Download LEADING THE WAY IN PROVIDER COMMUNICATION”

EFFECTIVE MD/RN COMMUNICATIONS
WITH BASICS
Authors:
Gregory J. Miller, MD
Medical Director, 1st Choice Hospice, Salt Lake City, UT
Director, Supportive Care and Rehabilitation, Utah Cancer
Specialists, Salt Lake City, UT
Diplomat, American Board of Hospice and Palliative
Patricia Berry, PhD, APRN, BC-PCM
College of Nursing, University of Utah
Background and Context:
Physician Perspective
 Why an issue
 Why resolution is necessary
 Assumptions from physician perspective
 Review of the existing literature
RN – MD COMMUNICATION
 Hospice is a unique practice environment that requires the
nurse to operate outside of the normal environment of
practice
 To be effective, the RN must be able to make a diagnosis
based on clinical assessment skills (e.g., history and
physical)
THE “AH-HA”
 NURSING ASSESSMENT






COMPLAINT
HISTORY (MED &
SOCIAL)
ROS
EXAM
PROBLEMS:
 ”ALTERATIONS” IN
COMFORT
PLAN:
 EDUCATION, ETC.
 PHYSICIAN ASSESSMENT








CC
HPI
PMH
SOCIAL HX
ROS
EXAM (LABS, XRAYS)
DIAGNOSIS
ND TO
 CHF 2
ISCHEMIC
CARDIOMYOPATHY
PLAN
 TREATMENTS, ETC.
THE “AH HA”
Nurses and physicians approach patients from
different perspectives and use different languages
to describe what they observe!!
Why is this so????????
RN - MD
Nurses use:
Physicians use:
 A subjective, holistic
 A hypothesis paradigm –a
approach providing
symptom is a result of
comfort care in a variety of
pathophysiology that once
settings using available
identified can be targeted
tools
for treatment and possible
cure
DOCTOR-NURSE GAME
 Object: nurse is to be bold, have initiative, be
responsible for making recommendations while at
the same time must appear passive
 Goal: RN recommendation appear to be initiated
by MD
DOCTOR-NURSE GAME
The Rub: open disagreement between the
players must be avoided at all cost. Thus, the
RN recommends without appearing to
recommend, the MD requests a
recommendation without asking for it.
DOCTOR-NURSE GAME
Evolution of nurses from being “subservient” to
being equal to other health care providers
Background and Context:
Nursing Perspective
 The past is prologue…virtue script versus knowledge-based





identity
Incorporation of holism
Assumptions
Myth that nurses have retained all of the physiology
knowledge taught in basic program
Depending on setting of care, education, and experience of
nurses vary
Not an APN – MD issue
Background and Context:
Nursing Perspective
 The past is prologue…virtue script versus knowledge




based identity
Incorporation of holism
Assumptions
Myth that nurses have retained all of the physiology
knowledge taught in basic program
Depending on setting of care, education,
and
experience of nurses vary
Not an APN – MD issue
So…who is in charge?
EXAMPLE: PATIENT PRESENTS
WITH SUDDEN DYSPNEA
 HOME SETTING: “911”
 LTC SETTING:
“911”
 HOSPITAL: RN CALLS MD WITH
OBJECTIVE INFO
 HOSPICE: RN CALLS MD WITH
OBSERVATIONS
Role play of
“nonproductive”
3 am call
Introduction and Assumptions
Assumptions: aimed at the “novice” level
practitioner, not the invitees, does not substitute
for critical thinking
Developed in the context of the 3 am phone call
from on call nurse to MD who may not know the
patient or be experienced in palliative
management
The BASICS Model
Blending medicine, nursing, hospice and palliative care,
including the patient and family as the unit of care
B:
A:
S:
I:
C:
S:
Background
Assessment of Symptoms
Situation
Interpretation
Communication
Successful Resolution of the Issue
B: Background
 Demographics (culture, gender, age)
 Terminal diagnoses and other diagnoses
 Working dx: (metastatic cancer from where to
where; end stage heart disease due to multiple
MIs)
 Current medications
A: Assessment of Symptoms
 What do you see?
 What does the patient/family tell you?
 Directed physical exam based on symptom or
“complaint”
S: Situation
 Patient/family goals of care, pertinent to the
situation
 Mind/body/spiritual dimensions pertinent to the
situation
 Contributing factors, such as living situation,
medication adherence, caregiver status, etc.
I: Interpretation
 Based on synthesizing the above information,
determine the possible etiologies and
interventions
 Utilize the algorithm
 Prepare recommendations
 Note allergies
C: Communication
 Contact the MD/provider and communicate in
a succinct manner
 Utilize best practice calls as templates
S: Successful Resolution of the Issue
 Negotiate a collaborative plan
 Obtain and implement appropriate orders
 Agree on a follow-up plan
System Modules
 Cardiovascular
 Gastrointestinal
 Hepatic
 Musculoskeletal
 Neurological
 Pulmonary
 Renal
Cardiovascular as the Exemplar
The Human Heart and Circulation
Deoxygenated
Blood
Aorta
Pulmonary
Artery
Superior
Vena Cava
To Lung
To Lung
From Lung
Right
Atrium
Left
Atrium
Pulmonary
Valve
Left
Ventricle
From
Lung
Pulmonary
Vein
Right
Ventricle
Atrioventricular
Valve
Aortic
Valve
Inferior
Vena Cava
Deoxygenated
Blood
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Oxygenated
Blood
Cardiovascular

Anatomy And Physiology
Heart


Circulation of blood through the heart
 Un-oxygenated blood: right atrium 
tricuspid valve  right ventricle  pulmonic
valve  pulmonary artery  lungs
 Oxygenated blood: pulmonary vein  left
atrium  mitral valve  left ventricle 
aortic valve  aorta
Cardiovascular


Heart sounds are for the most part the result of the
pressures in the left atrium, left ventricle and aorta
Tricuspid and mitral valves are atrioventricular valves due
to their position

Open during ventricular relaxation, due to higher
pressure in the atria blood flows into the relaxed
ventricles, close when ventricular pressure increase
which prevents the blood from flowing back into the
atria
Cardiovascular


Aortic and pulmonary are semilunar valves because of
their half-moon shape

Open when the pressure of the aortic and pulmonary
pressures is greater then intraventricular pressure,
blood flows into the pulmonary and systemic
circulations from the ventricles, close
intraventricular pressure drops from ventricular
contraction and ejection of blood
All valves are not open at the same time
Left ventricular pressure curve
120
mm Hg
0
Systole
Diastole
Aortic valve closed
Aortic valve open
Mitral valve open
Mitral valve closed
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Cardiovascular

Systole
 The ventricle contacts bringing about a fast rise
in the pressure then a rounding off of the
pressure as it ejects the blood from the heart
 The aortic valve is open so that blood from the
left ventricle can go into the aorta
 The mitral valve is closed so that blood does
not go back into the left atrium
Cardiovascular

Diastole
 When the ventricle relaxes, the pressure drops to
almost nothing. At the end of diastole, the
pressure rises slightly due to the increase volume
of blood into the ventricle from the contraction of
the atrium
 The mitral valve is open so that blood can move
into the left atrium into the relaxed left ventricle
 The aortic valve is closed so that blood does not
go back into the left ventricle
Cardiovascular

Heart sounds
 During diastole, pressure in the left atrium, which is
filled with blood, is greater than that in the relaxed
left ventricle. Blood then flows from the left atrium
into the left ventricle through the open mitral valve.
Atrial contraction produces a slight rise in both
chambers just before the onset of ventricular systole
Cardiovascular

When the ventricle starts to contract, pressure
inside readily exceeds left atrial pressure, which
closes the mitral valve. Closure of the mitral
valve makes the first heart sound – S1
Cardiac Cycle
Left ventricular pressure curve
120
mm Hg
0
Systole
Diastole
Aortic valve closed
Aortic valve open
Mitral valve open
Mitral valve closed
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Cardiovascular

Ventricular pressure continues to rise and is
greater than diastolic pressure in the aorta and
forces the aortic valve to open. There is no
sound for the opening of the aortic valve, though
an early systolic click (Ej) may indicate a
pathological process
Cardiovascular

Ejection of most of the blood from the ventricle
causes its pressure to fall. The left ventricle
pressure falls below aortic pressure, which closes
the aortic valve. The second heart sound (S2) is
caused by the closing of the aortic valve
Cardiovascular

During ventricular relaxation the pressure in the
left ventricle continues to drop, falling below left
atrial pressure. The mitral valve opens which
normally does not cause a sound though there may
be an opening snap (O.S.) in mitral stenosis
Cardiovascular

A period of rapid filling follows the opening of
the mitral valve. Early in diastole the blood
flows from the left atrium to the left ventricle.
There may be a third heart sound (S3) in
children and young adults
Cardiovascular

A fourth heart sound (S4) indicates atrial
contraction. It comes just before S1 of the next
beat. S4 is rarely heard in normal adults
QRS
QRS
Electocardiogram
Systole
Diastole
Heart sounds
S4 S1
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S2
S4
S1
S2
Cardiovascular


The electrocardiogram records impulses of the heart.
Each impulses produces a series of waves
Order
 Small P wave of atrial depolarization
 Larger QRS complex of ventricular depolarization
with
 A Q wave – formed whenever the initial
deflection is downward
 An R wave – the upward deflection
 An S wave – a downward deflection following
an R wave
a.T wave of ventricular repolarization or recovery
QRS
QRS
Electocardiogram
Systole
Diastole
Heart sounds
S4 S1
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S2
S4
S1
S2
Cardiac Conditions

Classes
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Cardiomyopathy
Coronary artery disease (CAD)
Cardiomyopathy

Etiology
 Idiopathic
 Multiple causes (e.g., infection,
connective tissue diseases, ischemia)
Coronary Artery Disease (CAD)

– atherosclerotic plaques within coronary
arteries lead to decrease in blood flow with
hypoxia…anoxia…cell death of cardiac muscle
Treatment

Surgical



Cardiomyopathy = transplant
CAD = coronary artery bypass, stints
Medical

Cardiomyopathy
 Increase contractibility = digoxin
 Decrease preload = diuretics, nitroglycerine, morphine
 Decrease afterload = ACE inhibitors, calcium channel
blockers
 Nitroglycerine, calcium channel blockers, ACE
Inhibitors, beta blockers
Advanced Disease

Congestive Heart Failure (CHF)



Is NOT a specific disease, it is the pathophysiologic
condition that results from cardiac disease and
compensatory mechanisms
CHF results from an inadequate supply of blood to the
heart and the body
CHF occurs because of one of three mechanisms



mechanical abnormality – e.g., valvular disease,
hypertension, restrictive disease
cardiac muscle disease – e.g., cardiomyopathy
cardiac arrhythmias – e.g., atrial fibrillation
Advanced Disease


Edema
Ascites, Effusions Malnutrition  Heart failure
Blood volume Oncotic pressure   Central
Venous, arterial pressure Cardiac output 
Effective arterial blood volume  Renal
vasoconstriction  EDEMA Renal retention of
sodium, H2O
Ascites,
Effusions
Malnutrition
Blood
volume
Heart failure
 Oncotic
pressure
 Cardiac output
 Central venous
arterial pressure
 Effective arterial
blood volume
Renal
vasoconstriction
 Renal retention
EDEMA
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of sodium, H2O
Pathophysiology

Decreased cardiac output (CO) produces acute and chronic
changes on the heart … one measure is ejection fraction
(EF)

Acute decrease on CO results in sympathetic tone
enhancement…causes increased vascular resistance…in
chronic condition results in decreased CO

Increase in blood volume by sodium and H2O retention,
goal is to increase ventricle filling and ventricular
contractibility…but chronic effect is ventricular stiffness
with chronic increased end diastolic ventricular volume,
ventricular contractibility decreases

Changes in ventricular size…acute dilatation of ventricle
results in greater stroke volume
Pathophysiology



Decreased CO results in increased ventricular end
diastolic pressure…leads to hepatic congestion and
edema
Decreased CO results in decreased effective blood
volume…leads to decreased renal blood flow
Hepatic congestion results in increased production of
renin, angiotensin and aldosterone
Pathophysiology


Decreased renal blood flow results in renal sodium
retention…further increasing production of renin,
angiotensin and aldosterone
Renin-angiotensin system: renin is secreted by kidneys
in response to decreased “effective” blood pressure in
kidney…renin causes production of angiotensin I by
liver…angiotensin I is converted to angiotensin II by an
enzyme ACE…angiotensin II stimulates aldosterone
synthesis…aldosterone acts on kidneys to retain sodium
and expand extracellular fluid volume
Symptoms





Dyspnea
Fatigue
Weakness
Nausea
Ascites
Edema and Shortness of Breath
 Multiple Etiologies
 Heart, Lung, Renal
 Treatment of Symptoms
 Treatment of Underlying Condition
Other System Modules
 Gastrointestinal
 Hepatic
 Musculoskeletal
 Neurological
 Pulmonary
 Renal
Role play of “productive” 3
am call
Review of Symptom Management
These symptoms were chosen as the most
common and the ones that most likely will
precipitate an urgent call.
Review of Symptom Management
Agitation
Confusion
Difficulty swallowing (dysphagia)
Nausea and Vomiting
Pain
Shortness of Breath (dyspnea)
Best Practice Calls…
First, some background and principles
Am I ready to call the physician?
If you are anticipating
an explosion, you are
not ready…..
Basic Communication Principles
 Understand the goals of care
 Approach as a colleague with mutual goals for the
patient/resident/client
 Think of the call as writing a business letter
 Anticipate physician questions
Complete the assessment
 Your are the provider’s eyes and ears
 Get the facts
 Use worksheet, fax sheet, best practice call, or
other format to organize your thoughts and/or the
important information
COMMUNICATE!





State why you are calling
Give assessment
Suggest plan
Summarize concerns
Follow BASICS as a guide!
In Summary……
 Understand the goals of care
 Complete the assessment for the call
 Prepare for the call
 Communicate your message
Case study for discussion
Mr. Jones is a 72 yo gentleman with a diagnosis of
metastatic colon cancer to the liver and spine. Mrs. Jones
phones you, the nurse on call reporting that he is agitated,
trying to climb out of bed. She cannot get him to take his
medication. She is frantic and is calling for HELP!
Current medications:
Sustained-release oxycodone 80mg TID
Immediate-release oxycodone 15mg Q 1h PRN
Dexamethasone 8mg QD
Other medications for hypertension and hypothyroid
 Write a goal for yourself and/or your organization
re: physician-nurse communication on the note card
provided
 Complete the session evaluation
Thanks very much!
Greg and Pat