Archive for category Surgical Quality

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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Hip Replacement — the engineer as a patient

artificial_hipPeople from all walks of life undergo hip replacement surgery.  Some of those people are engineers — people who design things, build things, and worry about the materials for manufacturing.  Those pesky engineers want information about hip surgery the average person might find boring but the engineer finds comforting.  So this guide is for the engineer who needs to have a hip replaced, not the engineer who actually makes the parts.

Original Equipment Failure.  The original specifications for the hip joint were not provided.  It seems there is a lot of variation from person to person.  Some hips last a lifetime, others do not.  The cause of hip failure mostly seems to be the result of gradual wear of the cartilage bearing surfaces within the large ball and socket joint that is our hip.  When the cartilage is so worn the underlying bone is exposed the joint fails with pain, inflammation and restriction of motion.  The time-course of joint failure can be sudden, but usually it is prolonged over many years with increasing symptoms of pain and loss of function.

Timing of Replacement:  The joint should be replaced when the joint function is causing unacceptable limitation of activity.  The time from initial symptoms until replacement is variable ranging from a couple of years to a decade.  There can be complications of surgery (including death) so jumping into surgery before it’s needed is a bad idea.

Expert Advice:  Orthopedic surgeons who specialize in large joint replacement are the experts.  They use a combination of examination and x-rays to give an assessment of the joint.  A good surgeon will never say you must have surgery — they always leave the decision to the patient.  Sometimes that attitude is disconcerting but actually is very reasonable.  After surgery, neither you or the surgeon want to say “I wish I had waited.”

Method of Replacement:  Special tools and jigs are provided by each manufacturer of  artificial hip systems.  Often, a hospital will limit the options to one manufacturer for obvious cost and storage reasons.  A sterile four-part hip replacement is selected:  1) the acetabular cup  2) the liner for the cup  2) the ball and 3) the femoral stem.  When the parts are ready the surgeon must cut into the thigh, visualize the hip joint, remove (with a saw) the ball from the top of the femur bone, ream out the inside of the femur and press fit a stem into the femur.  Then, the natural socket is removed (with a grinder) and the metal cup is inserted (often fastened with screws).  The liner is snapped into the cup (the socket of the joint).  The ball is pressed on top of the stem. Finally the ball is eased into the liner.  The surgeon sutures the various layers of the incision closed.  The final layer, the skin, is closed with staples.  A sterile dressing is applied over the incision.

Options:

Surgical Incision: Each surgeon has their favorite: anterior (in front of the joint), lateral (the side of the joint) or the posterior-lateral (the side of the joint toward the back).   The lateral incision technique was developed first so many surgeons use that method.  Surgeons trained within the past 10 years may have experience with the anterior approach.  The anterior approach seems to result in a quicker recovery and less discomfort.

Metal parts:  Stainless steel was used in the past but fell out of favor because tiny amounts the cobalt and chromium in the steel could be absorbed by the body and cause undesirable side-effects.  Now, metal parts are constructed with either titanium or zirconium.  Also, the newer materials are slightly more flexible than steel, spreading stress to the bones more evenly.

Acetabular cup:  A metal part that fits into the pelvic bone where the natural joint socket was located.  The side that touches the bone is rough.  There are holes through the cup for screws to attach it to the bone.  The other side is where the liner snaps into position.  

Liner for the cup:  This is one of the bearing surfaces in the joint.  Older liners were made of simple polyethylene plastic.  Excessive wear was a problem for some patients.  Now, the most popular liner is a special polyethylene treated with radiation to result in a highly cross-linked material that is much more durable.  Polyethylene also provides some shock resistance.  Some companies make a ceramic liner, but because of the concave geometry (fracture risk), the brittle nature of the material and the tendency to squeak it is not requested as often, but it is very wear resistant.  People in their 40’s and 50’s might want the extreme wear resistance of the ceramic liner just to avoid a repeat surgery 20 or 30 years later.

Ball: The most wear-resistant material is ceramic.  Because of the spherical shape of the ball a fracture of this ceramic part is less likely than for a ceramic liner.  Ceramic balls are becoming a standard.  Nitride coated zirconium is also an option for the ball but it not as wear resistant as the ceramic.

Stem:  This is the part that is wedge-fit into the thigh bone called the femur.  It is tapered and has a rough finish.  The tool kit for the system includes several test-fit rods to make sure the reaming of the femur is exactly the size needed.  Once the fit is adequate the stem is seated in the bone with a tap from a malet.  The ball is press fit on the other end of the stem.  The ball may be an integral part of the stem in some systems.

Attachment:  Metal parts pressed against bone need to stay in position for a long time.  If a patient has healthy bone the most desirable solution is a special coating on the metal that provides a rough surface for the bone to grow into.  Titanium parts can be plasma sprayed with pure titanium as one method to obtain a rough surface.  Another method is to bind a bony material called hydroxyapatite to the metal surface.  The alternative method, for people with weak bones, is polymethyl methacrylate glue.

Anesthesia:  A short stay in the hospital is desirable to reduce exposure to germs that are resistant to antibiotics.  Effective anesthesia with good pain control after surgery make shorter stays possible.  A favorite is spinal anesthesia (makes the body numb below the waist for a couple of hours) along with a sedative, like propofol which has few side-effects.  Of course, a few injections of pain medication and pain pills are needed.  For reasonably healthy people just an overnight stay is all that is needed.

Prevention of Complications:  The surgical technique, the anesthesia, and the materials in the artificial hip all are designed to minimize complications.  Two feared complications are infection and blood clots — both of which can be fatal in extreme cases.  An infusion of an antibiotic within two hours of surgery helps to reduce infection.  Pneumatic compression stockings or “boots” help to reduce blood clots during surgery.  After surgery, maintaining activity with frequent walking reduces the risk of clots.  Some surgeons add a low-dose aspirin to reduce the chances of heart attack and stroke.  Constipation is a common complication easily prevented with prunes, stool softener or a mild laxative.

Comment:  If you are an engineer or just someone who wanted additional detail hopefully this summary is helpful.  There is a lot of information available on the Internet but it is always difficult to understand medical jargon.  Out-of-date information can be really confusing.  Of course, your surgeon is always happy to answer questions — write down the questions and take them with you to your appointment.

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Medicare Penalizes Hospitals — safety problems

MC Hospital Penalties

Hospitals in the lowest quartile of safety scores from Oct 1, 2014 to Nov 30, 2015 were recently penalized 1% of Medicare billings as detailed on the Medicare.gov web site.  The above graphic highlights the results in terms of the number of hospitals penalized per million medicare enrollees in each state.  Red indicates the most hospitals penalized and green indicates the least with the lighter shades in between.

New York had many hospitals penalized but Alaska only had a few.   However, Alaska does not look very good considering they don’t have very many Medicare enrolees (or other people for that matter).  So a patient’s chance of experiencing safety problems is higher in Alaska.  This reflects poorly on the State-wide hospital quality programs and the importance hospitals in that state place on quality.   If you live in a state with poor performing hospitals then be especially careful to pick hospitals with the best scores.  KHN.org  lists the poor performing hospitals.

The four Medicare safety measures were somewhat limited and heavily focused on surgery:

  1. The AHRQ Patient Safety Indicator (PSI 90 Composite)
  2. Central Line-Associated Bloodstream Infection (CLABSI)
  3. Catheter-Associated Urinary Tract Infection (CAUTI)
  4. Surgical Site Infection (SSI) – colon and hysterectomy

What should be done?

  1. Patients should avoid hospitals with lower scores
  2. Poor performing hospitals should make better use of state quality resources.  Spend more money on boosting quality than on remodeling or building new facilities.
  3. High performing hospitals should redouble safety efforts.  Improved performance by competitors could push complacent hospitals toward lower ratings.
  4. Hospitals should not just focus efforts on the few areas that are rated — overall safe care and quality care are the goals.  The basis for financial penalties could, and very likely will, change.

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Urinary Retention — 1 in 10 men over 70

urologybillboardOne ER visit is a red flag — more ER visits for the same problem become an example of  poor quality health care.

Urinary difficulty is something older men don’t like to talk about.  But, 1 in 10 men over the age of 70 will end up in the emergency room with urinary retention — an uncomfortable situation where they can not pass urine.  Urologists are aware of this frequent problem — see the billboard story.  It is a serious problem;  in third world countries it may be fatal.

The usual cause is enlargement of the prostate preceded by symptoms of slow and frequent urination.   Sometimes there are few symptoms until a painful inability to pass urine forces a rush to the emergency room.

The usual medical approach is to insert a tube (a catheter) into the bladder to relieve the pressure, start a medication to help urination, and 3 days later to remove the catheter.  50% of men can then pass urine adequately (for a while).  The quality issue is that 50% have a recurrence within a week — so is another ER visit the answer?

A friend of this blogger landed in the ER a total of 4 times with urinary retention.  Why is the ER the center of after-hours treatment for this problem — once identified as an issue why is the health care system making it a recurring emergency?

The solution is Urologists need to own the problem and provide adequate patient care 24 hours a day once a catheter is removed.  Yes, own the problem, not turn off the phone and let the ER solve it.  Does that mean the urologist must be at the clinic 24 hours a day?  No, but there must be an arrangement for immediate care — no waiting in the ER, no ER charges, no secondary consultations.  An arrangement with a 24 hour urgent care center may be enough but some back-up plan and patient education are essential.

The majority of men with urinary retention end up having a surgery to ream-out the prostate (TURP).  According to healthcare-salaries.com a suburban US urologist makes $500k to $1M each year.  This is another example of the decoupling of cost and quality caused by involving multiple providers with no common financial risk.

A proactive patient who has a catheter removed should ask the urologist “what is the plan if this does not work?”  and “is there some alternative to the ER since you have already evaluated me?”.  At least find out how to get in touch with the on-call urologist!

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Complications after Surgery — blame or improve?

carrot-stickThe 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.

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Ambulatory Surgery Centers — where’s the data?

undertherugAmbulatory Surgery Centers (ASC) are adept at hiding problems.  Just try to find death rates, numbers of transfers to hospitals, organ punctures, and surgical procedures required to correct errors.  Nope — you won’t find those crucial bits of data for public view.  Here is a link to statistics collected for “internal” review:  Quality Reporting Program.

As with most health care entities the public expression of “quality”  is “certification” — which means an outside reviewer thinks the organization has the right programs and procedures so nothing stands in the way of quality care.  Likewise, nothing usually stands in the way of a student getting an A+ on a test — but A+ is not always the grade.  As Confucius says: “there are always greater and lesser”.

So, as a patient, what should you look for; what questions should you ask?

  • Is the ASC certified?  If not, find another ASC.
  • How many patients does the surgeon treat at the ASC  — expect at least 10 per week.
  • How often does the surgeon do the procedure you need at the ASC — expect at least 10 per month.
  • Will you be sedated? — if so, make sure an anesthesiologist or nurse anesthetist will be monitoring you while sedated — if not — find a different ASC.
  • How close is a hospital if you have one of those serious complications listed in the consent-for-surgery form?  If an ambulance would take more than 10 minutes to get you to the hospital consider another ASC.
  • If you have severe heart or lung problems (like a history of congestive heart failure or COPD) consider having your procedure at a hospital rather than at an ASC.
  • Ask if a pre-op check list, like the one the World Health Organization recommends, is used for all surgeries — if not, quality is a questionable.  If the surgeons says they don’t need a check list find a different surgeon.  Keep this in perspective — every airplane pilot must follow a pre-flight checklist, is your surgery any less important?
  • The person that comes with you needs to write down what the surgeons says after the procedure.  Patients who have been sedated, even if they seem fully awake, will have impaired memory for many hours.  Have the person with you write down what was found at surgery — what is the diagnosis and what are the specific instructions.
  • Absolutely avoid late afternoon surgery — because you will be shipped to the hospital for minor complications — the ASC will close and they don’t have staff to provide care after closing.

 

 

 

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Surgical Consultation — when is the right time?

Hhammerwithnailow to make a surgeon cry:  “I don’t want surgery.  What should I do about my hip pain?”  Surgeons are faced with this question every day.  Most of the time the answer is “well, when you are ready you can always come back.”  To be blunt, surgeons are trained to do surgery and surgeons lose money when they spend time doing something else.  In fact, they often don’t have much experience with the “non-operative” management of many conditions.

Think about the problem.   Would you ask a butcher what he would recommend for a vegetarian meal?  Would you ask a home builder about the best apartment to rent?  Would you ask a car mechanic about where to drive your car for a vacation?  It is possible the butcher, home builder or car mechanic will have a good answer but chances are not too great.  So why would this be different with surgeons or other specialists?

The general rule is to ask someone a medical questions who does not have a vested interest in the answer.  Or to do a good job of investigating symptoms on the Internet before getting a consultation so you can ask good questions and be “a little” skeptical.  A primary care doctor’s office is the first place to pose the question.   If the primary care office in uncertain about a diagnosis then a higher level consultation is in order — the question to primary care should be “who would best be able to guide me to the next step?”  Like, “I am having some mild hip pain.  I don’t want to consider surgery yet.  What non-operative treatment is available?”

Recently a friend was having knee pain.  She saw her primary care provider who suggested cutting back on hiking.  That did not seem very high tech so she saw a surgeon who recommended surgery.  Since the knee MRI was normal she was skeptical.  She took some Tylenol and a few weeks later the pain was gone.  The old saying “if you have a hammer then everything looks like a nail” is very true in the procedural world.

Another example comes from gastroenterology.  If a patient has gas and bloating which do you think a gastroenterologist will do first:  a $1000 colonoscopy or trial of a dietary change?  — you guessed it, often the colonoscopy!  Worse,  if the colonoscopy is normal you will likely be sent to primary care to try some dietary changes and some lab tests.  The appropriate route to take is to let primary care suggest the diet changes, get some lab tests and simple x-rays.  Then, if the problem is still not solved go for the colonoscopy.

In health care systems where physicians have a  financial incentive to provide quality and follow evidence-based guidelines the number of unnecessary procedures declines.  Surgical complications are probably higher than you realize.  Taking time to seek answers before getting that surgical consultation is very important.

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