Sometimes I agree with New York Times’ editorials. Sometimes I don’t. But I rarely learn much from them. To my mind, the problem with the form is that it encourages opining without evidence. So, I admit, I rarely turn to the editorials. .
But yesterday Buckeye Surgeon pricked my curiosity by referring to a recent New York Times editorial as a “masterpiece of naiveté and contempt.”
Such strong language suggested that the editorial might be entertaining. Thus, I went back and read what turned out to be a piece congratulating Medicare for having decided it “will no longer pay hospitals for the added cost of treating patients who acquire any of 10 ‘reasonably preventable’ conditions while hospitalized. Those include incompatible blood transfusions, severe bedsores, injuries from falls, poor blood sugar control, and infections after certain surgeries.”
This is what I mean about editorials: typically they are monologues that cry out for a good copy editor who asks sensible, logical questions. The first query that springs to mind is this: exactly what does “preventable” mean? How is a “fall” preventable?
If Mr. Smith decides to get out of bed, begins shuffling toward the hallway, feels woozy, loses his balance and falls, how could the fall have been avoided? Should a member of the staff be stationed not more than six feet from each patient, ready to race in and catch him if he teeters? Or should Mr. Smith have been tied to his bed? (Thanks to HealthBeat reader Howard B. for his comment on hospital falls about a year ago.)
Personally, I would prefer the risk of falling to the trauma of finding myself strapped to a hospital bed.
Of course if there were a banana peel on the floor, or a clump of green
Jell-o, I would agree: someone was negligent. But that’s not how most
hospital falls occur. A patient wants to get up and decides he can make
it to the bathroom. Maybe he rings for a nurse, and becomes impatient
when one does not materialize within five minutes. Is the fact that
the nurse was busy a preventable “error”?
Apparently the Times thinks so. Because it declares that “The
most important benefit will come if the new rules persuade hospitals to
work harder to prevent errors and protect their patients.”
Here, let me do a little line-editing. “Hospitals” don’t work hard.
People in hospitals—doctors, nurses, administrators—do the work. If
the writer means “the hospital’s administration,” say so. And, on that
point, I would agree: hospital administrators and hospital boards
should commit more time, thought and money to reducing problems that
threaten patient safety including medication mix-ups, incompatible
transfusions, and a high rate of hospital-acquired infections. They
need to invest in the systems (including electronic medical records)
that could significantly reduce the instances of iatrogenic illness
(illness inadvertently caused by medical care.)
As I have suggested in the past, too often U.S. hospitals invest in
hotel-like amenities—or monuments to a donor—rather than patient safety.
But the Times doesn’t seem to be talking about administrators so
much as staff. For in the very next sentence, it grouses: “The policy
focuses exclusively on hospitals, as directed by Congress, and lets
doctors off scot-free.” This seems to suggest that it is doctors (and
perhaps the nurses as well?) who need to “work harder to prevent errors
and protect patients.”
I wonder if the writer has spent much time in a hospital recently. Has
he or she spotted many physicians just lounging about? Or are the
slackers the nurses who, from what I have seen, appear to be
multi-tasking much of the time?
Let me suggest that telling staff to “work harder” is not the answer to
hospital errors. Most often, patients are harmed because too many
people are doing too many tasks under too much pressure—with too little
time to communicate properly with each other.
Nor are most mistakes caused by one person. Normally, it takes two,
three or four people to hurt a patient. The Times points a finger at
the surgeon who leaves a sponge in the patient. What about the surgical
nurses who are supposed to count the sponges at the end of the surgery
to make sure such a mistake doesn’t occur?
The Times also singles out the “surgeon who operates on the
wrong patient.” But how did that happen? Usually because someone else
wheeled the wrong patient into the operating room. And how did that
happen? Because someone else misidentified the patient while or after
he was being prepped for surgery. Normally it takes a series of
slip-ups to lead to a real humdinger like mistaken identity in the OR.
Except in cases of extreme negligence bordering on the criminal, many
of the things that go wrong in hospitals are systems errors. A patient
develops bedsores because the ICU doesn’t have a beeper system
reminding nurses that some patients need to be turned every two hours.
Even if they have a beeper, nurses may have ignored it because another,
sicker patient needed attention.
Hospitals cannot be prepared for every contingency. On the question of
bedsores, Buckeye Surgeon observes: “All it takes is 30 minutes of
unrelieved pressure from a mattress against your buttocks to compromise
capillary blood flow to skin and subcutaneous tissues. Now imagine a
500 pound post op gastric bypass patient flat on her back on an air
mattress. It takes 6 people to rotate her every two hours. She gets a
pressure sore anyway. At what point was her care compromised? Please
demonstrate the error. Ought we to have zero gravity chambers available
for such scenarios?”
Finally, Buckeye points out that the notion of a “Never” event is
deeply flawed when the list includes “urinary tract infections,
surgical wound infections… c. difficile colitis, delirium, deep venous
thromboses and other such events that often arise in the setting of
critical illness. Interestingly,” he writes, “you will not find a
publishable work of science that describes how to reduce the risk of
these events to zero. Why? Because it’s impossible. If you put a
rubber catheter into your bladder, I don’t care how sterilely it’s
done, eventually a certain percentage of them will cause a urinary
tract infection. It’s a foreign body, for godsakes.”
He has a point. Too often, patients want to pretend that medical care
is risk-free. It isn’t. Whenever you choose to enter a hospital, or
undergo an elective test or treatment, you are, in the words of
Dartmouth’s Dr. Jack Wennberg “making a wager.” You are gambling that
nothing will go wrong, that you will not fall victim to a serious side
effect, that you will not be touched by human error.
But in a situation where very ill patients are being treated by groups
of sometimes tired, often harried human beings, patients are
vulnerable. Certainly, you have a right to expect that the hospital is
doing its level best to reduce the odds that you will suffer harm. But
pretending that “never events” won’t happen—or that they can’t happen
to you –is just that, pretending. This is why you and your doctor
should always talk about risks as well as benefits before embarking on
any medical treatment.
Finally, while I’m an advocate of containing Medicare spending, this
doesn’t seem the best way to do it. If a hospital has a very high rate
of hospital-acquired infections, I’m not interested in “punishing” the
institution by refusing to pay for the extra treatment needed. I want
the hospital fixed—or closed down. Medicare should give the hospital a
set amount of time to reduce the rate of infections. If it fails,
Medicare should then refuse to send that hospital any more business.
(This would, in effect, close its doors.)
As for the serious mistakes that should truly “never” happen (wrong
site surgery, for example, or an incompatible blood transfusion), in
these cases Medicare should require a thorough investigation, and a
report, that is made available to the patient, the patients’ family,
and the public, detailing exactly what happened. If someone in the
chain has made an egregious mistake, that person should be fired. In
any case, the hospital’s system for ensuring that the right patient is
getting the right transfusion or the right surgery should be changed.
And Medicare should require a second report explaining what changes
have been made.
But the idea that refusing to pay individual physicians for “never”
events will somehow make our hospitals safer by making doctors “try
harder” to avoid harming patients is absurd. Trust me: a doctor’s worst
nightmare is that something she or he does will injure a patient.
Whoever thought that financial penalties are needed to “motivate”
doctors in this area does not understand the profession.
What doctors need are systems that work, and nurses who haven’t been
forced to work a double shift to help them do their job. Improving
working conditions for nurses and doing whatever it takes to fully
staff our hospitals would go a long way toward improving patient safety.
As for hospital administrations and hospital boards: yes, they might
pay more attention to adverse events if they know that Medicare will
not reimburse if an error leads to additional treatment. But the Times acknowledges that the new policy will not cost hospitals much money at first — “only about $21 million a year.”
Withholding relatively petty amounts of money, over what are often
relatively minor mishaps, doesn’t begin to approach the type of
structural reforms that our hospitals need. Instead, such financial
penalties are likely to lower hospital morale, dividing staff by
encouraging individuals to blame each other for adverse events.
Instead of simply focusing what should “never” happen , Medicare should use positive reinforcement
to encourage collaboration and esprit de corps, by paying lump-sum
bonuses for better outcomes—for example, bonuses that everyone who
treated those patients share.
Finally, Medicare should insist that, insofar has hospitals have
surpluses or profits, they plow that money into patient safety.
Hospitals that want to do business with Medicare should be asked to
disclose how they are investing their surpluses, demonstrating that,
when making financial decision, they are putting electronic medical
records and systems designed to reduce hospital-acquired infections
ahead of parking lots, new lobbies, bridges and new wings. In other
words, a hospital’s investment decisions should not be made by its
marketing department—nor by the “rain-makers” who want expensive new
equipment for their specialty.
First, do no harm.
“Ring for a nurse.”
That infers room service, and a one size fits all model of hotel services.
It’s the problem behind so much of the perception that nurses are generic staff.
They aren’t and that’s a key piece of the analysis of the inadequacy and fundamental flaw in denying payment for never events.
By dancing all around the elephant in the room, we point fingers at everyone and no one. Phantoms, ghosts and theoretical evil-doiers.
The root of the problem is the absence of professional nursing care.
When patients are cared for by registered nurses with a minimum of a baacualreate nursing education, they do demonstrably better.
So here’s what is needed in order to reduce never events to the near zero mark (Buckeye Surgeon is correct that you can approach but never reach absolute zero incidence until you can completely control every variable – and that includes patient compliance):
Nurse-directed patient care loads.
Nurse-directed patient ratios
Clinical nurse-directed nursing assessments and nursing care plans
Clinical nurse-directed case management.
Clinical nurse-directed patient care policies and procedures
Clinical nursing autonomy over nursing practice and workplace conditions.
Clinical nurses direct and deliver all nursing care.
Clinical nurse-controlled work schedules.
Joint appointments of nursing faculty and researchers in clinical settings.
Application of nursing research in clinical settings.
Clinical nursing career mobility to lure and keep expert nurses in direct patient care practice.
Put those in place, and then you can legitimately hold nurses accountable for meeting or exceeding desired patient outcomes.
Until then, it’s all a game of risk. Specifically, how much risk the patient care institution nurse employer is willing to assume by maintaining less than desirable working conditions and other than nursing controlled nurse staffing/task-oriented patient care delivery.
On a related note, I still think that hospitals are going to redirect uncompensated costs at the remaining payers sources, so that self-payers will be charged even more to recoup the Medicare reimbursement losses.
It’s folly to think that somehow those costs will simply be absorbed without patients paying in some fashion.
Risk is never zero–never. It is entirely reasonable to investigate hospitals for possible behavior patterns that produce, say, rates of hospital-acquired infections that are some amount greater than the mean. That would pool events such that cross-comparisons are possible, although even then the patient samples need to be looked at so you’re not comparing, say an AIDS patient getting a lung biopsy with a healthy guy having his hernia fixed. As Buckeye says, stating you won’t pay for something that is statistically inevitable, like post-operative infections, seems to me to be two things:
1. A play to the gallery that Medicare is somehow getting tough with miscreants.
2. A sneaky and disingenuous, rather than honest way, of cutting costs.
Editorialists love to tut-tut mindlessly like that.
Chris & Annie–
Thank you.
Chris, you write “risk is never zero”.
Yes, and it is so important for patients to realize that.
This is why they need to be very wary of unnecessary treatments and, in particular, unnecessary hospitalizations.
And I agree that this Medicare policy is largely about playing to the gallery, and “a sneaky, disingenuous way of cutting costs.”
The best way to cut costs is simply to say “no” to ineffective and marginally effective treatments. But patients don’t want to hear “no.”
And, too often, people who write editorials are in the business of selling newspapers to those people.
Annie —
You write:
“‘Ring for a nurse.’ That infers room service, and a one size fits all model of hotel services.”
Very well put. We have to get over the notion that hospitals are hotels. This isn’t to say that I have
anything against great views, nice carpeting etc. If a hospital already has these amentiies, fine. But looking forward, we need to be investing healthcare dollars in ways that meet patients’ Medical needs.
And the hotel metaphor
encourages both patients and hospital administrators to think that hospitals should be like hotels–all about convenience, cosmetics and “service” (Someone fluffing your pillows, bringing water the minute you want it, etc
These are not things that most nurses have time to do. And it is a waste of their education and training to expect them to function as servants.
This is why we have family and friends. They can do these things.
Hospitals have one mission: caring for you, by meeting your Medcal Needs, with compassion and competence.
Nurses are not servants.
Annie, much of what you have written here and in other comments reminds me that if we want to upgrade hospital care, we need more nurses in management–
figuring out things like how many nurses per patient
are needed on various services, how their time could best be used . . .
Of course nurses should not make these decisions in isolation–just as no physican specialty should make decisions about how much of a hospital’s resources it needs should be made in isolation.
There alwyas should be some push-back, debate and negotiation.
That said, I think nurses know so much about what is going on–and going wrong–in our hospitals. They should be in management positions–in large enough numbers that they actually have a vote. (A token nurse on a committee is not enough.)
Annie–If you have time, please send me an e-mail. I would like to talk to you about moving nurses into management.
Maggie:
There is another aspect of risk that most people don’t think about–the risk of an unneeded test that gives you either wrong or ambiguous information, leading to more tests or the wrong treatment. I sometimes have difficulty convincing families, and even other physicians, that it is never a good idea to do a test just because you are curious.
Most physicians have their own personal horror stories about what happened when that head MRI or whatever was done just because we could, leading to other things that, in retrospect, were wrong. This is yet another reason why the most expensive care is not always the best care.
Maggie I agree positive reinforcement is key. With every policy you will have unitended consequences which is precisely why postive encouragement is so important. Many of the following WILL occur without a doubt: patient dumping and refusal of admission, less transparency and more secrecy, further overtesting as hospitals try to cover themselves or undertesting so they don’t find disease in the first place such as an asymptomatic DVT in a post op patient.
The most striking one listed is UTIs from a catheter. Give me a break. Guess what’s going to happen? No one is going to get a catether. If I was the admistrator Foley catethers would no longer be stocked. You better get used to a diaper and lying in your own piss, because there will be no Catheter related UTIs on our watch and patients will be told Medicare doesn’t allow catheters. Precisely what you don’t want the public told if you are a fan of government run healthcare. Unintended consequences, they are critical in any policy.
Maggie, I strongly agreed with your original post about “never” events and the realities of hospitals/medical care. But just as strongly disagree with this in your follow up which hopefully was just off the cuff and not thought out: you say basically that nurses are not there to provide service such as making you more comfortable in bed, bringing water promptly, then you say “This is why we have family and friends. They can do these things.”
This is a terrible idea. Such things can be very important to the sick as Florence Nightingale in her writings pointed out; she notes things such as bumping against a bed which would not matter to a well person can be very hurtful to a sick person. And many sick people do NOT have family and friends, many are elderly who have in fact outlived their family and friends. And if I am the family or friend of a sick person I often still have my own job and responsibilities and CANNOT be there for these items much. It *IS* a part of good medical/hospital care for the institution to provide that.
Caretaker stress is already large and becomes even more unwieldy when institutions neglect these responsibilities. And as I said, as a former nursing home ombudsman I know how many people are SIMPLY NOT EQUIPPED any more with families or friends or their families and friends are not equally old and frail and not up to such responsibilities.
Yes it needn’t take an RN always to do these things BUT they are part of any good hospital’s responsibilities and of immense importance to sick, suffering people.
I agree with Annie’s comment, especially concerning nurse-patient ratios. When hospitals staff enough nurses, errors go down. When hospital administrators cut costs by decreasing nurse-patient ratios, errors go up.
Improving working conditions for nurses, means less nurses quit the profession.
The solution is Safe Staffing Legislation, guaranteeing minimum nurse-patient ratios. This is in place in California and the results are telling.
I’d also comment that one thing that WOULD help in hospitals and nursing homes with both comfort and safety is MINIMUM STAFFING REQUIREMENTS, which corporations are bitterly opposed to but which California nurses have been pushing for years.
Most medical people, as Maggie points out, absolutely WANT to do a good job – and they need working conditions that allow them to do so, which means adequate staff.
Maggie,
Great column. As a surgeon, I was shocked that they (Medicare) could come up with such regulations. Once it’s implemented, I predict that hospitals and staff will come up with creative ways of bypassing or covering up the rules, without actually preventing more errors.
I can relate more to nursing homes than hospitals because of my personal experience with them over the last five years. This idea about nurse management efficiencies has real validity in nursing homes. Besides the lack of CNA staff at nursing homes, LPNs are in charge of floors. LPNs do not receive training in nursing school on how to be a charge nurse. RNs have at least 3 months of training in leadership on a floor.
Therefore, nursing homes are being run by untrained staff, as well as insufficient staff. That is one reason RNs are hired to make sure paperwork is perfect for survey inspections. Nursing homes would improve greatly if all charge nurses were RNs. Nothing against all the fine LPNs, but they are not “formally” trained to do the job of an RN, yet they are placed in that role in nursing homes.
Containing Medicare spending by regulating “never” events isn’t the best way to go. Instead of having rules to persuade hospital/nursing homes to work harder to prevent errors and protect their patients/residents, improving working conditions for nurses by increasing minimum staffing levels and proper management efficiencies would go a long way toward improving patient/resident safety. Patients/residents are being treated by groups of sometimes tired, often harried human beings, and these patients/residents do become vulnerable.
Congress has the opportunity to improve resident safety standards in nursing homes. It’s called the “Nursing Home Transparency and Quality of Care Improvement Act of 2008.”
http://www.bestsyndication.com:80/?q=20081017_nursing_homes_legislation.htm
I applaud this blog of yours, Maggie. Excellent points. Asking hospital staff to work harder is just absurd—nurses and physicians alike are already so overworked and dealing with conditions that are not supportive to them to do the jobs they aspire to. I know. I interviewed over 150 of them for my book, Critical Conditions: The Essential Hospital Guide To Get Your Loved One Out Alive. Each and every registered nurse I interviewed said that they are asked to care for too many patients, to complete an inordinate amount of paperwork (charting) for each patient and if there happens to be a nurse-to- patient ratio law in the state, nurse support staff have mostly likely been cut, so the registered nurses are now doing the jobs of those who have been cut.
However, there is something that everyone can do immediately to prevent some of these “never events.” You must have someone, a family member or good friend, to act as a sentinel, a watch dog to prevent medication mistakes, the spread of hospital-acquired infectious diseases, bed sores, wrong-stie surgeries, and yes, even falls. No one wants their loved one put in restraints in a hospital bed. However, if the patient is at risk for a fall, what else is a nurse to do? He/she cannot be at bedside every minute. But a family member or good friend can. Every nurse I interviewed said that hospital care is in crisis and that every hospitalized patient must have someone acting as an advocate to prevent a host of medical mistakes, including falls.
You are right that no doctor or nurse wants to commit an error. That is the last thing they want. But with the drastic, nationwide nursing shortage, a shortage of physicians—especially in rural areas—there just aren’t enough eyes and ears to go around. Hence the need for an outside watchdog to oversee and support medical care. Even surgery on the wrong body part can be prevented simply by the family member/good friend accompanying the patient to the OR and asking to see the surgeon and going over a checklist with the correct name of the patient, the correct surgery, the correct site of the incision. If the surgeon isn’t available, the family member/good friend can request to see the anesthesiologist and nurses involved in the surgery and repeat the same checklist. Might sound time consuming but a loved one’s hospitalization is time limited. Tasks can be shared by a team of family members/good friends.
Your idea about offering bonuses for better outcomes is an excellent one.
Strongest point here is about culpability and why it is so hard to ascribe responsibility. Apologies for flogging the overused aviation analogy, but airlines don’t get off the hook by blaming impaired pilots or incompetent mechanics, tho the system requires that they all work together to deliver a safe product. As we all know well, there is no system here. So how does one get the non-system’s attention? money talks. If a hospital notices that it ain’t getting paid for botched work, perhaps it’ll take steps to correct or eliminate those who are doing it.
in any event, it is hard to think of another area of commerce where the customer is asked to pay for rework that’s messed up by the provider in the first pass. automakers take a hit on warranty costs if they don’t do it right the first time. participants in the medical game get a bonus. you don’t have to be a populist to find that both amazing and offensive.
Jim,
Thanks for your comments.
Jim– I tend to agree with much of your comment. We
do need better systems–more hospitals need to be implementing the work that
Don Berwick as been doing at the Intitute for HealthCare Improvement.
That said, when you write: “It is hard to think of another area of commerce where the customer is asked to pay for rework that’s messed up by the provider in the first pass,” I have to say that there are no warantees or guarantees in healthcare because so much of modern medicine involves working in the dark.
Anyone who signs on for elective surgery is, as Dr. Jack Wennberg says, “making a wager.” The
surgery may be successful–or it may not. Any good doctor will tell you that about half of the time, we just don’t know if or why a treatment works–and when surgery goes sour, often they just don’t know why. I’m not talking about a cover-up; I’m talking about the mysteries of the body.
Even if everyone inolved is very careful, the patient may wind up with a surgical site infection. And that infection may be resistant to antibiotics.
During any surgery, a procedure may involve 135 steps. This is much more complicated than the steps involved in a plane’s take-off.
Basically, an airplane is
a mechanical thing, and all planes of a certain model are alike. A human body is a breathing, changing thing, and each one is different. Also, within the body you have many more “parts” that are interacting with each other–heart, lungs, brain in ways that we do not fully understand.
See Dr. Atul Gawande’s wonderful book: “Complications: A Surgeon’s Notes On an Imperfect Science.”
That said, I agree that we must keep trying to minimize the relatively simple “mechanical” mistakes–givig the medication to the wrong patient, etc.
Electronic medical records would go a long way in that direction. We must change our prioritie sin terms of how we spend health care dollars.
But I don’t think financial penalties are really the answer. Everything we know about motivating human beings shows that postiive reinforcement works better than negative reinforcement.
Read Don Berwick’s book sometime (Escape Fire); he is a splendid writer and very, very good on how to get people in hospitals working together. (I also tend to think that, in many cases, the wrong type of people are running hospitals.)
Martine– Thank you-
And I agree entirely. Every patient in a hospital needs a family member or friend there as a patient advocate, 24/7 if at all possible. And
people can work in teams.
Hospitals are short-handed; the best way to protect the safety of a loved one is to be there. Even doctors have told me that they would never allow a spouse to be alone in the hospital. Even when the doctor(spouse)is there, dozens of near-mistakes happen.
And frankly, even if hospitals were fully staffed–meeting staffing requirments for nurses, we, as a society, cannot afford to pay nurses to be on call to bring a glass of water within ten mintues of the time a patient rings. . .
Gregory– I absolutely agree–we need RNs, who have been trained as managers, managing floors in nursing homes. And we need staffing requirements. From what I know the situation is worse in nursing homes than in hospitals.
Steven, Yes, I suspect this legislation will lead to more cover-ups– rather than people admitting to problems, and trying to figure out how to fix the system.
Anne and Penny– we absolutely need staffing requirements. Hospitals that oppose this illustrate what I mean when I say that the wrong people are running hospitals (businessmen who do not put patients first.)
And working conditions explain why we have such a hard time finding nurses to work in our hospitals.
Penny–
In the days of Florence
Nightingale, there was relatively little that health care providers could do except try to comfort the patient and make him as comfortable as possible as he died–or didn’t . If his/her body was strong enough the patient survived.
Today, there are many, many more things that nurses and doctors can do to help the patient heal and live.. Sometimes they do things that are ineffective. But much of the time they are fully occupied doing things that are effective.
Nurses truly do not have time to regularly fluff pillows or be there to bring the glass of water within 10 or 15 minutes.
And in a busy hospital, there just isn’t room for a lot of 16-year–old candy-stripers running around with glasses of water, and getting in everyone’s way.
Americans are very spoiled and expect a degree of “service” that citizens of other countires would never expect in a hospital. (Citizens of many other countries also are much closer to family and friends, and wouldn’t say, ‘I can’t visit because I have to work.’ They would take a vacation day and call another family member and ask him or her to do the same.)
Note–Obama is running for President of the U.S. and in the last weeks of the election he felt an obligation to visit his dying grandmother. I’m afriad that most American men in a high-pressured job would have said “I’m to busy.”
Finally I am not talking about patients in agonizing pain–They need to be comforted by professional health care providers, but controlling their pain is quite different from bringing a glass of water. They need adequate pain-killers.
As for elderly people in nursing homes. Sometimes they are alone in the world, particularly if they live into their 90s, and that is very sad.
But in my experience, people who have been kind to others throughout their lives tend to have neighbors, former co-workers, friends from church or other groups as well as a child, a niece, a nephew etc. who have very fond memories of them and will come visit them. And even frail or elderly relatives can bring a glass of water, fluff a pillow, bring a favorite food, reach the phone and give it to you, etc.
If there are only a few patients that are truly alone in the world, I suspect that good nurses do go out of their way to give them special attention. But they can’t do this for everyone. And we can’t afford to over-staff so that every patient gets such personal service.
jenga– that’s a very good example. I can well imagine a hospital administrator deciding that if they’re penalize me for cathether infectoins–we just won’t use catheters.
Chris– Yes, trying to reduced risk to zero does lead to unnecessary tests -and treatments. Niko has just done a post about Nortin Handler–author of “The Last Well Person.”
I haven’t read it yet, but Handler is very good on all of the things we do, just because we can.
Sorry–
My response below should have been addressed to everyone who has commented–Martine, Penny, Anne,Gregory,Jenga,Steven,
Chris . . .
The best way to prevent falls is to restrain patients, which has been politically incorrect for three decades.
The best way to avoid taking heat for bedsores is to early transfer the patient to a nursing home so the home can take the heat.
And how to keep mortality numbers down? Early transfer to a nursing home!
Life is not so simple sometimes.
The best way to prevent falls is to restrain patients, which has been politically incorrect for three decades.
The best way to avoid taking heat for bedsores is to early transfer the patient to a nursing home so the home can take the heat.
And how to keep mortality numbers down? Early transfer to a nursing home!
Life is not so simple sometimes.
According to government documents back in 2001, the Bush administration, through Thomas A. Scully, then administrator of CMS, wanted to ease regulatory requirements on nursing homes, reducing the frequency of inspections and lessening or eliminating some penalties (meaning deregulation).
The administration wanted to move away from adversarial enforcement toward a more collaborative one, in which regulators would work with nursing homes to improve care. You can see where that got us in the present market meltdown and economic crisis.
Senator Charles E. Grassley, long-time advocate of nursing home patients, has said it was risky to reduce the frequency of nursing home inspections. Today’s good nursing home can become tommorrow’s poor performing facility, if there is a change in ownship, a new administrator, a new director of nursing or an influx of patients with more severe illnesses.
One of those administration’s goals was to devise new measures of the quality of care by using data reported by nursing homes. Surveyors look at self-reported and unaudited data, data reported by the facilities themselves and unverified by any oversight agency to ensure it is even true. This leads nursing staff to do charting by rote, instead of charting care that they’re actually giving.
Government reports have said that nursing homes with a low ratio of employees to patients were significantly more likely to have quality-of-care problems. This administration did not want to set mandatory staffing ratios for the industry. Without sufficient staffing levels, patients don’t receive even basic humane care, which translates into even more taxpayer dollars down the drain.
If any of you can spare an hour, you should watch this slideshow/lecture given by John E. Wennberg on the Dartmouth Atlas project. He presents how treatment variations are widespread and very costly by don’t seem to be justified by better outcomes!
http://www.dhslides.org/mgr/mgr020907/
NG, Gregory and save the rustbelt-
NG — thanks much for sending us the link to Wennberg. For anyone who doesn’t know about the Dartmouth reserach, this is an easy, painless way to find out about it.
Gregory–
I hope that the next Congress (and administration) moves to re-regulate nursing homes.
I can imagine it was impossible under the Bush administration, but now, it should be doable. Though of course corporate intersets will fight staffing requirements.
Rustbelt–I know you are right. Transferring the patient to a nursing home is a way to avoid a world of trouble. And these penalties will only encourage shipping patients off to cover up “adverse events.”
Working harder won’t reduce medical errors
Maggie Mahar takes the NY Times editorial staff to task on Medicare’s never events. The piece stated that doctors and hospitals need to work “harder” to stop errors.
As if doctors spend all day drinking and cavorting.
Often times, medical errors occur
Staffing is a real problem. I’m probably due for a new pacemaker battery, and, as with the original one, my primary cardiologist doesn’t do them. Now, I was mildly uncomfortable after I had the implant, and I was annoyed that an unneeded IV had gotten snarled with assorted other wiring and tubing, including the nurse call button. At first, that didn’t concern me, because I observed that several of my cardiac monitor leads had fallen off, so asystole alarms should have been going off in the nursing station. After half an hour or so, I decided I couldn’t be resuscitated, so reviewed my options. To get untangled in my position, I’d have to take out the IV, one-handed, over my head.
The phone, however, was in reach. I called the hospital and asked for the nursing station. They wouldn’t put me through. Looking at the code call extension on the wall, I considered calling it, but decided that would be irresponsible. So, I called the cardiology group and told them to get the electrophysiologist to unscramble this mess, or I refused care and was going home. An hour later, I called back and fired him, and my personal cardiologist called and said he was now the attending. I said I wanted to go home right then, because I felt safer. He pleaded with me to stay where someone could watch for a pneumothorax. After pointing out that they hadn’t noticed my cardiac arrest, I told him that we were friends, and I would stay until the morning.
In the morning, my relationship with the nursing staff went over the nuclear threshold, and I disconnected my IV and left.
So, yes, I know that all the alarms in the world won’t help if there isn’t adequate or competent staffing. With that caveat, there are ways that technology can help with falls and bedsores.
Many new hospital beds now have a built-in electronic scale, which has a wide range of benefits. One of them is that a monitoring system can tel when weight leaves the mattress. Some beds also have sensors that alarm on lowering bed rails, unless some knowledgeable patient bypassed them. Who, me?
Anyway, with some relatively nonintrusive measures that also save nursing time on other things, it’s possible to tell when a restricted patient gets out of bed. If nothing else, a nurse can yell something over the intercom and might get the patient to wait for help.
I have worked with nursing workflow systems that have interactive communications with nurses. While I wasn’t able to get it put into the software, I developed a routine that put patients on bedsore alert, and paged the aide, etc., to turn the patient or adjust pads. The weight and rail sensors would tell us that a patient moved, and, in any case, the fully equipped room had a sensor that knew when the paged staff member came into the room — and escalated if it didn’t happen.
There are clinical decision support systems for physicians, but relatively little to make nursing and ancillary staff more efficient. Having individual communications, for example, lets me note a new blood draw or bedside respiratory request, notice a technician is on the same floor, and adjust their schedule so they have the shortest number of steps.
Howard–
Thank you.
As usual, a fact-filled, informative and entertaining first-person report.
Some kind of post surgery medicines can be a risk in this situation ?