Readers weigh in on VTE prophylaxis, critical care

Published in the November 2018 issue of Today’s Hospitalist

Regarding “What’s the evidence? Weak at best” (September), your source noted that at the medical center where he works, the heart failure order set still includes a two-gram sodium diet. His advice to readers: Talk to their cardiologists to see if they should continue using such an order.

I suspect that hospitalists are managing most decompensated or acute heart failure as the primary provider on the wards, consulting a cardiologist only in specific cases. Restricting sodium and water is well worth a discussion because many local cardiologists seem to ignore or dismiss evidence, operating a tradition-based practice instead. But if I see no compelling evidence to continue these kneejerk restrictions in my patient, why would I need a cardiologist’s permission?

~ Richard Gicking, MD
Portland, Ore.

More on VTE prophylaxis
Re: “Time to scale back VTE prophylaxis?” (August): One hospital where I’ve worked recently has embedded a well-written risk stratification for VTE prophylaxis in the order set. As a result, I’m ordering far fewer (unnecessary) prophylactic doses of low molecular weight heparin. At the other end of the bell curve, I worked for three years in a hospital with a dysfunctional EHR, and it took more than five clicks— as well as additional text—to NOT order VTE prophylaxis for a patient. The peer review committee there did not understand the concept of VTE prophylaxis not being indicated in all patients and always at the same doses.

With between 12 and 24 admissions every shift at that hospital, I couldn’t afford the extra clicks and text to properly not order prophylaxis for many of my patients. I reserved that extra effort for those who had obvious bleeding risk. Hopefully, institutions with low-functioning EHRs will redo their VTE order sets to accommodate correct use and dosing.

~ Suzanne Simmons, MD
Denver

More on critical care
Re: “No one taking your calls? Problem with ICU transfers and support“ (July): As a critical care physician, I see hospitalists doing too much. They ask me to see patients much later than primary care doctors did in the past. Rather than calling me for a critical care evaluation at the start of a patient’s hospitalization, I am not asked until the patient has been in the hospital for three or five days. At that point, the patient is usually much more ill than at the initial admission.

Without that consultation delay, I could be of assistance sooner and potentially prevent a prolonged hospitalization.

~ Mark Janes, MD
Dubuque, Iowa

Re: “No one taking your calls“: I applaud the hard work of David Aymond, MD, and his colleagues on the SHM critical care task force to design critical care training for non-intensivists. But I believe he’d be better served channeling his time into more core hospitalist issues. I know hospitalists think they need to prove their relevance to hospital administrators by taking on roles they haven’t trained for, and I am not referring to step-down. But if I wanted to take care of critically ill patients, I’d go back to school for a fellowship.

Common sense dictates that administrators who think their hospital is ready for an ICU should be ready to hire critical care specialists. But that would deprive hospitalists of coveted critical care billing, so we risk our medical licenses and potential burnout instead of insisting on patient safety. Until we take back our autonomy from administrators, we will always be playing catch-up.

~ Paul Adjei, MD
Boston

Dr. Aymond responds:

You’ve hit on some really good points. Where our opinions diverge is that my colleagues and I believe we are working on core hospitalist issues. The fact that you don’t feel that taking care of critically ill patients is a core issue likely speaks to you being a part of a larger health system.

One key point many urban colleagues miss is that if you’re the only doctor in the hospital—or, for that matter, the city—you’re on the hook when these patients go bad during their admission. If you do nothing, your answer to the medical review panel, judge or jury will have to be, “Well, there were no intensivists there, and I missed that day in med school.” That will not hold water, and you’ll be held to the same medicolegal standards as any other type of physician.

And thinking “why not just transfer?” is also a product of working in large health system. Even if (and it’s a big if) you can find a bed, it will be at least three to five hours from the time you attempt transfer. Tele-ICU has also been attempted, but that doesn’t thrive in some scenarios.

In the small towns where this topic is most prevalent, hospital administrators are great folks who actually know the patients in their hospital. Believe me, if they were available, small-town administrators would hire an intensivist tomorrow. But the majority of ICU docs are not seeking out a 40-bed community hospital that’s one and a half hours away from an interventional cardiologist, mall, car dealership or water that doesn’t come from a well and taste like rust.

Finally, not all hospitalists have the opportunity to complete a critical care fellowship; family medicine hospitalists, for instance, cannot. Through SHM and the American Board of Family Medicine, we have lobbied the American Board of Internal Medicine to consider allowing family medicine hospitalists to apply for critical care fellowships. If approved, this would go a long way to helping solve several of these issues, as family medicine hospitalists are very prevalent in the small towns where the need is the greatest.

~ David Aymond, MD
Leesville, La.