2 Ensuring Success in the Hospital Setting
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Dynamic Chiropractic – May 19, 2003, Vol. 21, Issue 11

Ensuring Success in the Hospital Setting

By John Cerf, DC
We have all heard patients complain about medical doctors who don't like chiropractors. Imagine being able to tell the patient that you work in the hospital with doctors and nurses who respect and value your abilities! It is great to be able to talk about the medical physician who instructed the nurses to rearrange the patients in a crowded emergency department (ED) because she would not allow a patient to be discharged without first being treated by the chiropractor. ED physicians demonstrate confidence in chiropractic every time they call the backup chiropractor when the "on-call" DC does not respond within a reasonable time. A busy staff would not take time to make extra calls if the DC were not a credible element of patient care.

To gain the respect of hospital colleagues, you need to do more than help patients. You need to be well-versed in hospital rules, regulations and procedures. This understanding will enable you to function in the hospital and prevent embarrassment and legal nightmares. Failure to follow the rules can lead quickly to a loss of staff privileges, or worse. Loss of staff privileges is reportable to the National Practitioner Data Bank. Breaking hospital rules can lead to problems with the chiropractic board, or possibly the courts. The hospital's rules and regulations are not complex, but they do need to be understood and followed. A DC who learns and follows the hospital's rules will gain self-respect and the respect of the chiropractic profession.

Patients frequently judge all chiropractors by the care they receive from an individual practitioner. In many cases, the ER chiropractor is the first to influence the opinions of patients new to chiropractic. Working in an emergency department may be one of the most valuable weapons for fighting the anti-chiropractic rhetoric all-too-frequently expressed in the popular media. Patients who receive quality care, and the medical physicians and nurses who witness patient improvement, become terrific advocates for the chiropractic profession.

The Emergency Department Chiropractic Program at Meadowlands Hospital Medical Center has been successfully helping patients for over two years. Recently, Dr. Victor Verlezza, the chief of chiropractic at East Orange General Hospital in New Jersey, arranged to have a seminar provided by members of the Meadowland Hospital's ED staff. Dr. Verlezza wanted the members of his newly instituted chiropractic department to enjoy the same success as the chiropractors at our hospital. As they learned, working in a hospital can be rather different than working as an independent, office-based practitioner.

The chiropractic department needs to be more than an assembly of willing chiropractors. You must keep the department cohesive and have tolerance for differing personalities and reasonable differences in philosophy and professional practices. The ED needs to develop a system of peer review as part of a quality-assurance and improvement program. It also is important to document the effectiveness of your program with patient surveys and referral statistics. Keeping statistics allows us to demonstrate the quality of patient care and the support of the institution. All members of the department must be versed in the appropriate manner in which to handle problems or approach the hospital with new ideas.

Working in a hospital without understanding the politics ultimately limits your scope of practice. You must follow the hospital's chain of command and its customary steps to resolve problems. It is crucial to know who is responsible for the different aspects of a patient's care. Stepping on the wrong toes by consulting on a condition of a patient who belongs to another physician can prove disastrous. Additionally, hospital billing codes differ from those used in the office. Inpatients are billed with codes 99251 through 99275. Services in the ED are billed using codes 99281 through 99285.

In the hospital, the chiropractor is treated as a specialist. Just as an internist doesn't perform surgery or nursing duties, the chiropractor shouldn't feel like an outsider by virtue of not performing procedures that are the responsibility of others working in the hospital. During emergencies, the chiropractor must act as any other member of the hospital staff. It is imperative to know what to do in the case of a fire; infant abduction; external disaster; threat of violence; bomb threat; internal disaster; or hostage or weapon situation.

While functioning as a specialist, the ED chiropractor cannot have tunnel vision that limits his or her examination to the spine. It is not uncommon for the ED patient to present with complaints of the worst pain of his or her life. The type of severe-pain patient you may see once or twice a year in your office is a daily visitor to the ED. You have to be sure the patient's symptoms are not organic in origin. Referred pain syndromes are more likely to be found in the ED than in the office setting. Abdominal aortic aneurysm; temporal arteritis; severe osteoporosis; severe degenerative joint disease; and fractures are important considerations when working in the ED. While chiropractors do not prescribe medication, we need to know if a patient has been taking medications, e.g., anticoagulants or steroids that could affect our treatment.

Chiropractic and medical care of patients with severe pain must be coordinated. The chiropractor needs to learn what conditions are necessary before patients can be admitted. There are standard procedures for coordinating patient care with the co-admitting medical physician. It is the chiropractor's responsibility to write the appropriate orders for testing and therapy, make daily assessments, and provide treatment during each patient's stay.

Consistent chiropractic care is crucial for the continued success of chiropractors working in hospitals. A patient who benefits from chiropractic care in a New Jersey hospital will feel comfortable being treated by the ED chiropractor in a hospital in Hawaii. Similarly, the hospital administrator in Montana will feel confident to promote the establishment of a chiropractic department if the staff provides care as it has been successfully performed in other hospitals.

Dr. Verlezza expressed appreciation of the shared personal experiences of chiropractors that had been placed in difficult ethical situations. What would you do if you found radiographic evidence of a fracture that had been missed by the ED physician? Would you continue with your examination of the patient? Would you document the fracture to make yourself look good at the expense of the referring ED physician? Would you pretend you had never been called in on the case? How would you deal with a nurse who verbalized doubt about the effectiveness of chiropractic care in front of your patient? To whom would you complain?

ED attending physicians and nurses need to be educated on the ED chiropractor's training, expertise and limitations. Would you accept the referral of a patient who has osteoporosis and is taking anticoagulant medication? How do you feel about getting involved with the treatment of a woman with a history of diabetes; a pacemaker implant; and a heart valve replacement, who suffered sweating and dizziness following an acute onset of lower-back pain? Imagine how gratified you would feel if the consulting cardiologist reviewed the findings and agreed with your opinion that the patient's symptoms were most likely a vasovagal response to her sudden, severe lower-back pain?

Patients presenting to the ED may lack familiarity with the health-care delivery system. EDs were established to care for serious and life-threatening injuries and conditions. While back and neck pain may be unbearable, the severity of the problem pales in comparison to myocardial infarction or cerebral vascular accident. ED physicians at Meadowlands Hospital and East Orange General Hospital have the option of having a chiropractor devote time to some of the less severely injured patients, while the ED concentrates its resources on patients with more urgent disorders. The result is better care and greater satisfaction for all patients in the department.

Chiropractors are valuable assets to hospitals: They have the skill and knowledge to enhance the quality of patient care. A working knowledge of the hospital environment can help lock you in as an important member of the hospital team.

John Cerf, DC
Jersey City, New Jersey

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