Encouraging thoughtful decision-making in the E.R.

Close your eyes for a moment and imagine a scenario. You are an emergency room physician that has just received a critical care patient. The patient seems to be presenting with signs and symptoms that indicate an acute stroke. Specifically, you suspect ischemic stroke, which occurs when a blood clot blocks blood flow to the brain. This patient meets all criteria for administration of tissue plasminogen activator (tPA). You are planning to order a CT scan to confirm, but lowering this patient’s blood pressure is your immediate concern. What do you do next?

Too often, physicians default to the treatment they have the most experience using. This seems antithetical to the patient-centric approach that healthcare increasingly demands. Wouldn’t you expect a physician to carefully consider the merits of each situation and patient prior to making a decision?

In reality, there are many different factors the physician is trying to balance, such as current case load, patient status, availability of diagnostic equipment, or even mental fatigue. Some factors that might be part of the physician’s thought process are more administrative than medical, such as determining if enough beds exist to admit the patient.

In actuality, time is one of the most crucial factors in these situations. The speed with which blood pressure is brought under control can make the difference between full recovery and a plethora of complications. As time ticks down on the "golden hour" (the hour between patient arrival and administration of therapeutic intervention), the patient moves quickly through the 3-hour window in which tPA can be administered. Often, the physician chooses a short-acting vasodilator, such as labetalol, rather than a longer-acting agent, such as Cardene I.V. premixed or nicardipine admixed in the hospital pharmacy. To achieve the goal blood pressure prior to tPA administration, it isn't uncommon for the physician to have to order several rounds of labetalol, as opposed to a single dose of nicardipine admixed or Cardene I.V. premixed. With so much potential for negative outcomes, this is a situation that clearly requires careful consideration prior to selecting a course of action.

There are many examples in emergency medicine where a commitment to great patient care has overridden logistical or administrative concerns. For example, the vasodilator nitroprusside is traditionally used by certain neurology sub-specialties, in spite of its risk for severe toxicity. Unfortunately, in recent years, its price has risen dramatically. (As a side note, isoproterenol has also become expensive. Both price increases are courtesy of Valeant Pharmaceuticals.)

Refusing to allow manufacture pricing spikes to detract from the value they deliver to patients, Baystate Health in Massachusetts responded thoughtfully and decisively through a "series of pharmacy and therapeutics committee meetings last year, with active input from three surgical departments and the emergency department physicians". They decided to remove nitroprusside from the formulary and substitute nicardipine and clevidipine, therapeutic agents with demonstrated equivalence to nitroprusside. This change in protocol saved both payers and hospitals money while providing safer care to patients without sacrificing treatment outcomes. This is an excellent example of thoughtful and strategic decision-making by a health system.

Opportunities for positive reinforcement as well as improvement in decision-making are numerous but unapproachable in a stressful emergency room environment. In order for change to occur, deliberate efforts must be made. One potentially impactful idea is an annual skill-building seminar added to the continuing education already required of each physician. During this seminar, each physician would be encouraged to identify and challenge any situation with potential to negatively affect patient outcomes. Perhaps course material could incorporate principles of cognitive behavioral therapy (CBT), creating a guide tailored for the rigors of hospital decision-making. This approach could have significant impact on various key decisions ER doctors make every day.

Ultimately, focusing on building solid decision skill sets could ensure that the right treatments are chosen for the only reasons that matter: improving patient-centricity and patient outcomes.

*Disclaimer - This post is not intended to replace consultation with licensed medical practitioners. My goal is only to highlight hypothetical situations in an emergency medicine environment that may benefit from a stronger decision-making framework.*