice. The real consistency that is needed is not WHO is giving the care but the PHILOSOPHY and repetitiveness of that care. (Sorry for the word philosophy.)

I have argued often that not only do we surgeons have different (and sometimes unimportant) biases, but almost always we have various and real differences in bias or implied definition of goals and directions of care from cardiologists, EP, anesthesiologists, intensivists, etc. The further we get from our usual team the more diffuse the goals of therapy become. While our patients are often complex we usually have very specific goals and priorities in the perioperative period, and less clear needs for the patient as the surgical trauma abates. The more confusion in goals the less effecient we become. (Ever go through all the patient's orders and wonder of the logic and effectiveness of the opus?)

 The other thing that screams out from those that know your practice is that there is an intrinsic economy for all practice systems. This is not the same as whether the patient has funding. One of the unappealing things about LVAD/ desperation cases is the amount of care (and in this case other economies) that must be denied as in other choices by programs or surgeons that choose to provide this care. This is true whether in a large program rich in bodies to insulate the decision makers, small private programs like myself, or Bill out in the countryside doing pediatrics. One must not only have goals for individual patients, but at the same time have goals for the program. Just as a research programs must consider whether an electron microscope is a core competency clinical programs must make similar decisions. As I also suggest over and over cost or revenue/ cost is a poor way to "value" decision making in medicine. It may be a simple and "objective" way
 of calculating value, but I believe it is a deficient calculus that leads to some of your concerns. We certainly see frequent criticism of business at large making this mistake. Medical business should be even clearer to fail in this regard.

tea

----- Original Message ----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, April 9, 2008 12:22:57 PM
Subject: Re: [HSF] ICU Management Systems

thats kind of what i thought and how i do it but what i am trying to
figure out is how others work around limited rsources (80 hr rules no
resident  many pts all over the place problems popping up left and
right)

On 4/9/08, Prasanna Simha M <prasannasimha at gmail.com> wrote:
> The Resident does it or the Nurse does it or you yourself do it !!
> Prasanna
>
> On Wed, Apr 9, 2008 at 8:53 PM, Michael Firstenberg <msfirst at gmail.com>
> wrote:
>
> > what happens when residents are not available (OR . home. busy. etc)
> > or when things get really busy?  also - not just management and
> > supervision but also doing the work.  we all take the calls and run in
> > in the middle of the night with huge problems - but who deals with a
> > lot of the low key stuff?
> >
> > On 4/9/08, alsadd <alsadd at ksu.edu.sa> wrote:
> > > Even though I work at a University Hospital but we follow Ed's model.
> > > Surgeons look after the patients. I believe this is the way to train
> > future
> > > surgeons which we do. I believe it is no good to operate and let some
> > one
> > > else manage especially when we have residents who have to learn. That of
> > > course means calls in the middle of the night for us the staff but we
> > got
> > > used to it. I am against having an intensivist when there are residents.
> > >
> > > Ahmed
> > >
> > > -----Original Message-----
> > > From: openheart-l-bounces at lists.hsforum.com
> > > [mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Edward
> > Bender
> > > Sent: Tuesday, April 08, 2008 5:57 PM
> > > To: OpenHeart-L at lists.hsforum.com
> > > Subject: Re: [HSF] ICU Management Systems
> > >
> > > At our small community hospital, the cardiac surgeons manage the
> > patients
> > > from admit to discharge.  Last year, with the addition of an intensivist
> > > service, I tried using them, but there were problems with availability
> > and
> > > expertise, so that ended quickly.  I do liberally use other services
> > when
> > > indicated, such as ID for endocarditis or severe surgical site
> > infections,
> > > pulmonologist (not so much for ventilator management, but to aid in
> > keeping
> > > patients off the ventilator), endocrinologist for poorly controlled or
> > > refractory hyperglycemia and/or DKA (which happens once or twice a
> > year).
> > >
> > > I have found the best adjunct to care is a well trained, caring, and
> > > available physician assistant or nurse practitioner.  Unfortunately, in
> > our
> > > area, these folks are less easy to find.  Most go into primary care,
> > since
> > > in the USA, this is probably going to be the health care model of the
> > future
> > > (economically doing away with primary care physicians).
> > >
> > > Ed Bender, MD
> > >
> > >
> > > On 4/8/08 6:46 PM, "Michael Firstenberg" <msfirst at gmail.com> wrote:
> > >
> > > > We are in the process of exploring options to assist in the pre/post-
> > > > operative care of our patients.  Our current system has us taking
> > > > full care and responsibility for all aspects of this process (pre-op
> > > > eval/tune-ups, post-op management, line changes, vent weaning, call/
> > > > working with consults, etc).  There are obvious pluses and minuses to
> > > > this process.  What are the other systems which people have to work
> > > > with and what parts of them do they like and dislike.  My concern is
> > > > that there are always plenty of people who want to be Chiefs, but few
> > > > who want to be Indians (American expression for many who want to
> > > > direct and run the show - esp between 9am and 5pm, but few to
> > > > actually do they real work - i.e. bedside care, put in orders, call
> > > > and discuss with consults, lines, tubes, weaning, even talking with
> > > > families and helping admit patients- and do it 24 hr a day and with
> > > > the same vigor which we - as cardiac surgeons do - particularly in a
> > > > world were our every move and outcome gets examined under a
> > microscope).
> > > >
> > > > In short, who does the "real" work in your ICU?
> > > >
> > > > Thoughts?
> > > > Comments?
> > > > Since we obviously have answer all of the other pressing surgical
> > > > questions and no one has anything else to talk about.
> > > >
> > > >
> > > > -michael
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> --
> Prasanna Simha M
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