Archive for category Hospital Re-admission

Emergency General Surgery — dangerous and expensive

viewinsideabdomenEmergency general surgery (EGS) is common in the United States.  11% of surgical admissions require emergency surgery.  The statistics on EGS seem to create more questions than they answer:

  • The 11% of surgerys classified as EGS are associated with 50% of all surgical deaths.
  • Poor people who have EGS have a greater risk of death than average
  • Rich people who have EGS have a lower risk of death than average
  • Seven surgeries (removing part of the colon, removing part of the small-bowel, removing the gallbladder, operations related to peptic ulcer disease, removing abdominal adhesions, appendectomy and other operations to open the abdomen) accounted for 80% of the deaths and hospital costs related to EGS.
  • The cost of ECS in the U.S. is about 7 billion dollars per year.
  • EGS patients admitted by a surgeon have lower hospital costs than those admitted by a hospitalist.
  • Specific quality guidelines for ECS do not exist.

One might be tempted to say the diagnosis is so complicated nothing could improve the situation for patients.  However, this would be like the situation for pilots and passengers 30 years ago when major airliner accidents happened at least once a year.  The quality movement swept over the airline industry which is now is rated as one of the safest of complex human endeavors.  Those same measures need to be applied to EGS.

When an airplane has an emergency the crew pulls together and acts as a team.  They follow a procedure practiced many times.  They have simulators and tests.  If an engine fails, if there is a fire, if a landing gear fails there’s a procedure to follow.  Each pilot does not invent a procedure just because they are the pilot that day. Likewise, every surgeon should not invent a procedure just because they are the surgeon that day.

It would be easy to blame surgeons or the patients themselves for such dismal outcomes.  But, as people in the quality improvement department say:

IT’S NOT THE PEOPLE, IT’S THE PROCESS.

The first step is to acknowledge EGS is a process.  When a patient arrives in the emergency room with abdominal pain, low blood pressure, free air in the abdomen and a high white blood count there should be no barriers to evaluation an treatment.

  1. The goal is to have the patient in the operating room within 90 minutes from  crossing the ER threshold (T).
  2. Blood tests and CT scan of the abdomen are done by T+ 20 minutes.
  3. Surgeon is in the ER to evaluate the patient by T + 30 minutes
  4. A decision for operation is made by T + 45 minutes.
  5. Pre-op antibiotics, fluids, and pressors are started as needed.
  6. Anesthesiologist begins care of the patient in the ER by T + 60 minutes.
  7. Central line is inserted, operating room is notified, ICU is notified, critical care team is notified by T+75 minutes.
  8. Patient is transported to the operating room.  The opening incision is made by T + 90 minutes.

Such a process is obviously difficult.  First, the ambulance crew can not transport a patient with an abdominal emergency to a facility unable to deal with the problem, like a small rural hospital or an urban community ER.  This will require training of the ambulance crews and communication with a high level ER.

General surgeons and back-up general surgeons must be available within 30 minutes.  It’s a difficult life to be immediately available — the hospital is responsible to either pay surgeons to be on-call or to hire surgeons to stay in the facility.  Hospitalists are not an appropriate substitute to deal with an acute abdomen or even severe abdominal pain of uncertain cause.  A helicopter ride to a higher level facility is the best solution for patients with severe abdominal pain entering a facility not capable of following the above protocol.  The crazy practice of having a night-time hospitalist admit a critical surgical patient for a surgeon to see “in the morning” must come to an end.

Since the mortality rate of EGS patients is quite high the intensive care unit is the place they should go after surgery even if they seem stable in the operating room.  Complications are very common so early recognition and treatment is essential.  Returning to the operating room later may be needed and should not delayed.  Critical care consultation should be strongly considered.  Multidisciplinary rounding with critical care specialists, nurses, pharmacists, dietitians, and social workers is strongly advised.  Rushing to get the patient out of the hospital to a secondary level of care is a mistake since re-admission is fairly common.  The patient needs to be as stable as possible before discharge.  Hospitalization for 1 – 2 weeks is not uncommon.

The difference in outcome of EGS between rich and poor is not uncommon for many things in medicine and surgery.  Several factors are at play but probably the biggest is fear of big medical bills — if you can’t pay one would wait till the last moment.  Second, medical literacy — always a bigger problem for lower socioeconomic groups — if you think Tums or Rolaids will fix anything you might wait too long to go for help.  Finally, a negative bias toward Medicaid or “cash” patients — sometimes the finances determine whether a hospital will keep or transfer patients.  At midnight many cases seem to be too “hard” and must be sent to a referral hospital which wastes valuable time.

Since prospective research is difficult and time consuming (taking years or decades) a local and national registry should be utilized.  The diagnosis, the surgical approach and the outcome must be tracked to find the best combinations for the best outcome.  As best practices are identified surgeons and hospitals must quickly change protocols and surgical techniques.  U.S. healthcare can not stand the usual 15 years needed to implement new practices.

References:

If any nurse out there has a standard order-set for EGS please share it.

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Hospital Re-admission — do phone calls help?

Jphoneust calling a patient on the phone does not prevent patients from being re-admitted!

Hospitals are very interested in preventing a patient from returning to the hospital (called a re-admission) within 30 days from discharge due to the financial penalties from Medicare.

For example, if a patient is hospitalized with a serious problem called congestive heart failure (fluid retention that causes shortness of breath) the hospital will be penalized financially if the patient gets the condition all over again and has to return.

The government idea is to force hospitals to be more accountable — it’s like a 30 day guarantee from an auto repair shop!  So hospitals are looking for ways to improve their performance (and avoid paying money).

There is no question frequent visits to a physician can reduce re-hospitalizations.  However, a recent hospital study found that hospital nurses who talked to patients before discharge and who called them after discharge did not help the readmission problem — in fact there were more re-admissions!

a)  How can this be?

b) Do well meaning nurses actually make the problem worse?

c) Does this mean hospitals should not be penalized?

The answers are: a) bad science b) yes  and c) no, perhaps they should be penalized more!

The “bad science” part is because there was no intervention to adjust medications or treatments that might prevent readmission.   A hospital nurse only has one option for a telephone  intervention:  “you better get checked at the ER”.  The conclusion from the study should have been stated “chatting with a patient does not prevent re-admission” — brilliant deduction.

The outpatient care provider’s  office is where action can be taken to stop re-admissions.  That’s where medications can be prescribed.  If the hospital wanted to prevent re-admissions they should have made an appointment and given the patient a coupon for a taxi ride to and from the outpatient office.   This is not rocket science.

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Wrong Aspirin Dose After MI — frequent errors

ASA81Highly 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.

bloodinsinkJust 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.

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Hospital Readmission — effect of condition at discharge

What aremr-vital-signse the causes of hospital readmission?  A previous post details the most significant factor:  fragmentation of health care.  This post focuses on disease and the condition of the patient at discharge.

Until the past 5 years the prevailing view of re-hospitalization was it is unavoidable due to the nature of the chronic disease.  The view changed when studies showed strong outpatient social and medical management vastly reduce re-admissions.

And yet, disease does catch up with those afflicted causing eventual death.  Sometimes patients are discharged from a hospital and much to the surprise of clinicians the patient is back in the hospital before outpatient care can engage to deal with a potentially unstable situation.  Even before the outpatient check 4 weeks after discharge the person decompensates and is hospitalized again.

Frustration born out of rapid re-hospitalization lead Michael Rothman to develop a statistical method to alert clinicians before hospital discharge to the presence of high risk.   Whether the outpatient care network is sufficiently robust to act on the information is possibly the bigger issue.  But, consideration of the “Rothman Index” is worth a few comments.

Mr. Rothman published the statistical findings “Development and validation of a continuous measure of patient condition using the Electronic Medical Record”  (Journal of Biomedical Informatics 46 (2013) 837–848).

Rothman found he could predict bad outcome (and hospital re-admission) based on routine measurements done in every hospital, just combined in a statistical way.  He divided the measurements into 3 equally weighted groups of (1) lab tests, (2) nursing observations and (3) vital signs.  Overall there were 26 items such as potassium level, nursing charting by exception (like normal or abnormal respiration), and blood pressure.  The index started at 100 and if all items were normal the index stayed at 100.  But, if items were abnormal an amount was subtracted.  The lower the score the worse the situation.  In fact, he showed his index correlated with the 1-year mortality of the patient.  The lower the index at discharge the more likely was re-hospitalization and even death. Mr Rothman started a company to calculate the index for interested hospitals.

The idea is great:  identify high risk patients and focus more outpatient resources quickly.

Doctors always try to normalize abnormal findings.  If the heart rate is too high find out why and correct it.  If the potassium is too low find out why and correct it.  If the blood pressure is too low find out why and correct it.  When the end of the hospitalization comes hopefully everything is in the normal range.  The Rothman Index basically says that if a concerted effort by doctors fails to normalize findings it means the patient will do poorly (an abnormality caused by a stroke just can’t be normalized).  The very definition of chronic illness is that it can not be resolved by modern medicine.

Rothman’s research shows some interesting findings.  The 1-year predicted mortality is increased by 10% if any the following findings are present at discharge:

Clinical item absent or below present or above
 Respiratory rate  14  20
 Heart rate  40  90
 Temperature  96.9  100.2
 Oximetry  96%  –
 Systolic BP  100  190
 Diastolic BP  50  105
 Sodium  138  145
 Potassium  2.9  4.7
 Creatinine  0.4  1.5
 Chloride  98  102
 Hemoglobin  10  17
 Blood Urea Nitrogen  –  25
 White Blood Count  4,000  14.000
 Heart Rhythm    anything other than
sinus rhythm
 Braden Scale (link)  19  
 Nursing Assessment
excluding pain
   any body system
abnormal

CONCLUSION:

The Rothman Index is important and either that index or other similar index should be calculated at discharge.  If the index indicates an increase in mortality then questions need to be asked and answered:

  1. Have the abnormal findings been investigated and treatment started — if an available treatment has not been started it should be.
  2. Has enough time passed for the abnormal finding to normalize — if not the patient should either stay in the hospital or be seen as an outpatient in just a few days.
  3. The estimate of a poor prognosis should be discussed with the patient and family to make sure they understand why follow up is important.
  4. If the estimate of poor prognosis is very high (over 50% 1-year mortality) and not expected to improve then planning for death should be started.

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Accountable Care — done the hard way

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Dr. Jeffrey C. Brenner, family doctor, is a 2013 fellow of the MacArthur Foundation.  He was awarded the distinguished position with a simple observation that medicine needs to be industrialized, meaning  standardized and protocolized.  He observed that physicians “try to do it all” when”they should be handing off less complex patients to clinical team members”.

His success was reported by Mary Ellen Schneider “Coalition Brings Health Care To N.J. City’s Neediest” in the October 15, 2013 edition of Internal Medicine News.  His accomplishments in Camden, N.J. are remarkable.

He managed to reduce repeat hospitalizations for patients with very difficult social situations.   Hospitals were loosing Medicare payments due to rehospitalizations so he convinced the hospitals, social services and outpatient doctors to be accountable for outpatients.  In essence, he built an accountable care organization the hard way.  No overarching organization, no mandated cooperation,  just the presence of an idea and protocols.

Could this happen elsewhere?  Probably not since Dr. Brenner does not have a twin brother.   But, he recognized the problem when 90% of hospital cost is due to 20% of patients.  He endeavored to treat that 20% more intently as outpatients with the benefit of hospital financial resources, nurses, social workers, physicians  and organizational know-how.  And, it worked.

Dr. Brenner attributes success to his organization (Camden Coalition of Healthcare Providers) making outpatient treatment more of a team effort guided by hospital data.  Past failure seems to be the lack of system thinking.  Primary care doctors  expect patients to seek outpatient help by walking through the office door.  Patients who do not walk through that door fail to receive medicines or social service help.  And, usually there is no money made by changing the approach.

Industrialization sounds mechanical and uncaring.  But, the approach in Camden was just the opposite.  Procedures, rules, data and delegated care lead to more caring and less illness.   Accountable care organizations have the same incentive and the same goals.  Hopefully, under the name ACO they can do as well as Dr. Brenner elsewhere in America.

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Hospital Readmission — some help

2 fingers

Here are two simple things hospitals could do to reduce readmissions:  1)  Make a primary care appointment for hospital follow-up at the time of discharge  2) Dispense enough of the patient’s medications to last until the primary care appointment or to last 2 weeks, whichever is longer.

Patients are often readmitted because they did not take the medications prescribed at discharge.  The beauty of the suggestions:  hospitals save money since the cost of medications is low by comparison to readmission, patients will likely take the medications they are given, primary care providers will be engaged, and there is a financial incentive to make the appointment within 2 weeks.

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Prediction of Hospital Readmission — it’s no secret

Not Top Secret

The cause of hospital readmissions is not a secret.   Patients are readmitted to the hospital because the patient, physician or both are too optimistic about the patient’s situation: too optimistic about the patient’s social problems,  too optimistic about the strength of primary care, or too optimistic about the possibility of surgical complications.

It feels better to be Optimistic than the alternative.  It feels better to the patient to be going home.  It feels better to the doctor to believe all is well.  But, the data about readmissions suggest the feelings are not always accurate.  Perhaps we should be optimistic there are ways to find and correct the reasons for readmission.  Providers need to focus on solving more problems before discharge, not just the problem of sending the patient out the door.  Providers need to follow a discharge check list, just like a pilot getting ready for takeoff – not just be optimistic the plane will do just fine.

Rehospitalization is often attributed to fragmentation of health care.  So, what constitutes a non-fragmented (smooth) transition from hospital to home?  The following is the basis of that preflight checklist:

  • The hospitalization is long enough to make sure the patient is stable.
  • Providers anticipate the day of discharge:
    • the likely date of discharge is discussed at least twice
      1. on the day of admission
      2. when the patient is feeling better, at least 48 hours before actual discharge
    • patient questions are answered
    • minimize medication complexity
      • absolute minimum number of meds
      • simplify dose schedule (don’t mix intervals)
      • educate about new medications
    • explain and write down
      • the reason the patient was hospitalized
      • the final diagnoses
      • the name of surgery performed
      • the complete list of medications including
        • home meds discontinued
        • home meds continued at same or different doses
        • new meds (make sure they are generic or on the insurance formulary)
        • why each medication is needed
    • financial problems addressed (can medications be purchased?)
    • home social situation reviewed
    • obtain home monitoring equipment (glucose meters, scales, blood pressure checkers)
    • send needed prescriptions to the patient’s pharmacy electronically
  • family engaged, discharge plans discussed with family
  • visiting nurses called if needed
  • primary care providers called and discharge summary faxed same day
  • discharge instructions reviewed verbally and in writing with patient
  • follow up appointments made
    • specialty care as needed
    • primary care within one week
  • transportation arranged
  • phone follow-up next day by discharging provider

What indicates high risk for rehospitalization?

  • Intensive care stay
  • Living alone
  • Previous readmissions
  • Lack of insurance
  • Poverty
  • No primary care provider
  • Smoking or other substance abuse
  • Congestive heart failure
  • COPD or asthma
  • Insulin dependent diabetes
  • Surgical wound drainage
  • Illiteracy
  • Weakness or falling
  • Over 15 lb wt loss
  • No phone at home
  • No transportation (except ambulance)

Rehospitalization may be foreshadowed during a hospitalization.   Health care providers sometimes fail to notice wound drainage, night time confusion, low grade fever, shortness of breath, leg swelling, anxiety,  or comments about the cost of medications.  The errors of omission can be reduced by minimizing provider changes and hand-offs — so patients do not “fall through the cracks”.  Providers should take a second look  at labs, vital signs and nursing notes before giving the green light for discharge.

Sarah Needleman of the Wall Street Journal was the author of “Rx to Avoid Health-Law Fines” which appeared August 8, 2013.   She reported on new companies that help hospitals reduce hospital readmissions by printing sensible discharge instructions and also by predicting the chance of readmission to help focus resources on high risk patients.

Discharge software is expensive and probably not more effective than a good checklist of risks.  Most importantly, hospitals must have action plans for each high readmission risk factor  (like no transportation or no phone).

The Robert Wood Johnson Foundation published  “The Revolving Door: A Report on U.S. Hospital Readmissions” in February 2013.  The report puts a strong focus on fragmentation of care, being a root cause of  rehospitalization.  The fragmentation can be significantly reduced by strong primary care, doing close follow-up after discharge,  engaging additional social services if needed, extensively  using the phone to communicate with patients who have chronic illness.

A good idea:  phone follow up.  Many primary care providers complain that post hospital phone calls are an unreimbursed expenses (so they don’t make the calls) — hospitals should consider paying a fee to primary care for phone calls during the month after discharge.

Another good idea:  the hospitalist outpatient check.  Some hospitalist groups actually have a discharge follow-up clinic for patients who had a long hospitalization or who have rehospitalization risks.   The visit is usually a couple of days after discharge and is focused on solving problems before they become big problems and also to make the transition to a new or existing primary care provider.

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