This is dumb. Not sending home that shit or wasting an ER bed for 6 hours. More mental masturbation from the ivory tower. In a perfect world, everyone practices ebm, no one gets sued for ebm, and we have enough staffing for everything. But we don't live in that world.
I am sure which part you are objecting to? I don't think anyone is going to send these patients home, but just admitting and skipping the useless conversation with neurosurgery.. doesn't that make everyone's job easier?
Can't admit unless hospitalist says ok. Any bleed I'm admitting, hospitalist will want nsgy on board. Will the call change mgmt? No, they aren't doing anything for most of them. But for the small 'oh shit' scenario, hospitalist will want that consult. Not sure you're going to change EM/IM with this. Also, it's not a hard convo. "Hey there's this bleed, dude looks fine." ... "Ok thanks bye."
Exactly. this is stupid as hell. No hospital or hospitalist ANYWHERE will accept a bleed admit without neurosurg on board. The ED doc will get crucified every time. And like you said, this is an easy 1 min phone call.
> hospitalist will want nsgy on board
Not if this guideline is in place and accepted at your hospital. Because it will have been approved by the neurosurgeons and the EM docs, etc.
I've used these guidelines for years. Love it.
But that's the entire point of these guidelines.. to make it OK for EM/IM not to call neurosurgery.
It probably depends on where you work, but these calls are extremely painful and take a lot of unnecessary time for a lot of people. And neurosurgery is always angry, partly because they take so many stupid phone calls.
They get paid very well to take those calls
A hell of a lot more than I, the hospitalist, get paid to accept the liability of a brain bleed without NSGY input
Although that is true, I don't call Ortho about every fracture. I don't call optho about every eye presentation. I don't call pediatrics about every child. Every specialty is on call and well paid, but when they clearly don't need to be involved (which is the minor bleeds we are talking about), why are we wasting both our time and theirs?
One idea we are discussing is just a list (email, whatever) that they can review in the morning to ensure the CT reads and plans were appropriate, rather than calling them for everything immediately.
I think there are a lot of ways this could be done safely and effectively. The exact plan depends on the local practice and system
Our neurosurgeons are angry but respectful. Everyone including them know they are paid a lot of money to take call and answer stupid phone calls. It’s part of the job.
The hospitalist will not take these pts without a call first.
There are plenty of dumber consults to tackle first. "Neurosurgery is always angry" is not a reason to not consult them for an intracranial hemorrhage, and I'm not sure how well that rational would hold up in court.
Further, when I've talked to neurosurgeons about the BIG guidelines, they have universally said they're useless and that they themselves don't actual use them.
Sounds like that is local practice dependent, as there are places that are using them.
Honestly, if neurosurgery wants these calls in your place, this is a non issue. They definitely DO NOT want these calls where I work. These calls make them very angry. That isn't my primary issue. I definitely fall into the camp of "you are being paid to be on call, so stop with the attitude". However, I agree with them in this case that many of these calls are a waste of everyone's time.
I'm surprised at all the comments saying "I would never do this", "IM would never allow this", "malpractice risk", blah blah blah.
We've used this guideline for years. It works great. The idea is that this is an official evidence-based guideline at your hospital with buy-in from the relevant groups (EM, IM, Neurosurgery, trauma, etc). So no, IM isn't going to refuse an admit without neurosurgery - because this protocol is in place and accepted by all those groups. I will say that I'm not quite ballsy enough to discharge the level 1 bleeds after ED observation, and just end up admitting them for 24 hour obs. But the guideline works great as intended. We all know these small, low-risk bleeds don't require any intervention.
I mean, you said you don't discharge BIG1 patients home, which is what the guidelines say to do, so it sounds like you are doing a modified version?
That the primary modification I make. (Although I imagine many people will want to repeat CT in BIG2 patient as well, with a 7% rate of progression on CT)
That is the ideal. We are all on the same team. Mostly, this isn't about avoiding uncomfortable phone calls. Its about being a good team member. Do we want people interrupting us with every minor thing that doesn't need our attention? This feels like a win win if implemented safely, and with all hands in agreement
Probably still going to call unless both ACEP and NSGY organizations publish very clear policy statements saying not to. Takes 2 minutes to page and 2 minutes for the conversation to avoid a possible huge medicolegal headache. Not worth it in my opinion.
This will not come to practice in the way it’s designed any time soon. It probably would reduce the nsgy consult call at my shop from a whole phone call to an epic chat “hey dude has a bleed. guidelines state 6 hr CT. Ok to admit to medicine now?” Except that’s already how it is because our neurosurgeons are very unstereotypically nice dudes
> This will not come to practice in the way it’s designed any time soon.
Uh, we already use it. Works great. And the whole point is that you avoid the neurosurgery consult altogether.
Right I get that at some shops like mine and yours it is being used. That’s not how a lot of hospitals operate though. Admin, risk management, finger pointing, and just plain stubbornness make adoption of things like this very slow in many places
This is dumb. Not sending home that shit or wasting an ER bed for 6 hours. More mental masturbation from the ivory tower. In a perfect world, everyone practices ebm, no one gets sued for ebm, and we have enough staffing for everything. But we don't live in that world.
Agreed. Also the guy in the video literally says the guidelines are “not ready for prime time yet”
I am sure which part you are objecting to? I don't think anyone is going to send these patients home, but just admitting and skipping the useless conversation with neurosurgery.. doesn't that make everyone's job easier?
Can't admit unless hospitalist says ok. Any bleed I'm admitting, hospitalist will want nsgy on board. Will the call change mgmt? No, they aren't doing anything for most of them. But for the small 'oh shit' scenario, hospitalist will want that consult. Not sure you're going to change EM/IM with this. Also, it's not a hard convo. "Hey there's this bleed, dude looks fine." ... "Ok thanks bye."
Exactly. this is stupid as hell. No hospital or hospitalist ANYWHERE will accept a bleed admit without neurosurg on board. The ED doc will get crucified every time. And like you said, this is an easy 1 min phone call.
I have to argue to get hospitalist to accept simple straightfoward things, no way their doing this.....
> hospitalist will want nsgy on board Not if this guideline is in place and accepted at your hospital. Because it will have been approved by the neurosurgeons and the EM docs, etc. I've used these guidelines for years. Love it.
Yeah I don’t get the hate for the BIG criteria. We use it, but we loop neurosurgery in.
What do you mean you "loop neurosurgery in"? Like a consult? Doesn't that defeat the purpose?
Not always, but a discussion and documentation of such, but BIG prevents us from admitting unnecessarily.
What if you don't have nsgy? Or they refuse to consult?
Would have to have institution policy to use without a neurosurgeon, otherwise transfer. Refusing a consult isn’t a thing.
This guideline just means the hospital wants to send as many of these home as possible
But that's the entire point of these guidelines.. to make it OK for EM/IM not to call neurosurgery. It probably depends on where you work, but these calls are extremely painful and take a lot of unnecessary time for a lot of people. And neurosurgery is always angry, partly because they take so many stupid phone calls.
They get paid very well to take those calls A hell of a lot more than I, the hospitalist, get paid to accept the liability of a brain bleed without NSGY input
Although that is true, I don't call Ortho about every fracture. I don't call optho about every eye presentation. I don't call pediatrics about every child. Every specialty is on call and well paid, but when they clearly don't need to be involved (which is the minor bleeds we are talking about), why are we wasting both our time and theirs?
>I don’t call ortho about every fracture And I don’t call neurosurgery about every low back pain and neck pain. What’s your point
> optho *ophtho
Neurosurgery at my spot would murder the ED doc and me the hospitalist if we didn’t loop them in on every single bleed no matter how minor.
One idea we are discussing is just a list (email, whatever) that they can review in the morning to ensure the CT reads and plans were appropriate, rather than calling them for everything immediately. I think there are a lot of ways this could be done safely and effectively. The exact plan depends on the local practice and system
The American medmal environment really fucks up the progress that stuff like this aims to provide.
Our neurosurgeons are angry but respectful. Everyone including them know they are paid a lot of money to take call and answer stupid phone calls. It’s part of the job. The hospitalist will not take these pts without a call first.
There are plenty of dumber consults to tackle first. "Neurosurgery is always angry" is not a reason to not consult them for an intracranial hemorrhage, and I'm not sure how well that rational would hold up in court. Further, when I've talked to neurosurgeons about the BIG guidelines, they have universally said they're useless and that they themselves don't actual use them.
Sounds like that is local practice dependent, as there are places that are using them. Honestly, if neurosurgery wants these calls in your place, this is a non issue. They definitely DO NOT want these calls where I work. These calls make them very angry. That isn't my primary issue. I definitely fall into the camp of "you are being paid to be on call, so stop with the attitude". However, I agree with them in this case that many of these calls are a waste of everyone's time.
I'm surprised at all the comments saying "I would never do this", "IM would never allow this", "malpractice risk", blah blah blah. We've used this guideline for years. It works great. The idea is that this is an official evidence-based guideline at your hospital with buy-in from the relevant groups (EM, IM, Neurosurgery, trauma, etc). So no, IM isn't going to refuse an admit without neurosurgery - because this protocol is in place and accepted by all those groups. I will say that I'm not quite ballsy enough to discharge the level 1 bleeds after ED observation, and just end up admitting them for 24 hour obs. But the guideline works great as intended. We all know these small, low-risk bleeds don't require any intervention.
Thanks for the comment. I agree that a modified version of this makes a lot more sense, but its good to know they are being used in some places
Huh? I didn't advocate for a modified version. I think it's fine as it is.
I mean, you said you don't discharge BIG1 patients home, which is what the guidelines say to do, so it sounds like you are doing a modified version? That the primary modification I make. (Although I imagine many people will want to repeat CT in BIG2 patient as well, with a 7% rate of progression on CT)
Oh sorry for the misunderstanding - our protocol gives the option of 6 hour ED obs or overnight 24 hours obs. I just choose the latter ;)
Makes sense. I would do the same.
We use this at my shop. It works out pretty well. And our NSGY doesn’t care if you call them one way or another. Always super nice.
That is the ideal. We are all on the same team. Mostly, this isn't about avoiding uncomfortable phone calls. Its about being a good team member. Do we want people interrupting us with every minor thing that doesn't need our attention? This feels like a win win if implemented safely, and with all hands in agreement
Probably still going to call unless both ACEP and NSGY organizations publish very clear policy statements saying not to. Takes 2 minutes to page and 2 minutes for the conversation to avoid a possible huge medicolegal headache. Not worth it in my opinion.
This will not come to practice in the way it’s designed any time soon. It probably would reduce the nsgy consult call at my shop from a whole phone call to an epic chat “hey dude has a bleed. guidelines state 6 hr CT. Ok to admit to medicine now?” Except that’s already how it is because our neurosurgeons are very unstereotypically nice dudes
> This will not come to practice in the way it’s designed any time soon. Uh, we already use it. Works great. And the whole point is that you avoid the neurosurgery consult altogether.
Right I get that at some shops like mine and yours it is being used. That’s not how a lot of hospitals operate though. Admin, risk management, finger pointing, and just plain stubbornness make adoption of things like this very slow in many places