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Breaking News: The Secret Life of Protocols (Making EPs' Lives Easier)

Scheck, Anne

doi: 10.1097/01.EEM.0000398950.84622.a3
Breaking News


Are there other directors of emergency medicine who dream of summoning querulous team members to a room, and telling them to stay put till they iron out their differences? Ryan Sundermann, MD, did more than just dream of it, and he got a good outcome, too — a new morbidity-preventing sepsis protocol.

Dr. Sundermann, the medical director of St. Luke's Hospital emergency medicine in Cedar Rapids IA, summed up the result: “It was great!”

In fact, a protocol for sepsis was already in place in the emergency department, but it has been modified now, thanks to this meeting of medical minds.

The idea arose from a bit of staff discord. The nurses wanted to clinch initial orders when they spotted a possible case of sepsis, and they believed it appropriate to ask the emergency physician on duty to help make that call. One such physician saw some of this as intrusive during busy shifts. And one such nurse — an ED standout — took issue with this concept of intrusiveness, Dr. Sundermann recalled.

The physician was “brilliant,” but often slow in answering requests by the nurses for atypical presentations. The nurses, in turn, regarded these delays as disrespectful. “It was totally the opposite. He really just wanted them to take charge and get things rolling,” explained Dr. Sundermann. But some “did not feel comfortable doing things without an order.” So the physician was asked by Dr. Sundermann to meet with the nurse “who led the charge” about the issue, and to come up with a plan. And that is how a new protocol was born — with big-time buy-in, to boot.

“He had buy-in, the nurses had buy-in, and the other docs trusted his judgment, so they had buy-in,” Dr. Sundermann noted. There is no problem now with a provision for more nurse autonomy in urgent cases and for quicker responsiveness when a physician opinion truly seems needed. Not only is this good for patient care and staff morale, but Dr. Sundermann said it makes his job easier.

Though this change in protocol might sound merely like a nice solution to a small problem at an ED in one corner of Iowa, that would be putting it way too simply. In fact, the ways in which changes in health care delivery occur, how these changes are decided, and when they are justified by evidence was a common theme at the annual meeting of the American College of Physicians (ACP) this spring in San Diego. The future holds the promise of built-in processes that make it “easier to do what is right, harder to do what is wrong,” observed Kathy Faber-Langendoen, MD, the founder and chair of the Center for Bioethics and Humanities at Upstate Medical University in Syracuse, NY, during an ACP session on ethics. Lying ahead for the ED: Protocols that are easily understood, that appear onscreen at the flick of a fingertip, and that show clear-cut alternatives, such as allowing for complete bypass of triage to immediate intervention.

It is essential to keep in mind that many of these new protocols are likely to be from former templates. “A protocol has to be tailored to the unique needs of the ED,” said Mark Reiter, MD, MBA, the chief executive officer of Emergency Excellence, which promotes standardized procedures for enhancing ED care. Protocols are only blueprints, ones that usually require specific revision for the institution, he said. Certain hospitals, for example, may be able to support a protocol for ST segment elevation myocardial infarction in which the paramedic can activate the cardiac catheterization lab based on the pre-hospital EKG. But many hospitals will not have the technology, training, or resources to accomplish that, he pointed out.

There has to be room for on-the-spot deviation from protocols, too, Dr. Reiter stressed. He cited a patient he treated with symptoms of acute stroke, who also showed some signs of aortic dissection. “We deviated from the protocol to perform a CT scan of the aorta with IV contrast,” he said, adding that this is precisely the way he explained it in the record.

Protocols shouldn't diminish “the connection to the patient,” said Dr. Faber-Langendoen, also a professor of medicine at Upstate Medical University. At the ACP meeting, she recalled one patient encounter she observed in which a time-pressured physician told a woman she needed a pap smear as part of the protocol for her visit. There was nothing amiss in this request, except the presence of eye contact, she pointed out. The health care provider “didn't even look at her,” which was obviously disconcerting to the patient, she said. There is no substitute for human interaction or clinical curiosity, Dr. Faber-Langendoen said.

Protocols are not a substitute for physician judgment, concurred Dr. Reiter. “They are a tool — a good tool — but only a tool,” he said.

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Five Easy Steps to a New Protocol

Are evidence-based protocols enough to boost patient care? Not according to a new study involving 11 hospitals from New Haven, CT, to Kansas City. It's organizational culture — the ability to embrace high-quality goals as a team — that make the difference, at least in treating acute myocardial infarction. That's the conclusion of the authors of the investigation, which was sponsored in part by the Agency for Healthcare Research and Quality. (Arch Intern Med 2011;154[6]:384.) Dr. Sundermann suggests these steps for use and adoption of new protocols:

  1. Bring on board your best and worst critics. Early on, persuade those skeptics to help in constructing the plan. “You can say, ‘I understand that it's not your choice to do this, but we have to; we need to maintain good patient care,’” he said. “You cannot be the one with all the answers. We've all been in meetings where we present some ‘fabulous idea’ that we had, just to have everyone shoot holes in it.”
  2. Listen a lot more than you talk. Sometimes the listening part is the most difficult task due to the fact that personalities seem to play a prominent role in the nature of complaints. “If you try to constantly shove new initiatives down everyone's throat, you will just be seen as the guy who is making changes,” he said. “The way I look at it [as medical director] is everybody else is my boss, and I need to listen to them.”
  3. Emphasize team mission, not negative consequences. Framing the new protocol in terms of making patient care more expeditious and effective has a more compelling impact than proclaiming the change is needed because emergency physicians are subject to contractual review, and a proverbial ax could fall unless top-notch ratings are attained (although that is an unarguable, looming truth). Instead, stress looking at how “we would want our own families to be treated if they came here,” Dr. Sundermann said.
  4. Make stick-to-itiveness a priority, but encourage tweaking. “You identify a problem, you tweak, you identify and tweak, lather, rinse, repeat,” he advised. While doing all that tweaking, “keep in mind that while practicing emergency medicine, it is better for the providers to do things the same 90 percent of the time than it is for them to be totally correct 60 percent of the time,'' he said.
  5. Get the cheering squad lined up. Being too “top-down” in instituting any change is a mistake, he said. But so is forgetting to get the supporters in your corner. Generally, these people are “influencers,” individuals who are highly regarded by peers for their skills and well liked by them, too. They can smooth the way for a successful roll-out of the protocol, he said. In fact, “they may be essential for it.” — AS
© 2011 Lippincott Williams & Wilkins, Inc.