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Difficulty: MediumInterprofessional Teamwork and Conflict Resolution

A 45-year-old woman is evaluated in the emergency department for severe right upper quadrant abdominal pain, nausea, and fever. Her temperature is 39.0°C (102.2°F), heart rate is 112/min, and blood pressure is 105/65 mm Hg. Physical examination reveals scleral icterus and marked tenderness in the right upper quadrant with a positive Murphy sign. Laboratory studies show a leukocyte count of 16,000/mm³ and total bilirubin of 3.2 mg/dL. Right upper quadrant ultrasound demonstrates gallstones, gallbladder wall thickening, and common bile duct dilation to 10 mm. The emergency medicine physician diagnoses acute cholangitis and consults the general surgery resident. After evaluating the patient, the surgery resident states, "She is hemodynamically stable right now. I recommend discharging her with a prescription for oral ciprofloxacin and arranging for her to follow up in our outpatient clinic next week." The emergency medicine physician strongly disagrees, explaining that the patient requires inpatient admission for intravenous antibiotics and likely urgent biliary decompression. The surgery resident reiterates the discharge recommendation and refuses to accept the admission. Which of the following is the most appropriate next step for the emergency medicine physician?

  1. Contact the on-call attending general surgeon to discuss the patient's clinical status and facilitate admission.Answer
  2. B
    Discharge the patient with oral antibiotics and strict return precautions as recommended by the surgical resident.
  3. C
    Admit the patient to the general medical service for intravenous antibiotics and observation.
  4. D
    Order a hepatobiliary iminodiacetic acid (HIDA) scan to provide definitive evidence of obstruction to the resident.
  5. E
    Initiate a Root Cause Analysis (RCA) to investigate the resident's decision-making process before proceeding.

Answer

The emergency medicine physician should escalate the situation by contacting the on-call attending general surgeon to discuss the case and resolve the conflict.
The correct course of action is to contact the on-call attending general surgeon. Interprofessional teamwork occasionally involves conflicts regarding patient management. When a disagreement occurs between peers or across specialties (e.g., an emergency medicine physician and a consulting resident), and the dispute poses an immediate threat to patient safety, standard conflict resolution protocols mandate escalating the issue up the chain of command. Acute cholangitis is a life-threatening condition requiring inpatient admission; because the resident refused the admission, the emergency physician must involve the surgical attending to ensure the patient receives appropriate and timely care.

Step-by-Step Solution

1
Assess the clinical scenario and the proposed plan.
The patient has acute cholangitis (fever, jaundice, right upper quadrant pain) and requires admission, IV antibiotics, and biliary decompression. The surgical resident's plan to discharge the patient is clinically unsafe.
Recognizing the severity of the patient's condition is necessary to understand that the consultant's recommendation puts the patient at immediate risk.
2
Identify the barrier to safe patient care.
There is an unresolved peer-to-peer interprofessional conflict between the emergency medicine physician and the surgery resident.
Direct communication has failed to resolve the disagreement regarding patient disposition.
3
Apply standardized conflict resolution and patient safety protocols.
The physician must use the chain of command to escalate the issue.
When peer-to-peer resolution fails and patient safety is jeopardized, established hierarchy (e.g., involving the attending physician) must be utilized to ensure appropriate care is delivered without delay.

Key Concept

In cases of interprofessional disagreement where a patient's safety is at immediate risk, healthcare professionals must utilize the chain of command to escalate concerns to attending physicians or supervisors.
Estimated Time:1m 30s
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Topics

Interprofessional Teamwork and Conflict Resolution

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