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

Vipindas Chengat syncopesystem at GMAIL.COM
Mon Aug 17 00:40:30 UTC 2015


Dear Dr. Benton,

  Thank you very much for sharing this unfortunate case of a missed
intra-abdominal sepsis and death. But, I am not sure if we can conclude
that NPs should not evaluate any cases of acute abdomen. We must admit that
even the second ER Physician was unable to make the diagnosis. These are my
thoughts.

1. As a system, we failed to recognize a life threatening emergency.
2. Premature closure. The NP or the ER Physician did not consider any of
these 90+ causes for that combination, or at least the top 20 of them in
the differential (http://postimg.org/image/5st1s9j9n/ ) - I don't know the
details of the case- so, I am just adding abdominal pain, tenderness and
elevate troponin to build a differential).
3. It is unclear if the initial CT was with contrast. We tried to reach
conclusion before considering the performance characteristic of the test.
4. We probably should not need a Cardiologist to recognize that the chest
pain is non cardiac.

It is probably a systemic problem in my humble opinion.

Sincerely,

Vipin

*Vipindas Chengat, MD FACP**  |  *Chairman, Physician Cognition, Inc.
  —————————————————————————————————
  Mobile: +1 (773) 575-3550
  Email: Vipin at PhysicianCognition.Com <Vipin at PhysicianCognition.com>
  Website: PhysicianCognition.Com <http://physiciancognition.com/>



On Sun, Aug 16, 2015 at 6:46 PM, Phillip Benton <
0000000697ec7b18-dmarc-request at list.improvediagnosis.org> wrote:

> 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>
> To: IMPROVEDX <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) <mcahill at ncsbn.org>
> mcahill at ncsbn.org
> National Council of State Boards of Nursing (NCSBN) 111 E. Wacker Drive,
> Ste 2900, Chicago, IL 60601-4277 312.279.1032 (F) <http://www.ncsbn.org>
> www.ncsbn.org
> Our Mission – NCSBN, Leading in nursing regulation
>
> *From:* Mark Graber [mailto:mark.graber at IMPROVEDIAGNOSIS.ORG
> <mark.graber at IMPROVEDIAGNOSIS.ORG?>]
> *Sent:* Wednesday, August 12, 2015 6:20 PM
> *To:* 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>
> 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> 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
> Email ruthryan at cox.net
> <image003.jpg>
>
>
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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