[HSF] Standard of care for lawyers {OT}

Sun Apr 13 03:07:22 EDT 2008

Michael - If things go according to plan our entire system would be built around PAs and intensivists by 2009 and at any given time there would be a PA *and* an intensivist in house including nights and weekends. Models like this obviously raise the question as to how surgical trainees will learn ICU care and a secondary question as to whether they need to if such models become standard.

Hal - I do not know our line policy. Our unit is ran by excellent intensivists and as it works very well i have never had reason to question care or duration of lines. All lines are inserted by PAs or intensivists and we have a very low incidence of line sepsis (central line associated bacteremia is a quality marker used by the NY dept of health). We are not as aggressive in removing lines as most centers are - indeed we use total parenteral nutrition (TPN) very liberally including for LVAD and transplant patients and elderly cachectic types and any patient who cannot get adequate enteral nutrition within 48h or so of surgery. Many patients therefore could have a line with TPN for several days and we really dont see any notable rise in infection (I can find out our exact line sepsis rate if you want as this is audited quarterly). I had a heart-lung transplant I did in 2006 on a very cachetic patient who was on combination of TPN and enteral feed for almost 3 months post-transplant and he never got infected and is alive with good quality of life now. I think it is a myth that keeping lines in valve patients risks infection of valves as early endocarditis is very rare even though we have patients with lines for days. We have several long stay (months) are complex valve surgery every year and despite prolonged ICU stay and repeated lines, endocarditis is rare. We do have a strict antibiotic policy and prophylactic antibiotics are never given beyond day 1 (day 2 for lvads) and rarely given in the absence of definite evidence of infection. Like michael's unit the balance of cases in my center is less than 20% isolated CABG so that at least a third will spend more than a day in ICU and a substantial proportion of these will spend more than 48 hrs. Patients with prosthetic grafts (thoracoabdominals, archs, LVADs etc) as a rule have lines in for at least 3 to 5 days even in best scenarios). On the general ward floor we would keep most lines in (dialysis catheters included) as long as they are needed (sometimes 2 to 3 weeks on a single line) - the indication to change a line would be pyrexia, bacteremia, local infection at insertion site or groin site where we would not leave them more than a few days.

Tea - the most common solution can certainly be substandard. Examples of such abound in health systems. For example the most common 'solution' for child birth in West Africa would be in a rural health clinic with no or limited access to doctors, no blood bank, minimal antiseptic precautions, no facility for assisted delivery -  this is substandard by even third-world standards and thus childbirth remains one of the most dangerous events in a woman's life in west africa where the lifetime risk of a woman dying during pregnancy is 1 in 16. That a system is the most frequently employed does not necessarily mean it is the not substandard (standard in this context i use does not imply average or standard as used in 'standard of care' and sometimes the standard may be unattainable).

I am certainly not an ICU expert Tea and have no ideas as to what the standard should be and how to achieve it. I am of course cognisant that any system has harmful as well as beneficial effects and for many a patient, leaving them to get better naturally with a kind nurse watching over them will probably yield a better outcome than having an intensivist, CT surgeon or PA tinkering with them from hour to hour - the aim should be to have a system that saves more lives (or disabilities) than it causes.

Ani

> From: msfirst at gmail.com> Subject: Re: [HSF] Standard of care for lawyers {OT}> Date: Sat, 12 Apr 2008 20:42:03 -0400> To: OpenHeart-L at lists.hsforum.com> CC: > > Ani,> > What is going to happen to your system which is built around > housestaff/fellows who may either be of marginal quality or may not > even be available at all.> > It sounds like a very reliable system is the smallest team possible - > a surgeon/PA/NP (anesthesiologist/pulm) group that works together day > in and day out for years rather than a different combination each day > - and every deals with their own problems?> > > -michael> > > On Apr 12, 2008, at 8:25 PM, Tea Acuff wrote:> > > John wrote:> > "By moving to the university about 7 years ago, I traded a lot of > > advantages for> > the rather dubious distinction of being a professor. John Felge"> >> > Well at least you are a "bonafied" expert now, John. I think you > > made my point that for the attending to consult directly with the > > nurse and visa versa is a very efficient system, and with time a > > fairly trustworthy and transparent one. It is seemingly now a novel > > one and substandard one at that. To Michael's cry for help in a > > "broken" system (like Prasanna we all have choices to make, > > Michael) i can not tell that the layers and layers of protocol, and > > layers of caregivers, P4P, JACHO interventions or adoption of the > > latest best new intensive treatments have added much to better > > care. That they are primarily the work of third parties defending > > turf or "consultants" trying to justify their repetitive surprise > > inspections. This is a characteristic of medicine and doctors to > > NOT think through the problems that they create and instead come up > > with a universal "fix" (usually new inflexible rule or new > > expensive care intermediate) to solve the problem for them.> >> > As for PA's, Ani, I have worked with the same one for well over a > > decade. She is another pair of eyes and a very consistent OR > > assistant. She halves my out of OR work day and likely shortens my > > OR day. However, she is not my night and weekend on call > > surrogate, nor is she a source of net income to my practice. I did > > not critisize your system except to say that I have fair skepticism > > for your blanket dismissal of one that may be the most common in > > the US certainly out of academia. How can the most common solution > > be substandard? I can understand if you merely think it inferior. > > Don't kid yourself or me, Ani. Everyone here and certainly any > > lawyer will qualify you as expert. Point out possible disadvantages > > all you like (I like hearing them), but be both clear and careful > > if you wish to establish standards for others.> >> > tea> >> >> > ----- Original Message ----> > From: "Jbflegejr at aol.com" <Jbflegejr at aol.com>> > To: OpenHeart-L at lists.hsforum.com> > Sent: Saturday, April 12, 2008 2:00:58 PM> > Subject: Re: [HSF] Standard of care for lawyers {OT}> >> > Hal, I am now in an academic setting. I relied virtually > > exclusively on> > nurses in a previous life and that for 25 years. They did not open > > the chest for> > tamponading patients and that didn't happen often anyway. I lived > > four miles> > from the hospital and if I was at home, I could get here in less > > than 10> > minutes during the night when no ordinary folks were on the > > streets. I doubt if> > intensivists would be much use there. The nurses did put in > > central lines and> > arterial lines with none of the complications that I see daily in > > my present> > setting and could have put in Swans but for some bureaucratic > > obstacles. The> > cardiologists charge for S-G, called right heart cath, and could > > not allow it> > to become a non-billable nursing procedure. I almost never saw > > pneumothorax> > during the first two postop days after I started routinely opening the> > mediastinal pleura a little bit so the mediastinal tubes would > > handle any lung> > leaks that might happen. We had a policy of not leaving any central > > lines in> > place for more than 48 hours and the nurses changed them. We did > > not have> > anesthesiologists or CRNA in the hospital at night those early > > years. Routinely I> > kept the patients asleep and on ventilator until the next morning > > after> > operation which eliminated the need for early reintubation which I > > would have had to> > do. With the patient ventilated and pacing wires in place the > > nurses could> > manage with telephone guidance anything but bleeding. Sometimes > > when there was> > a need for take back for bleeding I did it without an anesthetist > > and just> > gave a big dose of morphine and some curare. Often the anesthetist > > did not get> > there from home until the case was finished. We did not have in house> > anesthesia coverage until it was mandated to maintain the > > obstetrical service. By> > moving to the university about 7 years ago, I traded a lot of > > advantages for> > the rather dubious distinction of being a professor. John Felge> >> >> >> > **************It's Tax Time! Get tips, forms and advice on AOL Money &> > Finance. (http://money.aol.com/tax?NCID=aolcmp00300000002850)> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the > > policies and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the > > policies and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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