Posts Tagged hospital
According to a study at Johns Hopkins (2/1/15) improving hospital amenities improve patient satisfaction with the facility but otherwise do not improve satisfaction with care. This is important for two reasons:
- Patients really can tell the difference — a crystal chandelier hanging in the hospital room does not make nursing care better!
- Patient satisfaction measurement is a powerful tool to assess medical care — if the patient’s expectations are met, it is likely good care is delivered.
The tremendous building boom for hospitals is strange given this bit of science — are CEOs trying to improve quality by remodeling? Now it seems clear CEOs should focus money and energy on improving hospital quality until the level of quality is very high then if there is money to spare consider improving the physical amenities.
Increasing the distance a nurse must walk to see patients results in decreasing nursing visits. This seems simple enough, but the current trend in hospital remodeling is to eliminate rooms with multiple patients. The trend reduces RN visits, increases the need for nursing assistants, increases hospital cost and may increase falls for elderly patients.
The hospital that looks like a nice hotel seems to be the desire of hospital CEOs. This may be fine for obstetrics but may be wrong for geriatrics. A multi-bed ward with 4 patients allows one nurse to check on 4 patients quickly. 4 times the number of nursing visits makes it much easier to prevent falls. When nurses still wore those pointy white hats they had this figured out.
Progress marches on. American health care quality is as low as many 3rd world countries but at least we have nice surroundings in which to suffer the complications.
Hospitals 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).
- 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.
- Educate staff that IV fluid is not required to admit a patient (an old fashioned insurance rule).
- Educate staff that IV fluid is not a cure-all. Fluid would help a dehydrated patient but not others.
- 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.
- 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?
The U.S. Navy Submarine Service is attributed with the development of a communication technique for critical situations. The technique is to standardize a message from one person to another in the order of Situation, Background, Assessment and Recommendation. For example in a submarine:
- Situation: Captain this is #1, we are having difficulty maintaining our speed
- Background: We are near a fishing fleet
- Assessment: I think we may be entangled in a fishing net
- Recommendation: I recommend we surface and cut away the netting
The captain says “make it so” or perhaps he says “no, all stop, send out divers”
About 15 years ago the method came to the attention of patient safety experts. It had several great features: 1) The person on the front line (like an ER doctor or nurse) could make a report quickly 2) the method was easy to learn and was consistent even when emotions were running high 3) It leveled the hierarchy so the person on the front line made a recommendation with situational awareness that the person receiving the message might not have. In a medical situation SBAR might sound like:
- Situation: Doctor this is the ICU nurse, your patient John Doe has become comatose and is breathing very slowly.
- Background: He has lung disease and was just admitted 2 hours ago
- Assessment: I think he is in respiratory failure
- Recommendation: I recommend we intubate as soon as possible.
The critical care doctor says: “Get me a scope and a tube, I will be right there”
Those health care professionals who embraced the method found it very helpful and it is still being used at many institutions. But, the idea has not had universal success for reasons that were not clear at the outset:
- Fear. Recommendations might be rejected.
- License: Some felt their license did not allow an assessment which was the equivalent of a diagnosis.
- Semantics: The word assessment means physical exam to nurses but it means diagnosis to physicians.
- Litigation risk: Some felt if a recommendation was followed and later proved to be an error they would be blamed and possibly sued.
Improved communication in critical health care situations is very important to the patient in distress, in fact, poor communication is responsible for many in-hospital errors. The SBAR technique is more difficult than one might think. And, implementing it requires more than just saying “wow, this is great, do it”. Techniques for implementation include some of the following:
- Audio or video recordings of the technique in use
- Practice sessions including both doctors and nurses.
- Role playing — the doctor giving the nurse a report and visa versa.
- Explanation of why the technique works
- Examples of errors in communication and how patients might suffer
- Emphasis on teamwork and not blame. A single negative comment by a physician or supervisor can take a great deal of effort to correct.
- Understand a critical assessment is not a final diagnosis but just a step in the right direction. The assessment is made at the training level of the person stating it. Some might say “breathing difficulty” some might say “respiratory failure”.
- Continued education and reinforcement. All new members of a medical team need to be instructed. This is an ongoing process.
Good communication improves patient safety especially when quick action is needed. SBAR is a framework for communication. Other methods may do the same thing but the history and success so far suggest it has wide applicability. Users of the technique express satisfaction (1). Communication always involves two parties — both must be accepting and well trained to use the technique. The World Health Organization has included SBAR in some of its publications (2) so wider use of the technique is expected.
Personal experience with SBAR
(1) Beckett, C. D. and Kipnis, G. (2009), Collaborative Communication: Integrating SBAR to Improve Quality/Patient Safety Outcomes. Journal for Healthcare Quality, 31: 19–28. doi: 10.1111/j.1945-1474.2009.00043.x
(2) Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Journal on Quality and Patient Safety, 32 (3), 167–175.
(3) Anonymous (2007) Communication During Patient Hand-Overs. WHO Collaborating Centre for Patient Safety Solutions,Patient Safety Solutions,volume 1, solution 3, May 2007
Just calling a patient on the phone does not prevent patients from being re-admitted!
Hospitals are very interested in preventing a patient from returning to the hospital (called a re-admission) within 30 days from discharge due to the financial penalties from Medicare.
For example, if a patient is hospitalized with a serious problem called congestive heart failure (fluid retention that causes shortness of breath) the hospital will be penalized financially if the patient gets the condition all over again and has to return.
The government idea is to force hospitals to be more accountable — it’s like a 30 day guarantee from an auto repair shop! So hospitals are looking for ways to improve their performance (and avoid paying money).
There is no question frequent visits to a physician can reduce re-hospitalizations. However, a recent hospital study found that hospital nurses who talked to patients before discharge and who called them after discharge did not help the readmission problem — in fact there were more re-admissions!
a) How can this be?
b) Do well meaning nurses actually make the problem worse?
c) Does this mean hospitals should not be penalized?
The answers are: a) bad science b) yes and c) no, perhaps they should be penalized more!
The “bad science” part is because there was no intervention to adjust medications or treatments that might prevent readmission. A hospital nurse only has one option for a telephone intervention: “you better get checked at the ER”. The conclusion from the study should have been stated “chatting with a patient does not prevent re-admission” — brilliant deduction.
The outpatient care provider’s office is where action can be taken to stop re-admissions. That’s where medications can be prescribed. If the hospital wanted to prevent re-admissions they should have made an appointment and given the patient a coupon for a taxi ride to and from the outpatient office. This is not rocket science.
Delinquent, delayed and diverted the electronic health records in the US are missing. According to the Washington Post two Presidents set 2014 as the target for all medical records to be electronic — so has American medicine hit the target?
According to a study by the Robert Woods Johnson Foundation US healthcare has been very slow to adopt the technology. RWJF reports 50% of office practices have a “basic” system and 59% of hospitals have at least a “basic” system (25% of hospitals have a comprehensive system). To give perspective, a “basic” system contains medical reports and medication lists but no physician notes.
Barriers stand in the way of progress:
- Medical data is a very valuable business asset. EHR companies are threatened if such data could be easily transferred to a competitor.
- Fear of losing control. Doctors and hospitals don’t want their data to be too available to insurance companies or regulators. Quality problems could be easily exposed.
- Self-determination. Health care entities want to make their own systems — the CEO would rather manage than cooperate.
- Lack of governmental action. Doctors and hospitals are licensed by States — just putting the license at risk is all that is needed to make EHRs mandatory.
- High cost of building an EHR. Every office practice and hospital needs a financial system. But, really, only one EHR is needed in a State or perhaps only one in the entire US. Hundreds of EHRs across the country is a waste of money — they all do the same thing, and they can’t “talk” to each other.
- Failure to embrace a “cloud” computing solution for a large scale EHR.
Ask your doctor:
- Please show me my chest x-ray on the computer screen in the office exam room.
- Please electronically send all my records to a specialist across town.
- Please show me a record of all the prescriptions I had filled this past year and which pharmacies filled them and how much they cost. (surely you can trust your doctor with that small bit of financial information).
- Can I send you a secure email and expect a response?
- Can you securely send me the results of my tests?
- Can you easily look up the discharge instructions from my recent hospitalization on your office computer?
- Do all the doctors and hospitals and pharmacies in town share the same medical record system — why not? It would be very good from a patient standpoint.
NO answers exemplify the current data problem. The US has a far better tax system than a medical record system and a far better post office than a medical record system. Contrary to the story in the Washington Post this is NOT OK.
Saying “sorry” is the human thing to do. Doctors and nurses should say it when they feel it.
Saying “sorry” seems to have two meanings: 1) something bad happened and I understand your emotions 2) something bad happened and I had some connection with the event for which I feel partly responsible. Bad things do happen in health care but “sorry” is a very uncommon utterance for health care providers.
Dr. Abigail Zuger writing in the New York Times 7/14/14 “Saying Sorry, but for What?” compared how she felt about a plumber who broke a valve in her house with medical personnel who broke other things — neither said “sorry.” Sorry truly does not fix anything; but, the absence of “sorry” is infuriating.
The problem is ego. Ego infuses some health care providers with the notion bad things are an act of God but good things are an act of ME. Absence of “sorry” is a sure sign of defense (a defense of self). Perhaps the health care provider was spanked as a child or yelled at by teachers. Who knows … ego has gone wild.
Quality health care depends on people believing errors are due to system failures. When providers fail to embrace that philosophy they fail to correct problems. No failure, no correction.
A fall in the hospital can be deadly. Recently, a family member fell in a room while no nurse was present and they died. The nurse did not say “sorry.” There was no acknowledgement of responsibility. No acknowledgement the system was at fault, no realization there was a better way, and no reason to prevent future deaths. The simple statement “sorry, I wish I had been there to stop the fall, we will investigate this to help others” would be the right thing to say, and believe.
Lawyers are not the cause of excessive health care ego. However, lawyers with the threat of suit are a convenient excuse. When bad things happen honesty and caring are much more likely to assuage the displeasure of a family than stonewalling.
Hospitals suffer (and consumers pay the price) when drug companies price medications with usage targets and drug baskets. These techniques are euphemistically called “Guerrilla Marketing” but should be called ILLEGAL Pharmaceutical companies should be restricted to selling or pricing drugs one drug at a time.
What’s going on? The drug companies take advantage of the difficulty hospitals have to convince doctors to stick to a limited group of hospital drugs (a formulary). When the hospital convinces (by internal marketing) the staff to accept certain drugs it’s hard to reverse course.
- Usage Targets: a hospital gets a better price using one company’s drug 90% of the time. So good in fact, even if a less expensive competitor shows up hospitals don’t change — because the hospital pharmacy does not want to contradict the internal marketing they already did to reach that 90% target. And, when the usage falls below 90% a huge price increase hits. If they could totally stop using the drug things would be ok but they can’t.
- Drug Baskets: a hospital gets a sweet deal on a blockbuster drug by agreeing to exclusively use a few of that companies low cost drugs. Later, the drug company raises the wholesale price of the low cost drugs but still gives the hospital the same sweet deal. It looks like the whole basket of drugs is even a better deal. But, when the blockbuster drug goes generic it’s hard to figure out what to do. The basket deal seems good unless the hospital looks for substitutes to the formerly low cost drugs. Many hospitals stumble on the complexity. And the staff doctors complain about changes to several drug at once.
When hospitals stumble with these deals who do you think pays the price? Consumers (that means you). Guerrilla/Gorilla not much difference.