Disagreement between members of a care team is not uncommon in health care, but the tele-critical care (TCC) virtual setting makes it challenging to resolve disagreements. Many facilities are providing critical care coverage through the use of remote critical care physicians. The Society of Critical Care Medicine (SCCM) uses the term tele-critical care or TCC to include all services provided outside the physical confines of an ICU.([i]) The predominant TCC model is a “spoke and hub” structure where onsite clinicians at a “spoke” are advised remotely by critical care physicians or APPs who operate out of a “hub.”([ii]) The benefits of TCC include access, efficiency, cost containment and improved outcomes. ([iii] [iv])
If there was an in-person disagreement between teams, the care team would huddle, discuss concerns and ideally reach a consensus or a compromise. In the TCC scenario, the remote locations of the providers pose a barrier to an organic and meaningful huddle. In addition, the lack of familiarity among the care team can mean there is not a relationship basis of trust.
Risk professionals are often consulted after such a disagreement to conduct an RCA and identify ways to improve the process moving forward. This article addresses two common scenarios that raise issues related to TCC and provide risk mitigation considerations and recommendations.
Scenario 1: Difference of Plan of Care
A 44-year-old ICU patient needs a thrombectomy to be performed by an Interventional Radiologist (IR). The IR physician recommends the patient be intubated and sedated for the procedure given the patient’s level of agitation. The TCC Physician is called to put in orders for ventilator and sedation management. Based on her chart review, the TCC Physician is concerned the patient is likely to develop cardiac arrest during induction/intubation/sedation, and either should not be intubated at all or be given awake intubation instead. The bedside nurses convey the message from the TCC Physician to the IR Physician. The IR Physician still insists on sedated intubation. The TCC Physician is hesitant to put her name on the chart because she disagrees with the care plan. You are called to weigh in. What steps can you take?
First, confirm each provider has all the pertinent details. Perhaps there are facts or details that are not clear from the EMR and would impact the medical recommendations and decisions. Key facts can be inadvertently omitted and the EMR is not always the most up to date when clinical situations are rapidly changing.
Next, the providers must actually talk to each other. The TCC Physician must articulate the concerns about cardiac arrest to the IR Physician. That communication should happen provider-to-provider and NOT through a war of opinions in the EMR. Neither should that communication happen through a game of telephone with the nurses or other support staff in the middle. Remember, the TCC model requires trust and building trust is best done peer-to-peer.
The peer-to-peer conversation should be handled like an informed consent discussion. The TCC Physician can acknowledge the benefits of the IR Physician’s proposed course of action, but then the TCC Physician should clearly explain the perceived risks of proceeding with sedation/intubation providing specific, objective reasons for those concerns. The Physicians should discuss whether there are any alternatives that would mitigate the potential risks. If the TCC Physician remains concerned, she should clearly and professionally explain that based on the information she has, she is not comfortable moving forward with the proposed plan.
Documentation about the disagreement in the EMR must be in factual terms detailing exactly what steps all the parties took to assess the situation: TCC Physician was consulted for ventilator and sedation management; all relevant information available in the EMR was reviewed; the TCC Physician identified specific potential areas of risk relative to this particular patient; the TCC Physician directly contacted the IR Physician provider and discussed the proposed plan and perceived risks. The IR Physician acknowledged the concerns, but felt it was reasonable to proceed under the circumstances.
Scenario 2: Inherent Limitations
The TCC Physician was on camera in a Critical Access Hospital in-patient unit and working with the bedside team to manage a patient’s progressing hypoxia. Family is in the room. The in-site CRNA was called to intubate the patient. The CRNA advanced the ET using a laryngoscope and then started bagging. After bagging, the patient became more hypoxic. The TCC Physician suggested on camera that the continued hypoxia was due to an esophageal intubation; the CRNA in the room disagreed. The TCC Physician asked CRNA to remove ET and re-intubate the patient, but before the ET tube was removed, the patient coded. You are called the following day because the CRNA is reporting he was incorrectly pressured by the TCC Physician who did not supervise the intubation. How do you address this disagreement?
You should conduct debriefing interviews with the CRNA and the TCC Physician to discuss what happened and what could have been done differently. During the debriefing, remind the providers that each provider involved in the case has their own independent duty to practice within the standard of care and each provider will be evaluated on that standard of care. In this case, if the TCC Physician suspected an esophageal intubation, the TCC Physician MUST raise that issue. However, if the CRNA remains confident the ET tube is in the trachea, the TCC Physician should also help identify other reasons for the increasing hypoxia. Likewise, the standard of care requires the CRNA to consider the TCC Physician’s suggestion of esophageal intubation. If he disagrees, the standard of care requires the CRNA to articulate why this is not esophageal intubation based on clinical signs and factors. The CRNA will be responsible for the decision to maintain the airway or remove it—the “pressure” from a provider does not absolve the CRNA of a duty to the patient.
Remind the providers that the tone of the communication is critical—not only for optimal patient care, but remember in this scenario, the family is present in the room. The communication should show that there was a team working in concert to address this rapidly changing clinical situation—not a team pointing fingers.
TCC offers benefits but also comes with risk. The very
nature of critical care in itself makes the stakes high. Successful integration
of TCC requires dedication to communication and problem solving by the
clinicians on site and at the remote location. Risk professionals can
proactively help by educating staff about tools to enhance communication.
[i] Tele-Critical Care: An Update From the Society of Critical Care Medicine Tele-ICU Committee, Subramanian, Sanjay MD, MMM; Pamplin, Jeremy C. MD, FCCM, FACP2; Hravnak, Marilyn PhD, RN, ACNP-BC, FCCM, FAAN; Hielsberg, Christina MA; Riker, Richard MD; Rincon, Fred MD, MSc, MB.Ethics; Laudanski, Krzysztof MD, PhD, FCCM9; Adzhigirey, Lana A. MSN, RN, CPHQ; Moughrabieh, M. Anas MD, MPH; Winterbottom, Fiona A. DNP, MSN, APRN, ACNS-BC, ACHPN, CCRN; Herasevich, Vitaly MD, PhD, FCCM, Critical Care Medicine 48(4):p 553-561, April 2020. | DOI: 10.1097/CCM.0000000000004190
[iii] Lilly CM; Zubrow MT, Kempner KM, et al: Critical Care Telemedicine: Evolution and State of the Art. Crit Care Med 2014;42:2429–2436
[iv] Becker CD, Dandy K, Gaujean M, Fusaro M, Scurlock C. Legal perspectives on telemedicine part 2: Telemedicine in the intensive care unit and medicolegal risk. Perm J 2019;23:18.294. DOI: https://doi.org/10.7812/TPP/18.294
Maggie Neustadt, JD CPHRM, FASHRM is the Vice President of Risk and Claims Management for Saint Luke’s Health System in Kansas City, Missouri. Since 2019, she has been faculty at ASHRM’s Academy teaching the Applications in Risk Management module. She was awarded the designation of Fellow of the American Society of Healthcare Risk Managers in 2020.