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March 2008
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Hospital Privileges How chiropractic makes a difference
You have probably had some kind of hospital experience in your lifetime. Relying on that experience, imagine this scenario:
A patient is waiting in an emergency room lobby with intense, almost debilitating, back pain. He checks in through triage, and impatiently waits to see an emergency-room (ER) doctor.
After a long wait, the ER doctor examines him and says, “Here’s a prescription for some pain medication. Your pain should lessen over the next few days. Follow up with your family physician next week.”
Can you imagine the frustration this patient is feeling — having had to wait to see the doctor, only to receive pain medication for a temporary fix?
The situation could be different, though, if the ER had an on-call chiropractor at their disposal.
Starting a chiropractic relationship with a hospital could mean amazing progress for the chiropractic profession and for patient care. However, planting the initial seeds of such a program needs to be done correctly from the start.
Chiropractic Economics talked with four doctors (three DCs and one MD) who have been directly involved with starting chiropractic relationships in hospitals. They have been through the certification and verification processes, and have been instrumental in helping others do the same. Those doctors are:
• Joseph D. Salamone, DC, DAAPM, FRCCM, president of the American Academy of Hospital Chiropractors (AAHC);
• John L. Cerf, DC, AAHC vice president;
• Gina Puglisi, MD, AAHC treasurer; and
• Michael Bernstein, DC, chairperson of the New York State Chiropractic Association hospital program.
All of these physicians work in a hospital emergency room.
FIRST STEPS
The first step in creating a relationship between your chiropractic office and a hospital is to become familiar with the ins and outs of that hospital.
John L. Cerf has spent years teaching DCs about procedures and privileges through AAHC. The AAHC’s hospital protocol course is designed to help DCs learn about hospital culture and procedures. In addition to culture and protocol, the course, developed by Albert Cataffi, DC, trains DCs in universal precautions, CPR, emergency codes, hazardous materials handling, infection control, patient rights, patient confidentiality, and emergency department regulations. Hundreds of DCs across the country have become certified through the course.
Cerf, who is AAHC’s vice president, began his chiropractic work at Meadowlands Hospital Medical Center about seven years ago. Cerf is active in training DCs in the science of chiropractic in hospitals.
“One of the biggest problems I find is one of intelligence — not too little, but too much. Chiropractors who are intelligent and have been successful in their offices have the confidence to go to a hospital and get something started.
“The problem is they’re not familiar with the hospital. They don’t have the experience,” said Cerf. “They don’t know the culture of the hospital, and they don’t necessarily know the right way to go about doing that type of negotiation or presentation. We try to teach those things — the negotiation skills, the presentation skills, the culture of a hospital. The idea is for DCs to know these things before you get [to the hospital].”
Michael Bernstein began his chiropractic program at Parkway Hospital in April 2007, after spending 12 years as a New York City medic and 17 years as a practicing chiropractor. He believes bringing chiropractic into the emergency department of any hospital in any state is an absolute win-win for the profession and the local doctor.
“It’s a win for local doctors in that they will be building a complete sphere of influence, with the medical community helping build his practice. They will also be seeing patients from an untapped source that they could never imagine,” Bernstein said. “It is a way of constantly keeping your office busy, but you have to do your due diligence and do all your work and set up the program in the right way so that you meet all of the higher standards of a hospital.”
Learning the proper culture, language, and customs of a hospital before you try to enter into a relationship with one will help you avoid the mistake of getting put into a bad professional position. Another mistake to avoid is trying to start this process alone.
“You should never approach a hospital situation as an individual. You need to do it as a team, in a team manner, with the complete backing of your state association, the AAHC, and a local educational institution,” Bernstein said. “A triune of backers in this format is probably the best way to approach these situations, and it gives hospitals a very high level of confidence with you as a medical practitioner.”
BUMPS IN THE ROAD
While Cerf’s group at Meadowlands and Bernstein’s group at Parkway have both been largely successful, they have had their share of obstacles to overcome. Joseph Salamone, a DC with more than 20 years of practice under his belt, is the president of the AAHC. He remembers a time when things weren’t easy for chiropractors who wanted to practice in hospitals.
“A lot of medical doctors didn’t want chiropractors [at Meadowlands] because they thought we’d take away their patients, and also because it was a battle for their turf. We also experienced some resistance from the orthopedic and physical therapy departments. We had to prove ourselves,” Salamone recalled.
“After they saw what we could do, they decided that we really were assets to the hospital, and we did complement and work well with other types of physicians. We didn’t get in the way.”
Cerf also remembered when some medical staff members weren’t so accepting.
“It was interesting … all of the physical therapists (PT) walked out of the hospital; they all quit,” said Cerf. “We write orders for PTs there now, for in-patient services. We do the PT modalities in the emergency department, and there is absolutely no conflict whatsoever. We don’t take anything away from them at all.”
Gina Puglisi, MD, is the director of emergency services at Meadowlands and
AAHC’s treasurer. She was instrumental in getting chiropractic services into the ER. Puglisi has a very organized plan for avoiding chiropractic road blocks in her emergency department.
“Chiropractors play a very specific and important role in my department, and we now just have to convince the rest of the world. At Meadowlands, I approached administration with a specific plan for my DCs.
“I informed the board that I would make sure they stayed in their own niche,” said Puglisi. “We basically designed a program that was well monitored. We prove to our administration that the program is overseen, quality assurance is being monitored, and the program is constantly being reviewed for quality of care and customer satisfaction. You may be providing excellent quality of care, but if no one likes it, then you’re failing the hospital. This type of program coordination makes for a happy administration.”
PRIVILEGES AND BENEFITS
Once a chiropractor gets hospital privileges, it is important to use those privileges to your advantage, as well as to your patients’. Cerf uses his privileges in several ways — most of which benefit everyone involved.
“Hospitals tend not to get reimbursed well for patients who are admitted with back pain. A chiropractor could help prevent those costly admissions in the ER,” said Cerf. “We also have the ability to admit patients who need to be hospitalized. Sometimes the pain is so severe they cannot walk. They need some type of narcotic, so they have to be in there. I’ve had patients who have been injured. I had one who had a fractured orbit, and he had to be admitted. It enables us to keep ties with a patient.”
Bernstein is amazed at how many chiropractors he knows with privileges that do not use them to benefit their patients or their practices.
“When I speak to other hospital chiropractors, I always ask how many patients they have seen. Most of them tell me, ‘Hey, I’ve never even seen a patient, but at least I have privileges.’ That does the profession no good,” Bernstein says.
“The ER is the ultimate place to engage patient relationships. You see a tremendous number of patients. You either bring them into your practice or refer them to other doctors in the field, or to other members on your team for further chiropractic care.”
Cerf wrote, in a 2002 article for the Journal of the American Chiropractic Association, “Regardless of the presenting complaint, there is usually one common theme [with ER visits] — ‘pain.’ Minor or severe, stabbing or dull, pain is always associated with anxiety and distress. While emergency medicine is responsible for treating life-threatening conditions, a large majority of emergency visits are made merely to relieve pain.”
One of the most important factors to hospital administration is patient satisfaction. As a whole, patients are quite pleased with the level of care they receive from chiropractors in an emergency room or other hospital setting at hospitals across the country. Meadowlands patients are pleased; so are they at Parkway, according to Bernstein.
“Our program has been met with tremendous positive notes already. We’ve had nothing but rave reviews from the patients. When you do a patient satisfaction survey, about 99 percent of the patients report a tremendously positive response with the chiropractic team.
“That’s almost unheard of in a hospital,” said Bernstein. “Usually you go into a hospital, and your satisfaction level is in the 40s or 50s — people hate being in the hospital; they hate their experience. We’ve had nothing but in the 90s, and patients have been raving about it — which is great.”
DCs can offer support and range to medical doctors that only build on patient, as well as administration, satisfaction.
“If a hospital had a pregnant woman come in for neck or back pain, there is usually nothing they could do for her because they couldn’t give her medication. That’s where a chiropractor would come in,” said Cerf. “It’s also easier for hospitals to treat people who have had narcotic problems or alcoholics with a DC because both the patient and medical doctors want to avoid narcotics in that situation.
“Also, there are just some people who don’t respond well to medication, who may already have Demerol and are still in pain and need to be admitted to the hospital. By using a chiropractor, they could avoid that,” Cerf said.
“There are so many patients here [at Meadowlands] … if I could just call a DC, I could really take care of the root of their problems,” said Puglisi. “A lot of patients have some form of acute exacerbation, and chiropractors are able to make great impact in their pain, usually without narcotic involvement.”
Another benefit to a chiropractic relationship benefits the DCs directly.
“Chiropractors that work in a hospital setting usually get further educated in medicine,” said Cerf. “Chiropractors can learn about other medical treatments for the spine, so that when they identify a patient who can be better treated by something an MD can do, then they know who and how to refer it.”
In the ER, chiropractors can be used to facilitate less remedication of patients, as well as less use of narcotics and limit the risk of side effects. There are fewer repeat visits on the same day for the same problem, and hospitals are able to treat patients they have never been able to treat before.
Puglisi offered a final word of encouragement. “Getting a chiropractic relationship started does take vision, and a sizable investment of work and time. It is an emotional risk, definitely,” said Puglisi. “However, if you’re smart and up for a challenge, you’ll think outside the box and get a chiropractic department. Get them on staff, get them co-admitting, get them on call, and make it comprehensive. Your hospital will reap the rewards, as well as your patients.”
John V. Wood is a frequent contributing writer to Chiropractic Economics. A nationally published freelance writer, he lives in Willow Spring, N.C., and can be reached at 919-632-1827 or by e-mail at john@johnvwood.com.
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