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Bouncebacks - Advanced Practice Clinicians

Shonna Riedlinger, PA, Tim Scanlon, PA, Jennifer Stankus MD, JD, and Mike Weinstock, MD

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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN

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EM:RAP 2016 October Written Summary 754 KB - PDF

When you own the patient, you own the patient completely. Partial ownership can be a recipe for disaster.

Bouncebacks – Advanced Practice Clinicians

Mike Weinstock MD, Tim Scanlon, Shonna Riedlinger PA, Jennifer Stankus MD,JD


Take Home Points

       Handoffs of patient care between providers are high risk for error. Taking ownership of the patient can decrease the likelihood of error.

       Critical lab values should be called to the provider while confirmatory testing is in progress, not after results are available.

       If the midlevel provider feels the case is outside their scope of practice or level of expertise, the physician should take over the case without hesitation.


      Scanlon reported for his shift at 11pm and assumed care of a patient assigned to the physician leaving at 1am. The patient was a 28 year old male presenting with abdominal pain. He was diaphoretic, tachycardic and slightly confused. Scanlon was concerned that the patient would not be wrapped up before the physician left so he approached the overnight doctor to see if they would assume care of the patient. She was unable to help and referred Scanlon to the departing physician.


      What did Scanlon see? The patient was in obvious distress with a complaint of abdominal pain. He had nausea and vomiting. He was restless, diaphoretic and a poor historian. He had a concerned mother at the bedside. She was very impatient with questioning and evasive with some questions. 


      What was the differential diagnosis? Kidney stones, gallbladder disease, pancreatitis and perforated bowel. He considered toxic ingestion. The patient had previously had an appendectomy.


      This was a difficult patient and the diagnosis was unclear. The CO2 was 19.


      Midlevel providers need to know what they know and when to ask for help. The first physician left and Scanlon discussed the case again with the overnight physician.


      The patient’s mental status continued to deteriorate. The patient accidentally removed his IV several times. The patient had a low grade fever, leukocytosis and altered mental status. They considered the possibility of a CNS infection and decided to obtain a head CT. They ordered a drug screen and considered toxidromes. Scanlon wished for more oversight by the physician.


      “You’ve got this, right? When everything results, let’s get him admitted.” The sign-out between the physicians was minimal.


      How can we make handoffs positive?

o      A study by Horwitz looked at the development of a handoff evaluation tool for shift to shift physician handoffs. They came up with certain elements that were important to convey to the receiving physician; identifying information, problem list, medication list, anticipatory guidance and a to-do list.

       Horwitz, LI et al. Development of a handoff evaluation tool for shift-to-shift physician handoffs: the Handoff CEX. J Hosp Med. 2013 Apr;8(4):191-200. PMID: 23559502

o      Another study looked at potential errors of handoffs such as a high signal to noise ratio, not having a standard approach, having an ambiguous moment of transition of care and cognitive bias.

o      Incentive based models may encourage or discourage handoffs, which could affect patient safety.

o      Cheung found some solutions. Reduce unnecessary handoffs. Limit interruptions and disruptions. Provide succinct overview of the case. Communicate outstanding tasks with a clear plan. Have information available for direct review. Encourage questioning by the receiving party. Have a clear moment of transition of care.

      Cheung, DS et al. Improving handoffs in the emergency department. Ann Emerg Med. 2010 Feb;55(2):171-80. PMID: 19800711

o      Apker, J et al.  Exploring emergency physician-hospitalist handoff interactions: development of the Handoff Communication Assessment. Annals of Emergency Medicine 2010 Feb;55(2):161-70. PMID: 19944486

       They looked at handoffs between emergency physicians and hospitalists. They found the power differential between the physicians can decrease openness and the amount of accurate information conveyed.


      Handoffs are high risk. However, it is also high risk for a provider to avoid seeing a patient because they don’t want to handoff the patient to the incoming physician. Sometimes providers may avoid ordering a test that may not provide results in a timely manner.


      It is not the handoff that is the problem. The problem is that the second provider is not taking ownership of that patient. The risk of handoff significantly decreases if you take ownership. Go in and see the patient. Put a directed note on the chart. Make sure you discuss test results and evaluate the patient.


      What was the diagnosis? The patient had salicylate toxicity. The lab was so surprised by the level of toxicity that they decided to rerun the results to confirm prior to releasing the results. The salicylate level was 119. The patient was admitted to the ICU and dialysis was arranged.


      There were several aspects of communication breakdown in this case. The failure of the lab to notify the providers regarding the elevated level before confirming is a systems-based failure. There should be an automatic call to the emergency department regarding a potentially critical lab value. There was a power differential between the midlevel provider and supervising physician. Scanlon felt uncomfortable requesting the physician take over the patient.


      The patient’s condition continued to decline and his respiratory status worsened. The intensivist decided the patient needed to be intubated. Shortly after intubation, the patient arrested and died.


      Within a year, all three providers were subpoenaed for a lawsuit.


      The first physician was deposed first. They were asked, “Doctor, don’t you think if someone has abdominal pain, tachycardia and diaphoresis, the first thing on your differential should be salicylate toxicity?” His answer was “Yes.” “Shouldn’t your PA also consider salicylate toxicity at the top of their differential diagnosis?” The answer was “Yes”.


      The case was settled for $750,000.  There were several contributing factors to the decision to settle the case. The deposition by the first physician was not a good reflection of the realities of the case. Also, the overnight physician should have gotten involved sooner in the case. The documentation was not sufficient.  Scanlon did not have the opportunity to document real-time progress notes and the documentation was not started until the patient was admitted and his shift was ending.


      What could have been done differently? Scanlon wishes he was more assertive. Midlevel providers and residents look to the supervising physician and trust their input and advice but it is ok to disagree respectfully. If the midlevel provider or resident asks you for help, be receptive.


      This is an interesting problem in the emergency department. Midlevel providers often have overlapping shifts with physicians resulting in sign-outs. These are more challenging as you don’t know the patient as well.


      They did a good job managing the case. They made the diagnosis and arranged for dialysis. The attorney for the plaintiff argued care was not provided in a timely manner rather than failure to diagnose.  Timing is very important in these cases. The patient was likely very acidotic and had they received dialysis sooner, they may have survived.


      Don’t throw another provider under the bus. However, someone has to take ownership of the patient. The midlevel needs to have an honest conversation with the physician and let them know that they need help with the patient. The supervising physician has to take ownership of the patient. This is their role.

o      Document times. Document what time you spoke to someone and a brief description of what was said.


      The patient presented at 11pm. They were diagnosed with salicylate toxicity and serum bicarbonate of 19. Nephrology and toxicology was consulted. They planned to place a catheter and start dialysis. Unfortunately, the patient died.

o      Sometimes we do everything right and there is still a bad outcome. Juries may feel sympathetic for the patient.


      What is the take-home message for midlevel providers and physicians? If the midlevel provider feels the case is outside their scope of practice or level of expertise, the patient should be handed over to the physician. The physician should take over the patient without hesitation. The midlevel provider should not be placed in a position where they feel they are unable to care adequately for the patient.


Alon M. -

I really love EM:RAP, I mean, I REALLY love it. I listen to it constantly, I watch the videos, read the summaries and recently even spent my Friday night (that is 21:00-23:00 EST) listening to the EM:RAP Live session and I feel that I have been able to deliver better care to my patients because of it. This is why I was very disappointed when I heard Mike Weinstock using the term Midlevel Providers on this month's EM:RAP. This chapter reviewed the dynamics between different practitioners involved in the care of a patient who unfortunately ended up dying. The situation described sounds very familiar to me as I am sure it does to many other listeners. That said, I agree with many other Advanced Practice Clinicians (APC), as we refer to our colleagues in our hospital system, that the term Midlevel is inappropriate, belittles our experience and expertise, and misrepresents our role in the healthcare team. This is not an obscure issue, much has been written about it and the American Academy of Nurse Practitioners (AANP) released statements denouncing the use of MLP and similar terms and considers them derogatory.

I feel incredibly privileged to be able to do what I do for my patients in the ED and know that my actions, and not the letters after my name are what really matters. Nonetheless, I could not help but feel offended when a widely circulated and esteemed educational program used the term MLP, apparently unaware of the controversy.

Mel H. -

Alon - I want to apologize for using an outdated term. We will do our very best to use the APC naming convention since we TOTALLY reply on our colleagues to reduce suffering and save lives - this is a team sport - we are on the same team!

Mike W. -

Alon, I am glad you wrote and apologize for using the term MLP. I agree this terminology is changing, some places faster than others, and I assure you that no offence was intended. As the Medical Director of the ODU PA studies program, I am not only an educator but and advocate for APC responsibilities and privileges. Thx for your input!

Alon M. -

Thank you very much for your prompt reply and apologies. Thank you again for your amazing program, which continues to improve in an ever growing rate and thank you for advocating for APC.

On a side note, I also really enjoy listening to the Foolyboo Shows. Great educational content for those times when I want to take a break from emergency medicine. Please keep 'em coming.

James A. W., M.D. -

I have 2 comments:
1) Mike is right in that when you pick up a case it is yours. If you don't go see it you are just lazy and the ensuing errors are your fault. The second doc should have seen the patient in person at 0100. If she was too busy there is a staffing problem and one should consider a more appropriate job environment.
2) I wonder why the APC is seeing this very complex case. In the 1960s it was established that emergency care was best provided by emergency physicians. This has been the underlying premise of the emergency medicine specialty ever since. Insinuating another person between the patient and the physician is always dangerous and has potential for the problem to which we were just we introduced. Relying on an APC to do more than they are capable of is another form of laziness again bred in being too busy. The business model of replacing physicians with APCs is common but is always questionable, generated by business needs, and is mildly unethical in that patients often do not know the difference in level of provider.

Mike W. -

Thanks James, TAKING OWNERSHIP is key with all handoffs, APC, physician/physician, or EP/specialist. Jennifer summarized it in the segment beautifully - when someone asks for help... you go help!

Rabbott -

If you've seen the movie "Sully", you might have noticed a very brief but important line: "I've got the plane." That brief statement clarified the changing roles as the more experienced and senior Captain took over the hands-on flying of the plane from the (presumably) less experienced First Officer. Nice that the Captain recognized a potentially disastrous situation (OK, not too subtle in the case of the movie), and explicitly clarified that "the plane" was now his. Physicians might learn from this.

Mike W. -

I did see Sully and I agree w the parallel. The captain and first officer work together and this is the best model for success!

Chris W. -

The most important quality in both MLP and MD alike is the ability to communicate. If you are failing at this you are failing at your profession.

If at some point in your career you have not asked a colleague for help or their opinion on a complex case I ask what rite aid urgent care do you work at? If a team member asks you for help you give it. I find James MD comment #2 absolutely insulting. Every institution is different. Every MLP or MD skill set is different. For example at my institution it would be rare to see an attending do an intubation, chest tube, central/dialysis line over the PA and we have one of the most complex patient populations in the country. The question should be asked with every complex patient "do you feel comfortable with the plan/procedure; if not, what can I do? A team approach is critical!

Scott R. -

I'm sorry but there was an elephant in the room that I feel like got skimmed over here. When the APC was talking about the depositions and the first physician had answered "yes" to the question of "Doctor, don't you think if somebody has abdominal pain, tachycardia, and diaphoresis the first thing on your differential should be salicylate toxicity?" SERIOUSLY?!!?!? FIRST thing on the differential. Tox would be on my differential if I got a list of 5 but the specific of salicylate toxicity wouldn't hit a list of 20. I mean sure, if the symptoms were Tachypnea, Tinnitus, and Vomiting. Definitely at the top of the differential diagnosis then. I feel like you could have talked about how depositions could better be handled here too.

Juron F. -

Boom! When I heard that my jaw dropped. I was shocked no one mentioned it yet.

Mike W. -

We must, indeed, all hang together, or assuredly we shall all hang separately. Statement at the signing of the Declaration of Independence (1776-07-04), quoted as an anecdote in The Works of Benjamin Franklin by Jared Sparks (1840).

Xander Merboo -

#1 the overall discussion was outstanding. I really like the take home message that when a PA asks a physician for help, there should be the expectation that the physician will take the patient over without any blowback.

#2 as a very very small aside on the discussion - SEMPA [the PA counterpart to ACEP] has released their policy statement that PAs in the ED should be addressed by the title 'EMPA' and they do not recommend lumping together all advanced practice RNs [CRNA, APRN, CNM, NP] with PAs. In the case where non-physician practitioners are to be lumped together, SEMPA recognizes the term Advanced Practice Provider [APP]. Not that I agree with their nomenclature decision, but they are the main body to support, educate and advocate EM PAs.

Mike W. -

Thx Xander for your comments - this was a wild case and really demonstrated how we all need to work together!

paul f. -

It sounds like Tim did a good job taking care of this patient. At my hospital most admissions are discussed with attending. I can imagine being the night MD and asking about Vitals, did a CT get ordered ( abdomen and ? head) and wanting to review these once they came back as I managed all the other new cases. I would begin to really turn on the "thick slice" thinking once the images were negative. At that point CNS infection and toxic causes would be strongly considered and most toxic screens still add salicylate and acetaminophen. As an attending I would have likely taken ownership of the case in terms of complete reassessment, but it would not have changed the outcome in this case. The case made sense once the salicylate level was available. Because the patient died, it became a good case to review, but I think Tim did a great job. The first MD's testimony concerning salicylate poisoning is ridiculous. I also agree this would have been defensible. Tim, you did nothing wrong!

Cathleen M. -

In listening to this case,....I must say I felt sorry for Tim, PA. It didn't seem he was getting the help he needed in a complex case. Also, the first physician that was deposed seemed to throw him under the bus. The lawyer asked that first physician "if someone has abdominal pain, tachycardia, and diaphoresis, the first thing on you differential should be salicylate toxicity?"---The first physician said "Yes".
I completely disagree---there was no history of salicylate overdose!!! There are numerous diagnoses on the differential list before salicylate toxicity!! The PA was thrown under the bus both on the night the patient was in the ER and during depositions. Tim got the diagnosis and even though he did everything right sometimes there are bad outcomes. Tim, don't let this one case bring you down!

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Say Hello to BRUE Full episode audio for MD edition 217:39 min - 303 MB - M4AEM:RAP 2016 October German Edition Deutsche 115:41 min - 159 MB - MP3EM:RAP 2016 October Canadian Edition Canadian 10:10 min - 14 MB - MP3EMRAP 2016 October Résumé en Francais Français 35:33 min - 49 MB - MP3EM:RAP 2016 October Aussie Edition Australian 31:48 min - 44 MB - MP3EM:RAP 2016 October Spanish Edition Español 94:36 min - 130 MB - MP3EM:RAP 2016 October Board Review Answers 187 KB - PDFEM:RAP 2016 October Board Review Questions 292 KB - PDFEM:RAP 2016 October MP3s 257 MB - ZIPEM:RAP 2016 October Written Summary 754 KB - PDF