Posts Tagged CHF

Hospitals fail to stop IV fluids for CHF — poor quality care

ivfluidsHospitals are responsible to rescue patients from inappropriate treatment — especially when the need to intervene is obvious.   The hospital has a board of directors responsible for the care delivered in a hospital. They hire the CEO who hires a quality manager.  When bad quality management hurts or kills patients it is the hospital’s fault.

An article by Dr. Behnood Bikdeli and colleagues (JCHF. 2015;3(2):127-133) describes a huge study at 346 hospitals about treatment of patients with congestive heart failure (CHF).   Here is the essence:

  • CHF is life-threatening condition where the body collects too much fluid, usually due to a weak heart.  The fluid gets into the lungs and causes shortness of breath.
  • The treatment for CHF is to remove fluid from the body and give medications to improve heart and kidney function.
  • The absolutely wrong thing to do is to give extra fluid by the veins.
  • The study found about 12% of patients with CHF were treated with 1 to 2 liters of fluid in the veins during the first 2 days of hospitalization.  AND, most alarming, compared to similar patients not treated this way, they were more likely to end up in intensive care or die.
  • The most telling statistic is how often various hospitals let this dangerous use of intravenous fluid happen:  0% to 71%.  This means some hospitals did not let it happen (0%).  Some hospitals let it happen a lot (71%) — just hope your grandmother did not go to that hospital!

It is not rocket science to say fluid overload is not treated with extra fluid.  This is easy to detect when the admitting diagnosis is CHF and the doctor orders say “NS IV at TKO” (translation:  give salt water in the veins at a rate to make sure the veins stay open).  NO NO NO the patient does not need extra fluid.  This should not happen and there are lots of ways to prevent it or even rescue patients when Dr Welby writes such an order (or tries to use leaches).

Solutions:

  1. Mandate doctors use standard orders for treatment of CHF — there is plenty of latitude to customize such orders.  But, IV fluid is not one of the choices without stating why.
  2. Educate staff that IV fluid is not required to admit a patient (an old fashioned insurance rule).
  3. Educate staff that IV fluid is not a cure-all.  Fluid would help a dehydrated patient but not others.
  4. Nurses do a double check before admitting a patient from the ER with the question:  does this patient have CHF and an order for IV fluids — if so, call the physician to clarify the situation or to change the order — no clarity=no admit.
  5. All CHF patients should be weighed daily — if the weight is going up it means more fluid is being retained — the patient needs to be rescued.  Fix the problem or find someone who can, NOW.

Attention patient and family.  This is easy to spot.  The admitting doctor says the diagnosis is congestive heart failure but you see IV fluids being pumped into yourself or your family member.  SPEAK UP!  “Why is fluid treatment needed?”  do not accept the answer of “everybody gets an IV”.

Attention hospital board members:  do you know what your hospital is doing to prevent this obvious problem?  Quality is your responsibility, you must do something besides listen to financial statements.  Is your hospital the one with 0% or 71% record of treating CHF with IV fluids?

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Chronic Care Management — a patient guide

pnonenurseDoctors 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:

  1. 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)
  2. Supervision of home healthcare.  The provider gives orders for home care with lists of medications, duration of treatment and goals of treatment.
  3. Hospice care supervision.
  4. Provide a limited number of end-stage renal disease services.

The provider must have 5 capabilities and use those capabilities as needed:

  1. Keep your records in a computer
  2. 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.
  3. 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)
  4. 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.
  5. 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.

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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:

CMS – Medicare.gov

PBS Newshour

 Pershing Yoakley & Associates

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