Anesthesia-trained intensivists doing TEE outside of the OR

[dbiddy808]

I am an anesthesia-trained intensivist who runs a mixed medical/sugical ICU at a community hospital. I recently did a critical care fellowship and have a basic PTE certification from the National Board of Echocardiography. I occasionally do TEEs in my ICU and recently I have run into static from one of the cardiologists at my hospital. This cardiologist does not think that non-cardiologists should do TEEs and is trying to convince the administration of this.

I am wondering if anyone out there has any similar experiences?

I am no cowboy and if I had any questions about my findings, or if any of my findings would lead to a potentially dangerous invasive procedure, I would not hesitate to either have a cardiologist read or repeat my exam to confirm my findings.

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[jdh71]

sounds like turf battle bluster

though its all politics and cards always has a lot of pull because they bring any hospital a lot of money if they are doing any kind of cath's and stenting, so you never know, right?

But, I think if you calmly and simply lay out your case that you are trained with many years of experience in the use of TEE to use in your treatment algorithm of the sickest patients in the hospital to bring the highest quality care you know how to the patients, that it should go rather far.

I can't imagine your occasional TEE is getting into the cardiology money pile that much.

That sucks man.

 

[Stank811]

I have not dealt with it personally but have heard of similar stories. Keep it simple. You are performing them as a management tool that allows you to quickly determine the etiology of cardiovascular instability. Be prepared to answer the question of why TEE vs TTE. Just convince the cardiologist that you are not going to be stealing or reducing consults for ECHO.

 

[deuist]

1. Point out that your certification is from the same board as the cardiologists and therefore your training and skill is the same.

2. Do what we do in the ED whenever there is a turf battle: offer to give it up. Whenever specialists cry foul and state that only they should be the ones performing a particular procedure, our response has been, "We'll let you have it. But realize that since our patients are so sick and require immediate care, you need to come to the ED right away whenever we call. Even if you're in the OR, you will need to stop what you're doing and come to the ED immediately." The arguing stops after about a week.

 

[dbiddy808]

Thanks for the advice!

Turns out admin has my back. They told the cardiologist that since I was credentialed through the anesthesia department, and since my training had been verified, the cardiologist/department of cardiology cannot limit what I can and cannot do regarding TEEs. The administrator actually encouraged me to do more than I currently do since, as she says, if she is sick and in the ICU she would want me to have my skills as sharp as possible.

Nice to know that sometimes patient care takes precedence over politics.

 

[Hamhock]

I think it is great that your admin is supporting you.

However, when I read the original post, I found it very funny that an anesthesiologist was complaining that another specialist went to admin to try to limit his/her scope.

Reminds me of all of the EM docs in community hospitals with anesthesiologists telling them they can't do procedural sedation with propofol or treat acute pain with single shot regional blocks.

HH

 

[TrustMe]

If they had not responded in your favor just increase the number of emergent TEE's you need the cardiologist to perform between the hours of 2200 - 0700. That will get the cardiologist's to back off very quickly I'm sure.

 

[netrunner]

I agree with the above. To go a step further, we got the Cardiologists to actually help us in this way...
1. Tell them you need to do echos (TEE as well as TTE) in the wee hours of the night. And sometimes, repeat exams!
2. You will do the exam (no need for tech) but promise to NEVER BILL for an echo
3. Instead we bill for added critical care time--check your pro-fees for both to compare and you will see why this is better.
4. Loops are loaded to their system where they can read them as limited studies or whatever and bill for their reads on the next business day
5. You can then use their reports as a QI tool to help everyone learn--this acknowledges their contribution.

Win-win situation.

 

[Idiopathic]

i like netrunner

 

[europeman]

Yeah i think you peeps are wimping out.

In our surgical ICUs, one of the intensivists is well trained formally in echo and she bills. Her echos are for fluid assessment, and her reads hit all the Medicare required check-lists so it's legit.

Cards tried to stop her but she is so responsive and ICUs actually appreciate her echos whose purpose is fluid assessment that she has more than supported herself financially for it.

So cards got mad we are "stealing" their echos. Admin said she wasn't stealing anything and her echos were a different diagnostic tool than their echos ... So unless they wanted to do as many as she was , they should back off.

She won.

It's published.


"Making the financial case for a surgeon-directed critical care ultrasound program" murthi et al. Journal of trauma and acute care surgery feb 2014