Posts Tagged harm

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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U.S. Malpractice System is a Failure

Cut the ribbon

The U.S. tort system as a solution to compensation for medical errors is an abysmal failure.   It’s unfair to doctors and  it’s unfair to patients.

Here are a few statistics to make the point:

  • Every year 400,000 patients are killed by medical errors and even more are injured.  But, less than 2% receive compensation through suits.  98% never file suits.
  • 80% of suits against doctors fail.
  • 50% of compensation awards are paid to lawyers.
  • The average time from filing suit to winning compensation is 3.5 years.

The practice of “defensive medicine” is well known.  The fear of suits has caused many doctors to order more tests than are necessary.  Even the AMA estimates the unnecessary tests cost between $84 and $151 billion each year.  Worse yet is the effect on medical records:  doctors make records “look good in court” by leaving out embarrassing details — making the job of quality improvement much more difficult.

There can be no other conclusion:  the U.S. justice system is incapable of providing compensation to the vast numbers of injured patients and it stands in the way of quality improvement.

Other countries have much better systems.  One that really stands out is Finland.  They have separated compensation from accountability and quality improvement.  Compensation is decided by a compensation board — compensation is often paid in as little as 2 weeks.  Physicians can readily admit an error and say “I’m sorry” and go a step further and actually help patients get compensation.  

The Fins have a strong quality improvement program which can change the medical system that allows errors to happen and force practice changes as needed — the primary goal is to reduce errors, not to punish doctors (except for criminal behavior). 

The money spent in the  U.S. for malpractice insurance both by doctors and hospitals, and the fees for lawyers would be much better spent in a compensation system like Finland.  Current efforts at U.S. “tort reform” are aimed at reducing suits and thus reducing compensation.  The suits remain unfair to doctors and inadequate to serve injured patients.  “Tort reform” should be changed to “tort elimination” then replaced with a compensation board type system.

This is an excellent time to change the tort system because the U.S. is on the verge of universal health insurance.  The question of who will pay the cost of health care error  is “insurance” rather than bankruptcy court.  By setting up a compensation system more attention can be directed to fair compensation and much stronger quality improvement.

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