Many of our express care physicians receive the "JUCM", or Journal of Urgent Care Medicine,and the November 2012 issue had an excellent summary article in the "health law" section on malpractice reminders (page 33 in the scroll magazine below, if accessible).
http://www.jucm.com/magazine/members.php?issue=/magazine/issues/2012/1112/
The article written by a MD/JD had several tidbits to keep you from getting complacent in the everyday drone of mucus and aches.
1. Remember, in "drug seekers with recurrent back pain"-stay vigilant for the rare but catastrophic spinal epidural abscess. Per the article fewer than 10% of spinal epidural abscesses present with the textbook triad of back pain, fever, and focal neurological deficits, but if you do see fever and back pain, strongly consider emergent imaging in the ER. As always a thorough neurologic exam is crucial, even with routine back pain.
2. Yes, the "lab book" is the bane of our existence, but consider reminder #3- "failure to inform a patient about an abnormal test is a red flag issue." I think the biggest landmine here is when a chest x-ray to rule out pneumonia shows a nodule, or when the radiologist thinks it is pneumonia, but suggests "repeat x-ray in 6 weeks to confirm clearing." In these cases I strongly suggest, getting a copy of the CD, and writing in the discharge instructions to have a repeat xray in 6-8 weeks to confirm clearing. With a smoker, I would even go so far as writing, "to ensure no tumor is present" in the discharge instructions, which clearly and hopefully unequivocally conveys to the patient the gravitas of the situation.
3.The article has the solid perspective, " Urgent care is a very high risk environment-even higher than the emergency department. It is high risk because everyone, including the patients, thinks it is low risk and we can all be lured into a false sense of complacency. Remember, "(think) Worst First!"
4.If your discharge diagnosis is a diagnosis that may come back to haunt you, such as headache, chest pain, et al, then be very thorough in documenting your reasoning and pertinent positives and negatives. For example, go back to spring 2012 and review the blog article on "When to Refrain with Chest Pain" for some crucial pertinent negatives.
5.Minor head injuries in patients on coumadin are by defintion not minor.
6 Here is a classic, " The same patient presenting more than twice with the same complaint needs to be conclusively figured out/admitted on the third visit." I always try to adhere to a "3 strikes and you are out policy"- the ER comes on strike 3. Every "bounceback" exponentially increases your liability and appearance of ignorance to a jury. Refer and move on. It is hard to "save the world" when embroiled in a major, years long, malpractice battle, so again, move on.
7. Read the notes of others before discharging a patient. Pay close attention to the ED summary note with vitals, as it is easy for the nurses to type in a vital sign wrong- and that typo could make you look incompetent. I have seen legion times a mistyped temperature of 95, or a respiratory rate of 56. You may ignore it since you can see the patient, but it needs to be corrected, as that temperature of 95 will doom you when that elderly patient with what you "think" is manageable pyelonephritis goes home, becomes septic overnight, and dies the next day. Then, the lawyer is suddenly reminding you that hypothermia can signal advanced sepsis....and then we have a major problem. Also read the nurses "chief complaint section" to ensure his/her documentation is not contradicting yours-and write out the resolution. As the article states, you don't want your note to say "mild headache", but the nurse triage note to say, "worst headache of my life." You may state in your medical decision making, " nurse triage note reviewed, discussed with patient directly how severe headache was- patient stated 6/10, and was "throbbing" but "not worst of life." Overlooked discrepancies can hurt you immensely!
Never forget, as a medical provider in today's world you are one thing- a target.
Wednesday, November 28, 2012
Wednesday, November 14, 2012
Ring the Bell for Steroids!
http://www.neurology.org/content/early/2012/11/07/WNL.0b013e318275978c.abstract
Above is a current nice meta analysis abstract from the American Academy of Neurology summarizing that for Bell's palsy, the treatment of choice definitively should include steroids, and at best, antivirals should be an adjunct. I lack access to the full article, but being a meta analysis I assume one set dose and period of steroids was not agreed upon. A rough survey of older texts though seems to avoid the "Medrol Dose Pak" in favor of higher, constant doses to battle Bells. While there is some literature disagreement, most authorities concur that no steroid taper is required for 5 days of therapy, and I have seen quotes ranging from 7 to 9 days before a taper is required. A few other tips:
1. Again, this 2012 analysis emphasizes steroids for Bells. As the abstract states, antivirals can be used, but the proven benefit is modest- 7% at best.
2. DOCUMENT in your note how long the patient has noted symptoms, as most bad outcomes are linked to patients presenting over 3 days from symptom appearance. As such, a lack of response to therapy (ie- a patient saying "you horrible provider, you have not cured me yet!") is often due to late presentation-not your improper therapy.
3. Make it clear in your discharge instructions for diabetics about hypergylcemia issues, including the need for primary care follow up for possible monitoring, before you embark on the steroids. Ditto for history of severe/bleeding GI ulcers.
4. In a busy clinic it is easy to do, but recall- per my recollection- that this "Bells/steroids emphasis" is different from zoster/shingles, where the focus is more on prompt antivirals. Per my reading there is less conclusive data on the benefits of steroids in zoster, including post herpetic neuralgia. Please comment if you know of a renewed or newly proven emphasis on steroids for zoster.
5. DON'T FORGET THE EYE! In Bell's palsy people wil sleep and the eye cannot/will not completely shut. Without the constant stream of germ diluting eye secretions from the tear ducts, people with poor eye management in Bells have had devastasting corneal ulcers. Give written instructions to use sterile saline ad lib during the day and at night to "tape" the eyelid shut with paper tape. Eye irritation or discomfort should prompt an ophthalmology evaluation.
6. For what it's worth, I usually go with Prednisone 50mg tablets, one a day with food for 5 days, no taper. Do you all have any other "favorite" regimens?
7. Lastly, infectious disease specialists rant about considering Lyme disease in a patient with Bells palsy. While I see no problem with documenting a tick exposure history, I would kindly refer one to the legion articles in the past on this blog about the limits and pitfalls of Lyme testing. As I often say, "any fool can ordrer a test- the medical skill comes in proper interpretation."
Above is a current nice meta analysis abstract from the American Academy of Neurology summarizing that for Bell's palsy, the treatment of choice definitively should include steroids, and at best, antivirals should be an adjunct. I lack access to the full article, but being a meta analysis I assume one set dose and period of steroids was not agreed upon. A rough survey of older texts though seems to avoid the "Medrol Dose Pak" in favor of higher, constant doses to battle Bells. While there is some literature disagreement, most authorities concur that no steroid taper is required for 5 days of therapy, and I have seen quotes ranging from 7 to 9 days before a taper is required. A few other tips:
1. Again, this 2012 analysis emphasizes steroids for Bells. As the abstract states, antivirals can be used, but the proven benefit is modest- 7% at best.
2. DOCUMENT in your note how long the patient has noted symptoms, as most bad outcomes are linked to patients presenting over 3 days from symptom appearance. As such, a lack of response to therapy (ie- a patient saying "you horrible provider, you have not cured me yet!") is often due to late presentation-not your improper therapy.
3. Make it clear in your discharge instructions for diabetics about hypergylcemia issues, including the need for primary care follow up for possible monitoring, before you embark on the steroids. Ditto for history of severe/bleeding GI ulcers.
4. In a busy clinic it is easy to do, but recall- per my recollection- that this "Bells/steroids emphasis" is different from zoster/shingles, where the focus is more on prompt antivirals. Per my reading there is less conclusive data on the benefits of steroids in zoster, including post herpetic neuralgia. Please comment if you know of a renewed or newly proven emphasis on steroids for zoster.
5. DON'T FORGET THE EYE! In Bell's palsy people wil sleep and the eye cannot/will not completely shut. Without the constant stream of germ diluting eye secretions from the tear ducts, people with poor eye management in Bells have had devastasting corneal ulcers. Give written instructions to use sterile saline ad lib during the day and at night to "tape" the eyelid shut with paper tape. Eye irritation or discomfort should prompt an ophthalmology evaluation.
6. For what it's worth, I usually go with Prednisone 50mg tablets, one a day with food for 5 days, no taper. Do you all have any other "favorite" regimens?
7. Lastly, infectious disease specialists rant about considering Lyme disease in a patient with Bells palsy. While I see no problem with documenting a tick exposure history, I would kindly refer one to the legion articles in the past on this blog about the limits and pitfalls of Lyme testing. As I often say, "any fool can ordrer a test- the medical skill comes in proper interpretation."
Subscribe to:
Posts (Atom)