Posts Tagged heart attack

Wrong Aspirin Dose After MI — frequent errors

ASA81Highly educated and experienced cardiologists just can’t get it right:  the correct dose of aspirin after a heart attack is 81 mg (called low-dose), NOT 325 mg (called high-dose).  The current prescribing error rate is 60.9%  as published by the American Heart Association in 2014.

Personal communication with several cardiologists elicits the comment:  the higher dose is needed because of the risk of another heart attack — and “in my experience” it just works better.   It’s hard to believe this clinical error in this age of quality assurance.  The problem is BLEEDING not heart attacks!  The stomach BLEEDS due to aspirin and the higher the dose the higher the risk of BLEEDING.

bloodinsinkJust imagine the risk and strain for a recent heart attack victim who vomits blood, needs a transfusion and must undergo a stomach scope — some patients die.  From a cardiology standpoint: “they died from something unrelated to the heart attack” — great thinking.

Cardiologists completely and totally get it wrong when they simultaneously prescribe high dose aspirin and the anticoagulant warfarin — the ghastly mistake happens 40% of the time.

The chemical reaction of “acetylation” is caused by aspirin within small blood cells called platelets.  Acetylation of platelets is responsible for the favorable heart effects of aspirin.  It has been known for at least 30 years that 81 mg of aspirin completely acetylates every platelet a person has — more aspirin does no more.   According to the 2012 TRITON-TIMI trial:

“We observed no difference between patients taking a high dose versus a low of aspirin as it relates to cardiovascular death, heart attack, stroke or stent thrombosis,” according to Payal Kohli, MD involved in the study and quoted in Science Daily.

Hospital quality improvement programs need the “guts” to just say NO.  325 mg is not correct.  Cardiologists are the sweetheart doctors making millions of dollars for hospitals — it should not matter, JUST SAY NO.

It’s almost impossible for even the most proactive patient to question the great doctor that just saved their life.  So, hospital quality assurance has an even greater responsibility than usual.  The prescribing error needs to be corrected — hospital pharmacists and quality improvement departments need to be strongly involved — this error has gone on far too long.

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Observation Unit — Between ER and Hospital

Laura Landro of the Wall Street Journal reported on a growing trend in US hospitals.  The trend is the “Observation Unit”.  In hockey terms it is the penalty box where hospitals put patients they can’t send home but can’t admit, at least for a few hours.

The origin of this idea may have come from English hospitals.  Those hospitals run at almost 100% occupancy.  So, when a patient from the ER needs to be admitted there is a delay to wait for a room.  Those patients  get put in a big room next to the ER with several gurneys, a few nurses,  and lots of curtains (the observation unit).  The patients do get tests and treatments but they wait for a room.  As it turns out, some of the patients get better and don’t actually get admitted — they go home — the rest eventually go to a hospital room.  In England hospital care is free and the hospitals don’t have to worry about insurance or Medicare rules that separate  outpatient and inpatient charges.

US hospitals have plenty of beds available but US hospitals do have to worry about insurance and Medicare rules.  Care is not free and if a hospital makes a mistake (like admitting for indigestion) they don’t get paid.  And, if a doctor makes a mistake and sends a patient home who should have been admitted (for a heart attack) they could be in legal trouble.  Consequently, unlike the English hospital that needs to hold patients to wait for a bed the US hospitals need to hold patients because of red tape and legal worries!  It’s hard to tell which is worse.

The Wall Street Journal article puts a positive spin on the “new” idea:  “when operated efficiently observation units have been shown to reduce health-care costs and improve treatment”.  Obviously there is a balance of forces between the Hospital that makes money and the insurance company that looses money with each admission.  Regulators try to develop rules to speed evaluation and treatment so some patients can go home safely without a hospital admission and the huge associated costs.  Any patient who can bypass the hospital will also avoid the risk of hospital errors and exposure to hospital acquired infections.

Patients have two main concerns:

1) Getting the right care the first time and not coming back sick.   The unit may provide a little longer time to get test results and see if treatment is working which is good unless unnecessary tests are being done.
2) Minimizing out of pocket cost.  A person without insurance would get a lower bill by avoiding the hospital but having both the cost of observation and hospitalization is a real possibility.   The current trend for insurance  is to shift a higher percent of outpatient charges to the patient compared to inpatient charges.  So, depending on what a person’s insurance covers, there might be higher out of pocket expense for using observation.

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