Archive for category Surgical Quality
Emergency 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.
- The goal is to have the patient in the operating room within 90 minutes from crossing the ER threshold (T).
- Blood tests and CT scan of the abdomen are done by T+ 20 minutes.
- Surgeon is in the ER to evaluate the patient by T + 30 minutes
- A decision for operation is made by T + 45 minutes.
- Pre-op antibiotics, fluids, and pressors are started as needed.
- Anesthesiologist begins care of the patient in the ER by T + 60 minutes.
- Central line is inserted, operating room is notified, ICU is notified, critical care team is notified by T+75 minutes.
- 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.
- Washington Post
- JAMA Surgery
- J Trauma Acute Care Surg.
- The Joint Commission
- J Trauma Acute Care Surgery
- J Trauma Acute Care Surgery
- J Am Coll Surgery
If any nurse out there has a standard order-set for EGS please share it.
One 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!
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.
Ambulatory 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.
How 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.
Elisabeth Rosenthal reported “Patients’ Costs Skyrocket; Specialists’ Incomes Soar” in the New York Times today 1/19/19. She particularly targets one of the most popular specialties for US trained physicians, dermatology. Good hours, great pay, and compared to other specialties, easy to learn.
A highly trained thoracic surgeon can only do 2 bypass surgeries per day but a dermatologist can to 20 lesion removals per day and make almost as much money. Patients choose to go to a dermatologist when most primary care doctors can just as easily solve the problem at a fraction of the cost (like benign skin lesions, sun related pre-cancers, and acne). And, when infection sets in on the weekend the dermatologist’s answering machine says to go to the emergency room ($300 co-pay).
She describes a situation where a woman had a facial skin cancer removed at a cost of $26,014. The astounding cost was the result of a dermatologist removing a lesion and then being unable or unwilling to close the wound — but still billing for the procedure. And, the patient also received bills from the doctors that actually fixed the problem (perhaps they should have billed the dermatologist). Sadly, a bad system is more profitable than a good system.
It is easy to see why the patient and Ms. Rosenthal believe there is a problem with US healthcare. Because, THERE IS A PROBLEM!
Rather than complain about the problem, what is the solution? It is not rocket science. The dermatologist, surgeon, operating room personnel and anesthesologist all need to be employed by an accountable care organization (ACO)– that way there is just one predetermined fee for taking care of the whole patient for a year. If the system does the work correctly they make some money, if they goof-it-up (as in this case) they lose money. The incentive should be to do good and efficient work. Not to make money by making mistakes.
This solution is extremely easy yet extremely unpopular with hospitals, surgeons, anesthesiologists, pathologists, radiologists, ophthalmologists and dermatologists. The reasons are obvious — they make less money and must follow quality guidelines. Given the low quality and extreme high cost of US healthcare is that really a problem? A few more articles by Ms. Rosenthal and a few thousand letters to congress might help. Sadly, one industry lobbyist equals one journalist in this battle.
By the way, the lesion at the top is a benign seborrheic keratosis — harmless, but gladly removed by dermatologists ($250).
Jennifer Levits reported in the Wall Street Journal 12/18/13 “Doctors Eye Cancer Risk in Uterine Procedure“. She recounted the story of Dr. Amy Reed who had a hysterectomy. The uterus contained fibroids and the fibroids contained cancer. The procedure was done with an instrument, the morcelator. In kitchen terms it is a combination blender and vacuum cleaner. It is used during laproscopic surgery to chop up things (like a uterus with fibroids) and remove them through a small incision in the abdomen.
The problem is the morcelator does not remove all the tissue. A few cells escape the vacuum and they are left behind in the abdomen. If those cells contain cancer the cancer is then planted in the abdomen later to grow and likely kill the patient. Dr. Reed developed the seeding of cancer and claims other procedures would be better. Traditional surgery removes the uterus and fibroids intact with less chance of spreading any unsuspected cancer.
Here is what the package insert that comes with the morcelator says:
CAUTION: … use of the … Morcellator may lead to dissemination of malignant tissue.
So what are the statistics?
- 20% – 40% of women will develop fibroids
- 1 in 1000 cases of fibroids contain cancer
- intact removal of fibroids with malignancy failed to stop the malignancy 19% of the time
- morcelator removal of fibroids with malignancy failed to stop the malignancy 44% of the time
The big question is: should a morcelator be used if a woman has fibroids because it may double the risk of spreading an unsuspected cancer?
The simple answer is NO, because there are other surgical options. But, will women accept that answer? The laprosocopic procedure has less pain and quicker recovery, so the answer turns out not to be so simple. There are many forces at work on the decision to continue to use the morcelator. The analysis of these forces is called force-field analysis which was originally described by social scientist Kurt Lewin in the 1940’s. The following is such an analysis (the rating of force vectors is by the author of this blog):
So, what will happen? It seems at this point the morcelator will continue to be used. But, the risk remains. Law suits will continue. Perhaps a safer device will be developed. Perhaps a high risk of litigation will be perceived by gynecologists and the malpractice insurance companies as being too great. Such risk will lower the forces from doctors and perhaps tip the balance. Time will tell.
Update (8/1/14): since the original post the FDA issued a warning about morcelators. Yesterday, Johnson & Johnson, the major supplier, stopped selling morcelators. Looks like the forces to abandon the morcelator have been joined by the FDA and the manufacturer.
Update (2/27/15): yesterday the Wall Street Journal reported United Health (insurance) requires surgeons to obtain permission for procedures that might use the morcelator — “another blow” to the device. At this point any surgeon using the device must feel like they are walking a tightrope without a net.
You smoked 2 packs a day for 20 years. Your doctor orders the low-dose CT screening (above). Your doctor says you have a lung nodule, now what? That’s a lot to think about but before anxiety builds too much you need to know that of all the people with a nodule on their first scan 19 times out of 20 it is NOT lung cancer.
By asking some questions it is possible to work through the complicated logic of what to do next.
What if I am that unfortunate 1 out of 20?
If you know for sure the nodule is cancer you would get that nodule removed. Sure it’s a big surgery, hurts for weeks (sometimes longer), in the hospital for several days, and tons of risks the surgeon will recite. No walk in the park but the odds of a cure are better at an early stage. Lung cancer is a killer so it is easy to conclude: get rid of that nodule
What if that nodule is a bad type called “small cell” cancer?
Most specialists agree that chemotherapy is the treatment of choice. Surgery for small-cell cancer is not helpful and may actually shorten your life. A biopsy before surgery may help to avoid surgery for this type of cancer.
What if I am one of the lucky 19?
If all 19 get surgery there would be a lot of discomfort only to be told after surgery the nodule was just a scar or a harmless irritation. Biopsy or follow-up x-rays are sometimes helpful to avoid surgery.
What if I get a needle biopsy of the nodule?
A shot of numbing medicine, a long needle between the ribs, a tiny bit of tissue removed, and finally the pathologist sends a report. Such biopsies are 95% accurate. The wheel of fortune lands in one of 5 major categories:
- No cancer found
- Small-cell lung cancer
- Non-small-cell lung cancers
- Squamous cell carcinoma
- Large cell carcinoma
- Other cancers (much less common)
- Something which is not cancer
A needle biopsy answers critical questions. If it shows non-small-cell lung cancer surgery is the next step. If it is small-cell cancer the next step is chemotherapy. If it is something else, like tuberculosis, then entirely different treatment is needed. If it is “no cancer found” then you are back to square one — meaning a nodule is present and the cause is unknown (possibly a cancer that was missed by the needle).
I am willing to take some risk to avoid procedures.
We started this discussion with a 1 out of 20 chance of cancer. Is there some way to improve on the accuracy of that prediction? 1 out of 20 does not sound so good. But, if the odds of cancer in your situation are 1 out of 100 that would be more favorable.
Improved risk assessment
Canadian Annette M. Williams, MB and others reported in the New England Journal of Medicine in September 2013 an improved mathematical prediction method. Most pulmonary doctors and radiologists can readily provide the statistic. Basically, if the calculated risk score is below 5% then the chance of cancer is about 1 out of 100 .
If the risk is low you might just choose to get a CT scan every few months. If the size of the nodule does not change for 2 years then it is harmless. One sure thing, cancers grow. No growth means no cancer. But, if the nodule does grow you could change the plan and get the biopsy or surgery — there is a risk to letting a cancer grow for a few months (it could spread) but there are risks to biopsies and surgery as well.
If the cancer risk is high you might want to go ahead with a biopsy.
The above are the outlines of nodules 1) round 2) lobulated 3) irregular and 4) spiculated. Cancerous nodules can take any shape but tend toward the spiculated (spiny) form.
The improved statistical method is based on a few details about the nodule. Sex (women are more likely to have malignant nodules), size (the larger the nodule the more likely it is malignant), location (upper lobe nodules are more likely malignant) and spiculation (see diagrams).
If you want to calculate the risk statistic yourself, have a calculator and know the details listed above then click this: Calculate Risk. But, be warned, this calculation only applies to people who have a risk for cancer to begin with, not the incidental nodule found in a lifetime non-smoker or someone who only smoked a few years.
The forgoing material is intended as education, not a substitute for the evaluation and advice of your health care provider. If it seems helpful print it and take it to your provider for discussion. Medical care changes with time so always get up to date information.