Archive for category Teamwork Failure
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.
The AMA has 7,800 codes for all types of medical services. Discussion of end-of-life care has been considered part of routine primary care. Now, the medical-industrial-complex wants another fee for the service of discussing this topic.
The service in question is “Advance Care Planning“. Certainly, a good idea — a health care provider should be talking with patients about end of life issues. We all die, that seems obvious, but someone should ask: “when it does happen where do you want to be, who would you like to be there, and have you told someone about your wishes for medical care at the end?”
Virtually anybody can ask those simple questions. Sure, getting up the nerve to ask the questions is hard for family members. And, sometimes there is no family to discuss the questions or the answers. Like other issues of health care, the primary care provider should broach the questions and record the answers and facilitate discussions with the people close to the patient. It’s not a question that needs repeating at every visit, but periodically as conditions change. Is the discussion important? Absolutely. Soap operas are not where the answers exist.
There is an undercurrent of distrust. The distrust is because the medical profession seems so motivated by profit they may do unnecessary treatments when death is near. Thus, to avoid unnecessary treatment a person must clearly state what medical services are wanted at the end of life.
The issue is clouded by the huge shift in the doctor-patient-relationship over the past 10 years. The doctor who might see the patient in the primary care outpatient clinic is not the one who will see the patient at the care center, or the oncology clinic or be the admitting physician at the hospital. Unless the patient, family and friends have a clear grasp on what the patient wants the information may be lost or be misrepresented. It would be incorrect to think the medical record will be universally available — it’s not now and will probably not be that way for decades (if ever).
An equally difficult problem is the “grey area” between care that works and futile care. “Is this the end?” The care provider who is asked that question is really on the front line, not the primary care provider who discussed the issue 10 years before.
The elephant in the room is the cost of care. And, the fact many people do not have the resources to pay tens of thousands of dollars a month for care when their income is just Social Security. Very few people say “do everything”. But, can a person with no resources actually say “do everything” and expect that to happen?
The bottom line: the new CPT codes pay for something a primary care provider should already be doing so the additional cost is not needed. If the discussion is not happening then it is a case of poor quality primary care. Paying more never makes low quality care better, it just makes poor quality care more expensive.
An end-of-life discussion with a knowledgeable provider tends to set expectations in a reasonable range. Satisfaction with medical care is often about meeting expectations, so this is important for the patient and the care providers. It also should set expectations for friends and family — after the patient dies they are the ones who decide if expectations are met.
Doctors have long complained they don’t get paid to solve problems over the phone. Now primary care providers (not specialists) can charge $40 per month for something called “Chronic Care Management.” (CCM)
If you have several long term and serious conditions like diabetes, congestive heart failure and chronic obstructive pulmonary disease then Medicare will pay $32 per month and you or your supplemental insurance will pay the rest for this service. Many supplemental insurance plans have deductibles and co-payments — so many, if not most patients will be paying an extra $8 per month.
Who actually does all the work? The office nurse. The doctor supervises the decision making.
You will have to sign a consent for CCM in order for the doctor to bill you each month, so it is important to know what to expect. Some doctor’s offices will make the service helpful but in other offices you may never know where the money is going.
If you can’t tell you are getting CCM then simply stop the service — revoke the consent with a letter “Dear Doctor, effective at the end of this month please stop “Chronic Care Management”. I will continue visits as usual.”
In general, CCM is a good thing. Here are some of the problems it solves: Without CCM many doctors just don’t take the time to coordinate services except as part of an office visit — if you go to the emergency room the primary care provider would not act on recommendations until you actually go for an office visit. If your visiting nurse suggests some course of action then you go for an office visit. If you want to see a specialist you first go for an office visit. If you get discharged from the hospital and need physical therapy you go for an office visit before it will be ordered. With CCM the doctor gets $40 per month to coordinate care without always going for a face-to-face visit.
The minimum requirement for the provider is to spend at least 20 minutes per month working on your case without seeing you in person. Here is a list of things providers of CCM are required to do (at no extra charge) and thus things you should expect:
- Transitional care management: meaning admission or discharge from some medical service or facility (like giving orders for physical therapy after hospital discharge or providing full medical records to a rehab facility)
- Supervision of home healthcare. The provider gives orders for home care with lists of medications, duration of treatment and goals of treatment.
- Hospice care supervision.
- Provide a limited number of end-stage renal disease services.
The provider must have 5 capabilities and use those capabilities as needed:
- Keep your records in a computer
- Create a care-plan — an outline of goals and actions the provider will follow to meet those goals. Like “keep blood sugars in control — by weekly phone contact”. The provider should give you a copy of the plan — it should be specific to you and not a standard form applicable to anyone.
- Provide phone access to talk to a someone associated with the office 24 hours per day (they should be able to look at your computer record). Provide office visits as needed (presumably same day for urgent problems and within a week for non-urgent problems)
- Facilitate transitions in care. Like provide prescriptions and orders for therapy after discharge from a hospital or providing medical information to specialists for each visit. Or, keeping orders for home oxygen up to date. Or, immediately sending outpatient medical records to the hospital where you are admitted.
- Coordinate care. This does not mean providing all care, it is not a wall around you. If you need to see a specialist the provider makes sure all your medical data is transmitted to that specialist and makes appointments for you. And, follows the instructions of the specialist (as medically reasonable). Engages therapy such as home visits by nurses, physical therapy, occupational therapy or social service. And, makes efforts to meet the care needs outlined by those therapy services (as medically reasonable).
CCM does not eliminate office visits but it makes sure loose ends are dealt with and it obligates the provider charging CCM fees to provide access to someone that can look at your chart 24 hours per day. It also means the ER can call the primary care provider office and get up-to-date medical information about you in an urgent situation.
Disclaimer: the rules and fees for this program are in a state of flux. What is true today may not be accurate tomorrow. So, discuss the meaning of CCM with your primary care provider. Give them a copy of this article as a place to start a discussion. Here are some additional helpful links:
When Quasimodo answers your call light instead of the the nurse you know something is wrong. It probably has to do with all that paperwork — one third of a nurse’s time is spent doing clerical work either on paper or on the computer.
Laura Landro of the Wall Street Journal reported 7/21/14: “Nurses Shift, Aiming for More Time With Patients”. Ms. Landro highlights one hospital where nurses are getting more help from LPNs and CNAs so they can spend more time at the bedside.
More low-level helpers — where does that lead? Probably not to more Florence Nightingales at the bedside but rather fewer RNs who will mainly serve as supervisors. Nurses are getting expensive so the trend will save money for hospitals.
Nurses are hit from many directions. Shift-work is hard on family life and the educational requirements have increased. Highly motivated nurses often escape the shift work by training to become outpatient nurse practitioners — why try to climb the corporate ladder? Nurses aspire to be more like doctors at a time when doctors as hospitalists become more like nursing supervisors. And, hospitals don’t see much value to experience — they fire a 50 year old nurse so they can hire 2 twenty something nurses to save money.
Nurses are criticized for quality issues as well:
- Poor shift to shift communication — who knows what the guy at the end of the hall has?
- Collection of information that has no value 24 hours later — a huge waste of time. Unfortunately, the nursing model is focused on filling out forms or online queries. Always made worse by legal concerns.
- Training that inhibits drawing a conclusion. For example, if a nurse finds a patient is on the floor bleeding from a cut on the head … the conclusion is “deficit of patient comfort” rather than “scalp laceration and possible brain injury”. That’s the doctor’s job — too bad the doctor is not always there.
It’s almost a perfect storm. A general shortage of nurses, a background of quality problems, hospitals anxious to find lower cost employees, and nurses obtaining more training to command higher salaries. Nursing is not going away but the RN job will be different in the future.
Diagram of the Multi-Team System (MTS) for patient care is from the AHRQ web site. This is an idealized concept of what should happen that often does not happen.
A recent article in the New England Journal of Medicine (NEJM) described an unfortunate but all too common situation in hospitals. In this article a patient was very sick in the intensive care unit with respiratory failure (on a ventilator) and with an unusual skin rash. 40 doctors and far more nurses were involved in the patient’s care. So many people, in fact, that nobody knew who was in charge and except for ordering more and more tests nobody did anything. The NEJM article sites the “Bystander Effect” which is the tendency for everyone in a big group to assume someone else will act. Finally, the patient was saved by an acute problem which forced a doctor on the spot to actually do something.
Quality care is doing the right thing at the right time. On both counts the NEJM case represents low quality. Other factors beside the “Bystander Effect” may have been at work. Perhaps the “Silo Effect” where all the care givers were in their own silo without regard to the big picture. Perhaps it was the “Swiss Cheese Effect” where errors on several levels lined up and the patient fell through. But, most likely, the low quality was due to poor communication — the usual suspect. If the care team does not talk the sense of urgency and the sense of danger are lost. The patient was in grave danger!
So, you think this would never happen to you or happen at your local hospital? Think again. It happens all the time when more than one doctor is involved (including on-call doctors). Are there solutions? Yes. The most desperate need is always to designate who is in charge for every minute and every hour and every shift — including doctors and nurses. In-charge is not a title, it means willing and able to act. There should be a sign in each patient’s room with the name of the in-charge doctor and in-charge nurse. Also, there should be a sign on the intensive care door: “All consultants who enter must talk to the doctor in-charge before leaving”.
On a more hopeful note, research has some useful ideas for the teamwork-challenged hospital. Here are some pre- and post-shift check lists from the STEPPS program:
During the brief, the team should address the following questions:
___ Who is on the team?
___ All members understand and agree upon goals?
___ Roles and responsibilities are understood?
___ What is our plan of care?
___ Staff and provider’s availability throughout the shift?
___ Workload among team members?
___ Availability of resources?
The team should address the following questions during a debrief:
___ Communication clear?
___ Roles and responsibilities understood?
___ Situation awareness maintained?
___ Workload distribution equitable?
___ Task assistance requested or offered?
___ Were errors made or avoided? Availability of resources?
___ What went well, what should change, what should improve?
The question of “who is in charge” is critical for hospital care. Trauma surgeons seem to have this issue mastered (they are in charge) but other doctors are in a quandry when more than one is involved. Patient safety demands US hospitals do better!
Finally, a comment about cost. The lack of someone in-charge leads to high cost. The NEJM article itself failed to mention the cost of 40 doctors working on the case. In this time of rising health care cost the nation can not afford such lavish use of resources.