The beta-blockade rules: Still crazy after all these years
As of January 1, the SCIP guidelines for perioperative beta blocker (BB) administration have changed yet again. Has it occurred to anyone that maybe they didn’t make a great deal of sense in the first place?
We all know that BB have made an enormous difference in the treatment of hypertension and coronary artery disease. We get that. But when you tell me that I “must” give a periop BB within a certain time frame or my practice is poor, I protest.
Last year’s regulations stipulated that we had to give a perioperative BB within 24 hours of skin incision time or by the time the patient left the PACU. So if my patient took her BB yesterday morning at 8 a.m. and her skin incision wasn’t until 9 a.m. today, that dose didn’t count. The new rules now say that the dose yesterday morning counts, and I’ll get credit for periop BB. What changed?? Certainly not my patient’s heart rate or any other facet of her clinical care.
What really makes a difference to patients is that their heart rate and BP are well controlled before, during, and after anesthesia. That may involve BB, or it may not. Sometimes it’s a matter of needing better pain relief, not an artificially lowered pulse rate.
The “rules” say I have to give more BB even if the patient’s heart rate is in the 50’s, because only a heart rate less than 50 counts. Do they have any idea how hard it can be to manage sudden blood loss or a vagal reaction to trocar insertion if a patient is so profoundly beta-blocked?
Before January 1, it didn’t matter if the patient was bleeding to death and on high-dose pressors; the reviewers still looked at our charts for periop BB administration. Now they allow the use of pressors as a reason to hold BB. I suppose we should be thankful for a glimmer of common sense, but it’s long overdue.
Medicine by protocol is just about as good as anything done by committee–it sinks rapidly into apathetic mediocrity. If my patient needs a BB I’ll give it. If there’s a good reason not to, I won’t. Either way, I don’t need a chart reviewer to remind me. All these rule changes simply confirm my opinion that the rules were poorly thought through in the first place, and all the unintended consequences haven’t yet occurred.
This column appeared in Sermo on January 31, 2012
3 COMMENTS
Is there any kind of organized protest anywhere in regards to the SCIP guidlines. I’m not against following and changing recommendations. In this case mandating practice using non-specific non-evidence based arbitrary protocols is not just unwise, it borders on institutional malpractice. (Look at the anitbiotic prophylaxis literature and the SCIP guidlines. See if there is anything about urogynecology, perirectal mesh placement, and evidence based antibiotic duration…)
[Reply]Dear Dr. Hughes,
Thank you so much for your comment. I could not agree with you more. Perhaps you might be interested in my previous post, “Bring in the Vikings”, which I wrote immediately following my hospital’s last Joint Commission review last December. There is an organization called “DNV” which is gaining ground as a competitor to the Joint Commission with a far more sensible approach, and as physicians I hope we can use whatever influence we have with our hospitals to support healthy competition, rather than monopoly, among these accrediting services. The more clients TJC loses the better, as far as I’m concerned. They’ve gone way too far.
However, this does not answer your question about the SCIP guidelines. They are under continuing review and protest from many sides, and at least are being modified as problems appear. This doesn’t help, however, when things like antibiotic duration are being forced upon us despite our best judgment to the contrary. One of our senior surgeons routinely keeps all his colon surgery patients on cefotetan for a week, and–surprise!–has the lowest wound infection rate in the hospital. His patients don’t seem to be dying of C.diff. in droves, either. Our best defense is to document why we are deviating from the guidelines, and wait for further studies to disprove the fallacy of guidelines when they are, in fact, misguided.
If you’re not familiar with it, let me recommend to you an organization called Doctors for Patient Care, a nonpartisan group which supports the efforts of physicians to maintain autonomy in their practices and resists government-mandated rules that get between us and our patients.
I look forward to hearing from you again,
Karen Sibert
[Reply]Amen
[Reply]