Study Conclusion: NP diagnostic reasoning in a complex case scenario compared favorably with that of physicians.

Mark H Ebell ebell at UGA.EDU
Sun Aug 16 23:55:50 UTC 2015


Wow.

Yes, by all means, that one case proves it beyond a doubt, that all nurse practitioners are unable to evaluate acute abdominal pain. Obviously, ER docs shouldn’t be allowed to evaluate it either, since you state that a “Different ER Doc now thinks abdominal pain may be atypical cardiac pain since serum troponins were very slightly elevated, so he admitted patient for “cardiac observation.”

Mark Ebell MD, MS
University of Georgia
Athens, GA

From: Phillip Benton
Reply-To: Society to Improve Diagnosis in Medicine, "pgbentonmd at AOL.COM<mailto:pgbentonmd at AOL.COM>"
Date: Sunday, August 16, 2015 at 7:46 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>"
Subject: Re: [IMPROVEDX] Study Conclusion: NP diagnostic reasoning in a complex case scenario compared favorably with that of physicians.

Maureen,

Nurse practitioners are not trained for and should not be asked or entrusted to evaluate acute abdominal pain which may be surgical.

In an event four months ago a Nurse Practitioner working in a community hospital ER managed a 70+-year-old lady with acute severe abdominal pain; the patient had called 911 and was brought to emergency room by EMTs with IVs running. MD in ER noted lower abdominal tenderness to palpation and ordered abdominal CT, then left follow-up management to the NP. Radiologist reported hazy fluid in abdomen and a colon filled with stool. CBC and urine were ordered but were never reported. NP charted that abdomen was normal to her exam, then sent patient home with a diagnosis of 'constipation' and Rx of 'enemas and laxatives'. Symptoms worsened and patient returned to ER two days later. Different ER Doc now thinks abdominal pain may be atypical cardiac pain since serum troponins were very slightly elevated, so he admitted patient for "cardiac observation." Cardiologist consultant determines pain is not cardiac but is abdominal in origin. Hours later patient collapsed in her room and resuscitation there then again in ICU was not successful. Private forensic autopsy revealed 650 mL of frank pus in her abdomen (later growing E. coli and Strep species) noting cause of death to be " acute bacterial peritonitis," later deemed "spontaneous bacterial peritonitis" since there was no visible G.I. pathology except an intact Whipple gastro-jejunal anastomosis, done three years prior for benign pancreatic disease.

Bottom line: this NP undertook diagnostic care/disposition beyond her training, and misdiagnosis resulted in the patient's death. This NP should not have been given and should not have accepted this responsibility.
P.G. Benton MD
Atlanta, Georgia


-----Original Message-----
From: Maureen Cahill <MCahill at NCSBN.ORG<mailto:MCahill at NCSBN.ORG>>
To: IMPROVEDX <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Sent: Thu, Aug 13, 2015 11:26 am
Subject: Re: [IMPROVEDX] Study Conclusion: NP diagnostic reasoning in a complex case scenario compared favorably with that of physicians.

We, in the nursing and APRN community, are very interested in learning where there may be diagnostic challenges in our care and especially tools and resources that enable us to have greater diagnostic accuracy with improved patient outcomes.  This is one of the areas of continued competency for which there is great interests, but as yet, little data.
Maureen

Maureen Cahill [Associate] 312.525.3646 (D) <mailto:mcahill at ncsbn.org> mcahill at ncsbn.org<mailto:mcahill at ncsbn.org>
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Our Mission – NCSBN, Leading in nursing regulation

From: Mark Graber [mailto:mark.graber at IMPROVEDIAGNOSIS.ORG<mailto:mark.graber at IMPROVEDIAGNOSIS.ORG?>]
Sent: Wednesday, August 12, 2015 6:20 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Study Conclusion: NP diagnostic reasoning in a complex case scenario compared favorably with that of physicians.


Its hard to know what to make of a small study using a single case, but I’m delighted to see ANY data that tried to look at relative diagnostic competency.  This is going to be one of the most interesting questions we face going forward, as more and more diagnoses are rendered by PA’s, NP’s, nurses in outreach and storefront clinics, etc.  Even if there is a small difference in diagnostic competency, which would not be surprising, the improved access to someone to help with diagnosis might offset any such difference in terms of improving overall diagnostic accuracy and timeliness.



On Aug 11, 2015, at 5:07 PM, Julianne Nemes Walsh <nemeswalsh at gmail.com<mailto:nemeswalsh at gmail.com>> wrote:

Hello Ruth,

I think the commentary makes a great point about each profession being independently licensed but the importance of making complex decisions as a team.  The Ontario Health Professions Act of 1991 addresses the need for each profession to set the standards and regulate its own profession for the sole purpose of protecting the public.

Thanks for sending the link.  I enjoyed reading.

Julianne Nemes Walsh, DNP(c), MS, PNP-BC


On Tue, Aug 11, 2015 at 4:23 PM, Ruth Ryan <ruthryan at cox.net<mailto:ruthryan at cox.net>> wrote:
In Medscape at http://www.medscape.com/viewarticle/848710?nlid=86363_785&src=wnl_edit_medp_nurs&uac=9733BN&spon=24src=wnl_edit_medp_nurs&uac=9733BN&spon=24&impID=789938&faf=1

I think you have to register to access it, but it’s free of charge.

The methodology was interesting, worth a read. Participants were given a complex inpatient case presentation, and instructed to use a "think aloud" protocol. Judgement of correct dx was by an expert panel.

It must have been complex case indeed: MDs made the correct diagnosis 61.9% of the time. NPs made the correct diagnosis 54.7% of the time. The differences were not statistically significant. Participants who took longer to complete the case scenario were more accurate.

Pirret AM, Neville SJ, La Grow SJ. Nurse Practitioners Versus Doctor Diagnostic Reasoning in a Complex Case Presentation to an Acute Tertiary Hospital: A Comparative Study. Int J Nurs Stud. 2015;52:716-726.


Ruth

Ruth Ryan RN, BSN, MSW, CPHRM
Medical writer
Risk management/patient safety
Continuing medical education
Telephone (504) 256-8797<tel:%28504%29%20256-8797>
Email ruthryan at cox.net<mailto:ruthryan at cox.net>
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