Patient centered approach at clinics

[spimx]

Patient wife "which hospital are ya'll taking him to"

Me "Regional hospital is the closest hospital

NP "He going to the Baptist Hospital" 30 min further and on diversion

I always recommend the closest hospital unless I think the patient needs specialty care that is not at that hospital or the patient has a Hx at a different hospital like recent admission or surgery.

Clinics always recommend the same hospital under any circumstance because their DR has privelages at that hospital

 

[DrParasite]

Patient wife "which hospital are ya'll taking him to"

Me "Regional hospital is the closest hospital

NP "He going to the Baptist Hospital" 30 min further and on diversion

I always recommend the closest hospital unless I think the patient needs specialty care that is not at that hospital or the patient has a Hx at a different hospital like recent admission or surgery.

Clinics always recommend the same hospital under any circumstance because their DR has privelages at that hospital

Have you tried... asking the patient which hospital they want to go to? the NP can say the patient is going to baptist all day long, but unless the NP is going to drive the patient there personally, if the patient says they want to go to regional, guess where the patient is going?

How about this: why don't you address this with your medical director? This sounds like a clinical issue, that you could use his or her guidance on how best to handle the situation, while still doing what's in the patient's best interests. And, if the NP does complain, you have have him or her speak to your medical director about the situation.

 

[E tank]

I work in a tourist area most of these people are from over 1000 miles away. They are sending people to the same place every time regardless of the pathology because it's an affiliated facility. How can you explain CTMC in San Marcos Texas sending a STEMI past a PCI facility for an extra 20 min to one that they are affiliated with. Patients don't know they are passing a cath lab on the highway unless you inform them.

Can anyone say that the patients should not be informed of their options before a facility is recommended? Our closest hospital is 35 min and longest trip is over an hour, these are not short trips where the difference in time is inconsequential. It's a problem of respect for autonomy that is exacerbated in the setting or rural EMS.

You keep saying 'PCP' when you say you're talking about patients a thousand miles from home. What options are a patient 1000 miles from home going to be aware of and informed of the services provided there than the provider you're taking the patient from? Does every hospital you pass have interventional radiology? An EP lab? CT surgery? ECMO? Does the patient even know what those are? Can you say when you load the patient better than the provider what, if any of those the patient will need?

Maybe it's an over call on the part of the sending provider and that might be a decision that is way over their pay grade. But it's definitely over yours.

 

[E tank]

Don't all/most hospitals use the EPIC system, and can't a provider in one hospital look up records for the patient in front of them from other hospitals too?

EPIC is just one of many EMR's and they don't all talk to each other unless someone on the sending side actually sends it. I will say that EPIC is the least of the hot messes that EMR's can be...but then you have the periodic upgrades that screw things up while you wait for the 'upgrades' to be fixed.

 

[Jim37F]

Wait, I'm a little confused, are you talking about transports initiated via 911 where you respond, and then they tell you take the patient to Hospital X and you take them straight to the Emergency Department to be checked in there?

Or are you talking about an actual IFT where the sending facility has already contacted the receiving facility, done a report and arranged for the patient to be seen by a specific department and you take them straight to the floor? Diversion status wouldn't matter much in that case right?
And if continuity of care has already been established between the sending and receiving facilities, wouldn't changing the destination afterwards ultimately delay patient care long term because now the new facility (even if closer) wasn't expecting the patient so now they have to wait vs the original receiving who is now wondering where their patient is and holding their room?

If you feel your IFT patient is unstable and you need to divert to a closer facility, don't you have protocols covering that? Divert, call base station, document, etc?

But yeah, if it's a big deal, talk to your supervisors, see if you can chat with your medical director.

 

[spimx]

Wait, I'm a little confused, are you talking about transports initiated via 911 where you respond, and then they tell you take the patient to Hospital X and you take them straight to the Emergency Department to be checked in there?

Or are you talking about an actual IFT where the sending facility has already contacted the receiving facility, done a report and arranged for the patient to be seen by a specific department and you take them straight to the floor? Diversion status wouldn't matter much in that case right?
And if continuity of care has already been established between the sending and receiving facilities, wouldn't changing the destination afterwards ultimately delay patient care long term because now the new facility (even if closer) wasn't expecting the patient so now they have to wait vs the original receiving who is now wondering where their patient is and holding their room?

If you feel your IFT patient is unstable and you need to divert to a closer facility, don't you have protocols covering that? Divert, call base station, document, etc?

But yeah, if it's a big deal, talk to your supervisors, see if you can chat with your medical director.

I'm talking about 911 calls, I don't do transfers but I think ethically patients that are being transferred should be given an option.

 

[CCCSD]

I'm talking about 911 calls, I don't do transfers but I think ethically patients that are being transferred should be given an option.

You have much to learn about the medical system, insurance, and Drs treatment plans.

 

[spimx]

You have much to learn about the medical system, insurance, and Drs treatment plan

I dont care about insurance. Autonomy and patient centered approach is what's important to me

 

[CCCSD]

I dont care about insurance. Autonomy and patient centered approach is what's important to me

To the detriment of the patients…right.

 

[spimx]

To the detriment of the patients…right.

You are the detriment of patients, because you dont respect autonomy

 

[ffemt8978]

Just a reminder, keep it respectful or become the focus of my complete and undivided attention.

 

[E tank]

You are the detriment of patients, because you dont respect autonomy

autonomy is a two edged sword, bro/sis....it assumes some pretty hefty informed judgement and consent that is not under duress, neither of which you have demonstrated in the presented scenario. Invoking a principle of medical ethics is noble and cool and all, but a.) using it as a cudgel and b.) misapplying it betrays a certain ignorance of the stakes, fundamentals and purpose of medical ethics....I'd check with a hospital chaplain for more information...

 

[spimx]

autonomy is a two edged sword, bro/sis....it assumes some pretty hefty informed judgement and consent that is not under duress, neither of which you have demonstrated in the presented scenario. Invoking a principle of medical ethics is noble and cool and all, but a.) using it as a cudgel and b.) misapplying it betrays a certain ignorance of the stakes, fundamentals and purpose of medical ethics....I'd check with a hospital chaplain for more information...

Assume you are wrong. How can consent be under duress? Yes, informing the patient is critical. If I inform the patient and make a recommendation and then give the patient options, that is patient centered health care. Directing the patient to the same hospital every time because of an affiliation, without informing or delivering options is unethical.

So explain how you preferer to transport from the same clinic to the same hospital that is affiliated while bypassing 3 other hospitals?
Explain how you prefer to transport from CTMC in San Marcos past a cath lab for a STEMI patient to go to Austin because of an affiliation?

 

[ffemt8978]

Assume you are wrong. How can consent be under duress? Yes, informing the patient is critical. If I inform the patient and make a recommendation and then give the patient options, that is patient centered health care. Directing the patient to the same hospital every time because of an affiliation, without informing or delivering options is unethical.

So explain how you preferer to transport from the same clinic to the same hospital that is affiliated while bypassing 3 other hospitals?
Explain how you prefer to transport from CTMC in San Marcos past a cath lab for a STEMI patient to go to Austin because of an affiliation?

You could be wrong in your assumptions too. After all, you're assuming that the patient's primary care physician has been approved to practice or admit at the hospitals you're recommending; you're assuming that the patient's insurance will pay for them to be seen and treated at the hospitals you're recommending.; you're assuming that patients don't have the right to consider the financial impact on their family when deciding what hospital to go to; you're assuming that the clinic doc hasn't already done a consult with a doc at the receiving hospital and fully briefed them on what to expect; etc...

See what happens when you make assumptions?

That being said, if you're being ordered to bypass a cath lab with a STEMI patient, that is an issue you should bring up to your chain of command and medical director. There may very well have been a vailid reason for the bypass that you're not aware of, or it could be simply due to affiliation. Either way, you don't have the information or ability to fully investigate it and determine what needs to be done and take the appropriate actions to resolve it.

 

[spimx]

You could be wrong in your assumptions too. After all, you're assuming that the patient's primary care physician has been approved to practice or admit at the hospitals you're recommending; you're assuming that the patient's insurance will pay for them to be seen and treated at the hospitals you're recommending.; you're assuming that patients don't have the right to consider the financial impact on their family when deciding what hospital to go to; you're assuming that the clinic doc hasn't already done a consult with a doc at the receiving hospital and fully briefed them on what to expect; etc...

See what happens when you make assumptions?

That being said, if you're being ordered to bypass a cath lab with a STEMI patient, that is an issue you should bring up to your chain of command and medical director. There may very well have been a vailid reason for the bypass that you're not aware of, or it could be simply due to affiliation. Either way, you don't have the information or ability to fully investigate it and determine what needs to be done and take the appropriate actions to resolve it.

If the NP is going to give a report or consult to a receiving facility they need to gain consent from the patient for that destination first, which should also require, informing the patient and delivering options.

They chose the destination based on affiliation only

 

[ffemt8978]

If the NP is going to give a report or consult to a receiving facility they need to gain consent from the patient for that destination first, which should also require, informing the patient and delivering options.

They chose the destination based on affiliation only

And you know this how?

 

[E tank]

So explain how you preferer to transport from the same clinic to the same hospital that is affiliated while bypassing 3 other hospitals?
Explain how you prefer to transport from CTMC in San Marcos past a cath lab for a STEMI patient to go to Austin because of an affiliation?

I've already explained it. You disagree with me and that's OK.

 

[silver]

Explain how you prefer to transport from CTMC in San Marcos past a cath lab for a STEMI patient to go to Austin because of an affiliation?

CTMC is a hospital/freestanding ED? If it is then that's not a true 911 call and they are required by law to have an affiliation in place to transfer to PCI capable facility. The goal is to improve outcomes and get patients the care they need sooner by streamlining the transfer and hand off process.

 

[FiremanMike]

Have y'all encountered a scenerio where in a clinic the doctor does not give the patient options? On multiple occasions nursing homes stand alone ER and clinics the doctor directs the patient exactly where to go and they must go my EMS, without options. Recently I pushed adenosine in a clinic and the NP directed the patient to the furthest possible ER that was also on diversion.

I respect my patients autonomy. Why are doctors and mostly NPs and PAs directing patients to specific ERs without options. I don't buy this ******** that continuity of the NP at the local clinic is important. I perform an assessment inform my patients and include them in their healthcare

Seems like there's a lot of stuff in this thread already irritating you..

I just wanted to pop in and say that a stand alone ER is completely different from a nursing home or a clinic. A transfer from a stand-alone ER (whether they called 911 or not) is an entirely different animal and you must take them to the hospital (more specifically, the physician) that accepted the patient transfer unless the patient becomes unstable en-route.

You must understand that no matter how they got ahold of you, a stand alone ER transfer to a different facility is an interfacility transfer and there are laws that cover these.

 

[DrParasite]

Ok, I think I see where some of the confusion is... and @FiremanMike did exactly what I was about to do...

a transfer from a free-standing ER, even if it was initiated by a 911 call, is a MUCH different situation than a 911 call at a nursing home or clinic. In those cases, you are doing a transfer between facilities, and if you have issues with the destination, I suggest you talk to your chain of command, including your medical director. The discussion of sending facilities policies is both above your paygrade, and likely above your education level (that is a medical director conversation, not an EMT/Paramedic).

If the NP is going to give a report or consult to a receiving facility they need to gain consent from the patient for that destination first, which should also require, informing the patient and delivering options.

Let me ask you something: other than having the NP mad at you, what is stopping you from diverting to a different destination (with the patient's consent of course), that is in the patient's best interest after you leave the clinic or nursing home? I'm not saying you should, I'm saying what will happen? will your employer support your decision? will your medical director?

While I understand your frustration with the situation, if neither your operational management (supervisors and admin) nor your clinical management (medical director) will support you in doing what you feel is in the patient's best interest, I think the only thing you are doing is frustrating yourself and causing yourself undue stress.