Q&A: Sending queries for ethical concerns

Q: Have you, or would you ever, send queries for an ethical reason? Meaning, a query for a concern that does not have any financial impact, but raised red flags during the chart review. At my previous facility, I sent two such queries. One was because of a cardiologist’s documentation which indicated that  the patient was suicidal, had a gun, and a plan, and “didn't want his wife to know.”  There was no psychiatric referral, no suicide pre-check—nothing else documented. So, I sent a query asking for the treatment for the patient’s depression. I also called the cardiologist at the same time. He immediately ordered a psychiatric referral.  

The other one was for a patient who was already emaciated and malnourished, and went 11 days with intravenous fluids only. The patient received “nothing by mouth,” and there was no other documentation of tube feeding or food consumption. I sent the query, paged the physician, and emailed them. After not getting any response, I called risk management the same day. I had to fill out an official complaint. Then an investigation was opened and the chief of staff spoke to the physician, and tube feedings were started one day later. 

Now, I have a somewhat similar case. The patient has “multiple rib fractures in various stages of healing.” The patient says she got them from coughing. She’s 30-years-old and lives alone with a male caregiver.  I did put a query on the chart for the acuity and “type of fracture (e.g., stress, osteoporotic, etc.). I’d just feel more comfortable seeing a statement that the patient denies abuse, or some such thing, since she definitely denies trauma or falls. Any advice here?

A: As CDI specialists we are often the only individuals privileged to read the entire medical record. With that privilege, comes the responsibility to the patient. For those serving in the CDI role with a nursing background, we understand the responsibility of patient advocacy and working to ensure that the patient receives the most appropriate care and interventions is the core focus of nursing practice. It is an ethical requirement to speak up and communicate such patient issues.

The challenge, and the one your question speaks to, is that in the role of a CDI specialist, we’re not working as an active member of the patient care team and should not in any way appear to be leading or directing the plan of care for any patient. Your question essentially boils down to how we can balance our actions to meet the needs of both roles—RN and CDI specialist.

First, I want to share a story with you about a time when I found myself in a similar situation. I was reviewing a record of a post-operative patient in the ICU. I was very concerned that the patient’s needs were not being adequately met and that the provider’s treatment plan was actually causing harm and would lead to poor outcomes. As a nurse, working at the bedside, I could easily voice my concerns to the provider, suggest alternatives, and seek guidance from patient care committees and peer review if needed. That is what nurses are required to do when advocating for their patients. The issue was, as a CDI specialist, I did not feel I could directly challenge the provider. I chose to report the issue to risk management, much like you described. My thought was they could review the issues and arrange for peer review of the case (provider to provider) and ensure the patient received proper care.

I do think this is the correct path for us. The issue grew worse, however, because the staff in the risk management department informed the provider involved that it was my request that they review the case. The provider became angry and defensive. He never willingly supported our efforts in CDI again. His conclusion was that our mission when reviewing the documentation was to critique his medical decision-making—no matter how hard I tried to explain that our efforts were aimed at critiquing his documentation, not his care. It was difficult for me defend against his conclusion. I felt that I was set up for failure. This provider never trusted me again.

This occurrence led to a number of discussions. Because of the situation, we worked to develop a more organized approach to situations when CDI staff uncover potential patient care issues. We don’t want to overstep or sabotage our relationships with providers, but we also want to ensure we uphold the responsibilities of the credential and as CDI professionals we bring any concerns to the appropriate parties.

We concluded that, when concerns related to the physician’s practice (diagnoses and treatment plans) were raised, this would be formally reported to the risk management team, but that the CDI specialist involved would not be identified as the one bringing these concerns to light, nor would they be involved in any discussions/conclusions related to the standard of care provided. Meaning, once I reported a concern, I was not privy to the discussions or conclusions reached by those involved in the review. Only a physician can evaluate the practice of another physician. This must be a confidential peer review process.

But, as you indicate in your question, sometimes the issue we find in the record is not so complicated. For example, in reviewing a record, a CDI specialist might note that the antibiotics ordered actually don’t cover the organism found in culture, or that perhaps a patient is living in an abusive situation and no one has picked up on those clues. We can influence action in these situations, but we need to ensure we are not in any way leading the physician or making assumptions regarding the care of the patient.

In such situations, I would speak to the charge nurse, director, etc. to ensure the concern was discussed with the provider. For example, the situation related to the orders for the wrong antibiotic can be easily addressed by the patient care nurse calling the provider and discussing the cultures and sensitivities and obtaining an order for a more appropriate medication. The CDI specialist can place a query in the record to ensure the provider identifies the contributing organism. Or, for the case of possible abuse, the nurse caring for the patient can initiate social services consult for these concerns to be addressed and the CDI specialist (who is not actively a member of the care team) can then query to ensure any appropriate diagnoses are documented based on the social services assessment.

As CDI professionals, we must understand that we should in no way be influencing orders for services or suggesting diagnoses. If we are involved in decisions related to patient care, it could be interpreted as an issue related to compliance and ethical practices of our role. That said, there are times when our experience and attention to detail note areas of concern. We do need to ethically ensure that the patient’s needs are being addressed. I think CDI programs would benefit from having conversations such as those raised by your question and perhaps devising policies for how such situations should be handled, with a goal of first and foremost protecting the patient, but also to respect all involved in the patient’s care.  

I do hope my answer offers you some guidance. It is evident you are very good at what you do and are astute to the role of patient advocate.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI education director at HCPro in Middleton, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.