Dear Director: The ICU director just called me to say our ED docs aren’t working the patients up appropriately before calling the ICU team. He said he couldn’t give an examples but “in this case, perception is reality!” How do I respond to that?
I’ve come to accept that perception is reality when it comes to patient satisfaction. But we shouldn’t accept that when it comes to our colleagues critiquing the quality of work that we provide. I have a pretty simple rule when I have these kinds of discussions – I need specifics. Send me a case. A med-record number. Anything. But I need to understand the details in order to provide a fair review and ultimately, make a change if it’s needed.
A Kernel of Truth
I used to have a hospital administrator who always referred to the kernel of truth in every complaint. No matter how ridiculous the complaint seemed, whether it was from a patient or a physician, she had me consider whether there could be a kernel of truth in it. In the end, there was always a little bit of reality in every exaggerated complaint. Unfortunately, this is why, behind the scenes, we have to consider the perception-is-reality phrase.
I remember one of the first complaints I ever got from a patient. She was 31 years old, healthy, and had atypical chest pain. I pulled all kinds of strings to get her a stress test late in the day when the cardiologist was telling me to send her home or work her up for a PE. My shift ended and I signed out while she was at her stress test. Her stress was positive and she ended up in the cath lab getting treatment for her single vessel disease. The complaint said I was an idiot but thankfully the second doctor recognized her symptoms and admitted her for treatment. My failure wasn’t in the medical management, but it was clearly in my communication with the patient about the behind-the-scenes work, my differential, and the possible outcomes. The complaint was clearly the patient’s perception, but when we dug deep enough, it wasn’t hard to find something that could be improved upon.
Here’s your scenario. You receive a phone call from the ICU director saying the ER docs need to be more thorough. You respond with: “Give me some examples.” He doesn’t have any. If you leave it at that, nothing will improve, and there will likely be more phone calls or being called out at meetings. And trust me, there’s nothing worse than being blindsided with a comment like this at a medical executive committee or a clinical risk committee where others may quickly pile on. Therefore you need to act.
Ideally, you have some real cases to review. However, in your case, you’ll need to see what you can find out with some detective work. An easy place to start is with the patients that have been admitted to the ICU over the past week or so. I always find that I get calls related to a patient’s care from other chairman/directors after they’ve spent a few days on call or taking admissions as the hospitalist or the intensivist. I’m probably the same way, come to think of it. Everything from our consultants is peachy until I work a weekend and realize how slow the resident was in coming to the ER, thus delaying my disposition. Then I schedule a meeting with that resident’s director to complain about the delays residents are causing in the ED.
Start with your patient list. Audit a handful of cases and critically look at the work up, when the call was placed to the intensivist, and what happened after that. If the ICU bed was requested for a “septic shock” patient whose systolic blood pressure was in the 80s on arrival but they hadn’t received their IV fluids yet, perhaps that request was made too early. On the other hand, if the lactate is 6, the bundle has been completed, and the patient is on pressors, then you can feel good about the thoroughness of the care.
After you’ve done your chart reviews, the next step is to talk to some of your docs. Remember, they’re on your side and your job is generally to protect them from being hassled so they can provide high quality care. But also keep in mind that you’re trying to see what reality lies behind this one doc’s perception. Ask about ICU admissions, delays, pushback, etc… If you talk to everyone, it shouldn’t be too hard to find the one case that caused this intensivist to generalize about the care provided. You can’t be a successful director if you don’t have some other close allies in the hospital. In this case, you may also need to take advantage of your relationship with the hospitalist director. You’ll certainly need to consider the politics and the relationships that exist between the hospitalist and the intensivist directors, but if possible, find out if they’ve heard about any issues from the ICU docs.
You’ve asked for examples. You’ve done your homework, trying to sniff out the kernel of truth in the initial complaint. Ultimately, you need to have a meeting. Best case would be to keep this low key. One on one. The goals are simple. Ask questions. Get to the root of the problem. If the complaint has a basis in reality, take ownership and say you’ll fix it. But then it’s your turn to ask for something. Make sure this doc understands the pressure that the ED is under to achieve short waits, high patient sat, and a low length of stay. This can only be accomplished when the impatient services understand “why” we do certain things. Getting the ICU bed as quickly as possible on the obvious ICU admission (think intubated COPD exacerbation), is not only in the best interest of that patient, but it’s in the best interest of the patients in the waiting room and all the other patients that nurse should be caring for, but can’t because she’s doing 1:1 nursing with an ICU patient. Once you can establish the first diagnosis that can be expedited to the ICU, I suspect you’ll find more. Such as the post arrest patient who is stable and not going to the cath lab. How about septic shock, the intracranial hemorrhage, and severe hypokalemia (okay, maybe they don’t want every patient with a K of 2.0 but what about 1.6?) It’s equally important to listen to their perspective. Whereas we can often make a disposition based on a subset of tests (acidosis and ketones, severe electrolyte disturbances, findings on a CT, etc…) their workflow may necessitate having all the data back before they want to see a patient, have a final plan, and dictate a note. It’s in these future discussions where you can work out the details of what a minimum amount of information is required before requesting the bed and also what the ER doc will take responsibility for after the bed is requested. While I don’t believe that we have to fully work up every patient and wrap them in a ribbon prior to the admission, we do need to remember, that all the docs in the hospital are busy and have their own priorities. However, if you do what’s best for the patient, you’ll usually do the right thing. And certainly in the case of ICU patients, getting them out of the ED and into the ICU is typically in everyone’s best interest.
Relationships, team building, and establishing mutual goals doesn’t happen overnight, and certainly not with one meeting. But it starts by having a discussion about issues, mutually agreeing to address and improve the situation, and understanding each side’s perspective. It’s important not to dismiss vague complaints related to quality (or other complaints) as they may contain a kernel of truth. Of course, getting specific examples allows for a more productive discussion.