Archive for category Hospital Quality
According to a recent report in the BMJ medical errors are the third leading cause of death in the United States. The chart below shows where the estimated number of deaths from medical error fit into known mortality data. The article makes the remarkable observation “medical error” is not allowed as the cause of death to be recorded on death certificates. Indeed, when “medical error” is entered into the ICD 10 look up site for CMS here is the result: There are no ICD-10 Codes that match that fragment.
To be fair, the rule for death certificates is the cause of death must be the final cause. For instance, even though smoking causes heart disease which leads to a myocardial infarction (heart attack), the allowed cause of death is myocardial infarction rather than smoking, which is truly the root cause. That’s just how the system has worked for decades. So if a medical error causes a myocardial infarction the doctor must list myocardial infarction as the cause of death — in most states the qualifier “due to …” is allowed and smoking could be entered by the doctor. Interestingly, if “medical error” is listed the death would become an “accidental death” requiring review by the medical examiner (not something most physicians or families want).
251,000 deaths in the United States are caused by medical errors. This fact has been hidden, like many other underlying causes of death. The effect is that research into medical errors is lacking, the funding for research is lacking and the problem is ignored. Why should heart disease research be funded when some “cardiac” deaths are actually due to a nurse giving the wrong medication to the patient. The research really needed is to find how to prevent the medication error.
Although the graph above is bad enough, consider that the size of the bars for heart disease, cancer and COPD should all be smaller — because the real cause, in many cases, is medical error.
The number of medical errors is staggering. The errors that cause death are just the tip of the iceberg. Lots and lots of medical errors only have minor consequences. Every physician makes several errors each day. Every review of a medical chart reveals numerous errors. Care providers are astounded by this news. However, simple things like not seeing a lab report with a low blood count until the following day is an error even if nothing bad happened as a result. Of course, it would be malpractice if something bad did happen as a result.
The prevailing notion in quality improvement circles is, “don’t waste your time unless there was a bad outcome.” This notion comes from a lack of staff, and intense criticism when a provider is involved. “What do you mean there was an error, my care was excellent, nothing bad happened, you should be fired.”
Although there is a real tendency to want to blame an individual provider, both small and large errors are the result of poor clinical processes. Even errors due to provider fatigue and lack of sleep are truly process problems — a provider who worked during the night should not be working the following day. A provider sick with a cold should not be working, but so often they are.
What needs to be done:
- Just like alcoholism, the first step is to admit there is a problem.
- See medical care as a process. Strive to make sure the same problem gets the same treatment every time in every location. OR change the process.
- Stop seeing medical care as art. What work of art ever killed a person?
- Separate the compensation for medical errors from improving medical processes. Injured patients need quick compensation and medical care needs quick changes to improve. Lawsuits seem to have little impact on process of care — if lawsuits prevent errors why are we in this mess?
- Establish a non-profit foundation to advocate for reducing medical errors — something the public might be very willing to support. Sorry, Heart Association, Lung Association, Cancer Association — some money needs to go toward reducing errors. After all, if a wonderful heart medication is given to the wrong patient what good is that?
The long and difficult training for surgeons often leaves them with little intrinsic drive to improve surgical care. Anyone who has had to discuss surgical quality with practicing surgeons is lucky to leave the discussion without a fear of losing their job. So, with little intrinsic drive to improve quality, the government and insurance companies resort to the old carrot and stick methods.
For surgeons the carrot and stick are financial. So, if a surgeon and associated hospital have patients that are readmitted within 30 days the hospital is penalized — the hospital is unhappy and verbally passes that unhappiness on to the surgeon.
A study just published “Underlying Reasons Associated With Hospital Readmission Following Surgery in the United States” expresses surgeons’ negative opinions of the penalty saying it really won’t have much effect on surgeons — wow, what a stonewall attitude!
The argument is based on the findings that surgical patients return to the hospital because of an infection where the skin was cut or because of bowel problems from pain medication. Somehow, the surgeons writing the article seem to think complications, coming to light after the patient leaves the hospital, are beyond their control — so the hospital should not be penalized. In other words, complications are and ACT OF GOD.
Wrong answer! Patients, families, insurance companies and Medicare do not want to further enrich surgeons and hospitals for bad outcomes. A much better answer would be to double the efforts to improve quality and reduce complications and to have surgeons spend more time out of the operating room figuring how to improve surgery in the operating room.
Admiral David Farragut is attributed with the phrase “damn the torpedoes, full speed ahead” — was he really a surgeon in disguise? We all know intrinsic motivation (dedication and innovation) is much more effective than extrinsic motivation (carrot and stick). Intrinsic motivation comes from training programs that place emphasis on quality and downplay personal profit.
The solution: surgeons should be employees of the hospital (an ACO model) so they personally feel the financial pressure to minimize costly complications — not just watch as the hospital is penalized. And, improve post-graduate surgical training to have more emphasis on quality.
According to a study at Johns Hopkins (2/1/15) improving hospital amenities improve patient satisfaction with the facility but otherwise do not improve satisfaction with care. This is important for two reasons:
- Patients really can tell the difference — a crystal chandelier hanging in the hospital room does not make nursing care better!
- Patient satisfaction measurement is a powerful tool to assess medical care — if the patient’s expectations are met, it is likely good care is delivered.
The tremendous building boom for hospitals is strange given this bit of science — are CEOs trying to improve quality by remodeling? Now it seems clear CEOs should focus money and energy on improving hospital quality until the level of quality is very high then if there is money to spare consider improving the physical amenities.
Increasing the distance a nurse must walk to see patients results in decreasing nursing visits. This seems simple enough, but the current trend in hospital remodeling is to eliminate rooms with multiple patients. The trend reduces RN visits, increases the need for nursing assistants, increases hospital cost and may increase falls for elderly patients.
The hospital that looks like a nice hotel seems to be the desire of hospital CEOs. This may be fine for obstetrics but may be wrong for geriatrics. A multi-bed ward with 4 patients allows one nurse to check on 4 patients quickly. 4 times the number of nursing visits makes it much easier to prevent falls. When nurses still wore those pointy white hats they had this figured out.
Progress marches on. American health care quality is as low as many 3rd world countries but at least we have nice surroundings in which to suffer the complications.
Hospitals are responsible to rescue patients from inappropriate treatment — especially when the need to intervene is obvious. The hospital has a board of directors responsible for the care delivered in a hospital. They hire the CEO who hires a quality manager. When bad quality management hurts or kills patients it is the hospital’s fault.
An article by Dr. Behnood Bikdeli and colleagues (JCHF. 2015;3(2):127-133) describes a huge study at 346 hospitals about treatment of patients with congestive heart failure (CHF). Here is the essence:
- CHF is life-threatening condition where the body collects too much fluid, usually due to a weak heart. The fluid gets into the lungs and causes shortness of breath.
- The treatment for CHF is to remove fluid from the body and give medications to improve heart and kidney function.
- The absolutely wrong thing to do is to give extra fluid by the veins.
- The study found about 12% of patients with CHF were treated with 1 to 2 liters of fluid in the veins during the first 2 days of hospitalization. AND, most alarming, compared to similar patients not treated this way, they were more likely to end up in intensive care or die.
- The most telling statistic is how often various hospitals let this dangerous use of intravenous fluid happen: 0% to 71%. This means some hospitals did not let it happen (0%). Some hospitals let it happen a lot (71%) — just hope your grandmother did not go to that hospital!
It is not rocket science to say fluid overload is not treated with extra fluid. This is easy to detect when the admitting diagnosis is CHF and the doctor orders say “NS IV at TKO” (translation: give salt water in the veins at a rate to make sure the veins stay open). NO NO NO the patient does not need extra fluid. This should not happen and there are lots of ways to prevent it or even rescue patients when Dr Welby writes such an order (or tries to use leaches).
- Mandate doctors use standard orders for treatment of CHF — there is plenty of latitude to customize such orders. But, IV fluid is not one of the choices without stating why.
- Educate staff that IV fluid is not required to admit a patient (an old fashioned insurance rule).
- Educate staff that IV fluid is not a cure-all. Fluid would help a dehydrated patient but not others.
- Nurses do a double check before admitting a patient from the ER with the question: does this patient have CHF and an order for IV fluids — if so, call the physician to clarify the situation or to change the order — no clarity=no admit.
- All CHF patients should be weighed daily — if the weight is going up it means more fluid is being retained — the patient needs to be rescued. Fix the problem or find someone who can, NOW.
Attention patient and family. This is easy to spot. The admitting doctor says the diagnosis is congestive heart failure but you see IV fluids being pumped into yourself or your family member. SPEAK UP! “Why is fluid treatment needed?” do not accept the answer of “everybody gets an IV”.
Attention hospital board members: do you know what your hospital is doing to prevent this obvious problem? Quality is your responsibility, you must do something besides listen to financial statements. Is your hospital the one with 0% or 71% record of treating CHF with IV fluids?
- use good judgement — nice
- revere your teachers — nice if you are a teacher
- order a good diet — still a matter of question
- don’t hurt or damage people — really or just statistically?
- don’t poison people — makes sense to me
- comport oneself in a Godly manner — doctors have no problem here
- don’t do surgery if you don’t know how — duh
- doctor visits should be for the advantage of the patient — patient centered care is nothing new
- keep medical information private — HIPPA before its time
Doctors often take some revised or modernized version of the Hippocratic Oath. Sadly, the idea that doctors have some responsibility for the care provided by other doctors is missing. The idea is front-and-center in most work on quality improvement — where the idea is indeed to improve everybody’s care. Doctors should have 2 responsibilities: 1) care for the patient and 2) improve the quality of care for all.
Most doctors don’t accept item #2, instead the list is: 1) care for the patient and 2) care for personal finances. In essence, doctors shun quality improvement because “I’m not paid to do that”.
How many doctors participate in quality improvement activities? Meaning, find a problem, make a plan, do something, study the result, then act to improve the plan and repeat the cycle. This is not rocket science. A physician is not expected to do molecular biology research in the office but there is an expectation they will improve waiting time and reduce prescribing errors — things easily within their grasp. How many physicians have a quality improvement meeting each morning or at least once a week — I dare say less than 1%.
Systems of care are very important. But, the lack of physician involvement in quality improvement is a serious deficiency in many health care systems. In some respects this is a structural issue for health care — it’s not a process, and it’s not an outcome. It’s like a foundation for a house — no foundation means the house will not last.
Highly educated and experienced cardiologists just can’t get it right: the correct dose of aspirin after a heart attack is 81 mg (called low-dose), NOT 325 mg (called high-dose). The current prescribing error rate is 60.9% as published by the American Heart Association in 2014.
Personal communication with several cardiologists elicits the comment: the higher dose is needed because of the risk of another heart attack — and “in my experience” it just works better. It’s hard to believe this clinical error in this age of quality assurance. The problem is BLEEDING not heart attacks! The stomach BLEEDS due to aspirin and the higher the dose the higher the risk of BLEEDING.
Just imagine the risk and strain for a recent heart attack victim who vomits blood, needs a transfusion and must undergo a stomach scope — some patients die. From a cardiology standpoint: “they died from something unrelated to the heart attack” — great thinking.
Cardiologists completely and totally get it wrong when they simultaneously prescribe high dose aspirin and the anticoagulant warfarin — the ghastly mistake happens 40% of the time.
The chemical reaction of “acetylation” is caused by aspirin within small blood cells called platelets. Acetylation of platelets is responsible for the favorable heart effects of aspirin. It has been known for at least 30 years that 81 mg of aspirin completely acetylates every platelet a person has — more aspirin does no more. According to the 2012 TRITON-TIMI trial:
“We observed no difference between patients taking a high dose versus a low of aspirin as it relates to cardiovascular death, heart attack, stroke or stent thrombosis,” according to Payal Kohli, MD involved in the study and quoted in Science Daily.
Hospital quality improvement programs need the “guts” to just say NO. 325 mg is not correct. Cardiologists are the sweetheart doctors making millions of dollars for hospitals — it should not matter, JUST SAY NO.
It’s almost impossible for even the most proactive patient to question the great doctor that just saved their life. So, hospital quality assurance has an even greater responsibility than usual. The prescribing error needs to be corrected — hospital pharmacists and quality improvement departments need to be strongly involved — this error has gone on far too long.
Medication mistakes are common. A recent study by Amanda Mixon following discharge from the hospital pegs the error rate at an astounding 50%. The study focused on whether instructions given to patients at the time of discharge from the hospital matched what the patient later took at home.
The study is biased by assuming all the errors are caused by patients — not the providers. The authors point to patient problems of low health literacy and a poor facility with numbers. Illegible instructions, poor communication skills, excessive complexity of medical regimens, conflicting instructions, and giving verbal instructions to the wrong person are all provider or institutional issues.
Even a simple phone call after discharge might have cleared up patient confusion — perhaps the study would have been better with a phone call and no phone call comparison.
The article conclusion is to apply more effort to find those high risk patients. Another conclusion would be to find those high risk hospitals having difficulty telling patients what drugs to take. The study was done at a VA facility affiliated with Vanderbilt — a good place to start the search.
Today’s medical futility is tomorrow’s routine care. A very hopeful thought. However, in the present consider a modern intensive care unit. A treatment area in most hospitals where a month of care could easily cost half a million dollars. That’s a big bill for any individual, hospital or insurance company and there is mounting pressure to use technology more wisely.
Cost is the most important factor to consider in a discussion of medical futility. Futility means doing something that will fail. Of course, our modern definition is doing something that will likely fail but might not if we spend enough money. If there is only one treatment for a horrible disease and it only costs a penny — we would spend it instantly, even if the treatment is futile. But, if it costs ten million pennies … we think about futility.
American medicine has been plagued with the problem of implementing treatments before they are affordable or even proven. Nobody asks a medical innovator “could you work on the invention a little more to make it less expensive”. Nobody asks a surgeon if a surgical procedure is proven — coronary bypass surgery is a good example, since the proof of effectiveness came 20 years later — turns out it’s not for every patient, just a select few.
The same question of effectiveness exists for intensive care. It’s clearly not for every patient, just a select few. But, how are doctors identifying those select few?
Critical illness is fraught with uncertainty. We have lots of expensive treatments but where do we draw the line. Deploy the technology or let nature take it’s course? Ethicists and theologians suggest they know the answers.
Yet, patients and families seek a pragmatic solution: grandpa was in great health but now his aneurysm has ruptured — he looks bad, should he have surgery?
Research shows critical care doctors actually predict outcome fairly well in this sea of uncertainty. They tend to favor using their skills to “give it a try” and make money doing so. But, if they say the chance of meaningful survival is less than 10% — absolutely do not go down that road. The road is often a dead end — the end may be after weeks in the ICU, or weeks in rehabilitation, or months in a nursing home.
Critical care is extremely stressful to the body. Research has shown that persons over 65 who survive an illness but who spend a week connected to a mechanical ventilator only have a 50% chance of living 6 months. So, even walking out of the hospital after critical illness is not a guaranteed success.
Back to the question of futility. Severe illness does not provide the luxury of time, time to check the internet, or time to go to the best doctor. This is when going to a hospital with a high quality score is important. There are always media splashes about miracle cures or soap opera dramas — the reality is patients and families do not want futile care. This is one time “ask your doctor” is exactly the right thing to do — listen carefully.
Saying “sorry” is the human thing to do. Doctors and nurses should say it when they feel it.
Saying “sorry” seems to have two meanings: 1) something bad happened and I understand your emotions 2) something bad happened and I had some connection with the event for which I feel partly responsible. Bad things do happen in health care but “sorry” is a very uncommon utterance for health care providers.
Dr. Abigail Zuger writing in the New York Times 7/14/14 “Saying Sorry, but for What?” compared how she felt about a plumber who broke a valve in her house with medical personnel who broke other things — neither said “sorry.” Sorry truly does not fix anything; but, the absence of “sorry” is infuriating.
The problem is ego. Ego infuses some health care providers with the notion bad things are an act of God but good things are an act of ME. Absence of “sorry” is a sure sign of defense (a defense of self). Perhaps the health care provider was spanked as a child or yelled at by teachers. Who knows … ego has gone wild.
Quality health care depends on people believing errors are due to system failures. When providers fail to embrace that philosophy they fail to correct problems. No failure, no correction.
A fall in the hospital can be deadly. Recently, a family member fell in a room while no nurse was present and they died. The nurse did not say “sorry.” There was no acknowledgement of responsibility. No acknowledgement the system was at fault, no realization there was a better way, and no reason to prevent future deaths. The simple statement “sorry, I wish I had been there to stop the fall, we will investigate this to help others” would be the right thing to say, and believe.
Lawyers are not the cause of excessive health care ego. However, lawyers with the threat of suit are a convenient excuse. When bad things happen honesty and caring are much more likely to assuage the displeasure of a family than stonewalling.