PookieMD's Blog: Where Physicians Learn About the Business of Medicine

From the ACQR website (Agency for Health Care Quality and Research, a government agency, under the auspices of HHS) is a list of 30 practices to promote better health care.

How does your hospital measure up? Here’s a partial list of outstanding items that hospitals/providers must:

• Institute adequate level of nursing (!)
• Management of ICU patients should be by critical care docs.  (Much disagreement in the literature about this one!)
• Have active participation by pharmacists in medication dispensing, use and monitoring
• Use standard abbreviations (I think we all had this beaten in to us!)
• Clearly document Patent’s “COR” status.
• Implement processes to prevent pressure ulcers.
• Implement DVT prophylaxis protocols — surgeons are you listening?!!!
• Monitor patients with renal insufficiency
• Do surgery on the right patient, and do the right surgery, and do the surgery right!
• Clean your hands.

Okay this is a summary.  But, truly, how well are we doing?  My hospital could use a little improvement on a couple–the COR status and the DVT prophylaxis, not to mention appropriate staffing by nurses.

It was a busy night at my local hospital.  I spent a lot of time in the ED, and the pager was in status.  The hospital I was at is a large tertiary hospital, and receives transfers from small mountain clinics that send us stuff like chest pain (easy) and hypertensive urgency/renal failure/barfing patients (hard.)  We get patched in to the Tiny Mountain Clinic Doctor, who gives us the skinny, and then we banter a bit about treatments etc, and then the helpful “connect” ombudsman arranges transport.

All good, so far. Except when the mountain doc wants to talk to me right as I am transferring a crashing patient to the ICU.  The helpful connect ombudsman calls me, and tells me that the Tiny Mountain Clinic Doctor needs to talk to me.  “I’m really busy,” I say, “I’m moving a patient to the ICU.  Can I call you back in 10 minutes?”  The helpful ombudsman agrees.  (BTW, our conversation is recorded, and we have all been warned to be polite as the powers that be will slap our hands if we are not.)

I’m busily assessing my patient, trying to get the transfer orders done, when the pager goes off again, not 5 minutes later.  It’s the helpful connect ombudsman.  “Tiny Mountain Clinic Doctor needs to talk to you,” she says.  Needless to say, Tiny Mountain Clinic Doctor takes first priority, even though I already said I would call back after the fire I’m putting out is taken care of.  (After all, we are being tape recorded!)

Oh how impatient we are.  But sadly, oh how impatient I am as well!  Could I just have a minute to think?

I’m done with H1N1, but I fear it is not done with me.  Last week, rounding at my hospital, I felt like I had been transported back to the days of the plague.  Everyone wore masks, and outside each room were signs with warnings like “Droplet precautions!”  Carts stood beside each room, filled with masks, gowns, blue gloves, hand sanitizer and plastic stethoscopes.  The entry ways of the hospital are manned by “greeters” (ala Walmart!) who don’t allow anyone in under the age of 18, and ask potential visitors about flu like symptoms.  Those visitors deemed too young, or with flu symptoms, are sent away and not allowed in the door.

The Emergency Department is over run with those who are sick, or not so sick, with flu.  We go to meetings nearly daily on flu updates, and our hospital has a “control center” to deal with flu.  I received the H1N1 vaccine via nasal mist, but many of those required to get the shot because of age or having small children have not yet received their vaccine as my hospital has run out of shots.

We are also facing shortages of masks, gloves, gowns and antiseptic wipes.  According to the infection control nurse specialist, we are doing too good of a job wiping off surfaces with the wipes–the supply is going too fast.  Masks and gloves are part of a “strategic reserve” stock piled and allotted by the government.  So is tamiflu, which is more tightly controlled than narcotics at this point.  We are short on gowns, because the gowns were automatically loaded on the isolation carts, and so we all started putting them on when we saw them on the carts.   “Can’t you read the signs?” Asked one my ID colleagues.   Yes, we responded, but which do you believe–the sign that says wear a mask and gloves or the cart fully loaded with gowns?

They removed the gowns.  They can’t seem to decide what type of masks we should have: sometimes it is the N95, with special respirators, and now lately, just simple surgical masks.

The ones that seem to get the sickest are the young people–those 20 or 30 somethings.  They get sick quick, and end of “tubed and paralyzed” with in hours as one of my more grim colleagues puts it.  We wonder when we will run out of ventilators.  The good news appears to be that these youngsters get better after spending some quality time on the vent–about 1 or 2 weeks.  One of my non-medical friends was shocked–”That’s horrible!”  I, on the other hand, was delighted that they lived.

Be careful out there.  Wear your mask, use the hand sanitizer, and pray for spring.  And boy, do I wish I had bought stock in Purell!

photo of H1N1

I am a fan of the blog Running a Hospital, by Paul Levy, the CEO of the Beth Israel Deaconess Medical Center in Boston.  It is a teaching hospital, and the CEO is on a mission to make constant  improvements in multiple areas.  Sometimes I get frustrated with Mr. Levy’s comments because he occasionally gets too far afield for a community hospitalist like myself.  But none the less, he recent blog on improving the ICU experience for families was a gem.

Here’s what they did to improve the ICU experience for families:

Communication: 

• residents learned to run family meetings by having simulated conference.s
• nurses performed hand offs to floor nurses with the both nurses in the room with the patient.
• families were invited to participate in multidisciplinary rounds.  (The hospitals I work at already do this.)
• the hospital provides a brochure on what to expect while a patient is in the ICU, including tips like where to park.  I would like to see how many families actually read this, and query effectiveness.  (See previous blog on how much paperwork patients receive while in the hospital.)
• families are given pagers so they can be reached easily and “untethered” from the patient’s bedside.
• the hospital eliminated ICU visiting hours, allowing open access.  (I thought there were studies that showed this had adverse outcomes–anyone know?)

Spiritual care: the chaplain makes proactive rounds.  At one of my hospitals, the chaplain participates in multi disciplinary rounds.

Improving facilities: the hospital “revitalized” the waiting room, provided family sleep rooms, and placed computers in the waiting rooms so families could have Internet access for emails and social networking.  The hospital also provided a platform so families could blog about their experience.

The post provides great fodder for thought. Some of the changes are costly such as the family sleep rooms, but I love the family pagers.  I’ m marginal on the blogging platforms as I’m not sure what real value this adds.  Overall, I think I’m just jealous that there is such an innovative hospital!  Bravo, Mr. Levy!

I love science, and miss doing research.  I try to run mini “experiments” and thought you might enjoy the latest.  I decided that after each admission interview, after I did the obligate H&P questions, the exam, the outlining of the treatment plan, the answering of patient/family questions, I would ask one last question to the patient.

Here was my question:

What one thing can I do for you right now that would make you feel better?

I also vowed that I would do what it was the patient requested if it was reasonable and within my power.  I figured I would get a bunch of baloney requests, like, “Can I get some of that dilaudid for home use?” and “Cure my cancer,” and “Send me home.”

Surprise, cynics!

Here were the responses:

• Can I get something to eat?  (Yes, we got him a sack lunch in the ED.)
• Can I get something to drink? (Yes, I got him a cup of ice water.)
• Can I go to the bathroom? (Yes, I got the nurse to unhook him and take him to the bathroom.)
• Nothing, I feel much better already. (Wow, those ED docs are good!)

All of the responses were along these lines–requests to help out with simple needs.  There was no sarcasm from the patients, and no absurd requests.  I was able to comply with all of them, except for the patient who had to be kept NPO because he was waiting for a procedure.  I told a couple of people about the experiment, and one nurse had a very insightful comment:

“Isn’t it sad how far we get away from meeting our patients’ basic needs?”

Yes, it is sad, and I will continue my little experiment.  Sometimes, I have to ask the nurse for help, as providing physician level care is a priority, but on the other hand, didn’t I take an oath to help people? Apparently, it’s the little things that bring the most relief.

In the last two weeks I have spent time at two completely different hospital system, and by default, spent a lot of time in their EDs.  One ED is efficient, the other over orders and under delivers, and easily becomes overwhelmed.  So what is the difference?

First, the two EDs serve two very different populations.  One is the go to hospital for a large HMO in the area.  The other is a large, urban trauma center, serving a significant population of the homeless as well as weekend warriors that are getting fancy hip replacements.  Guess which one is more efficient and effective?

If you guessed the HMO hospital, you guessed wrong.  The large sprawling hospital with “we take ‘em all” attitude is more efficient at healing and dealing with patients.  They don’t have a fancy EMR, they don’t have smarter docs, or better nurses, or fancier equipment.  (It’s actually kind of an arm pit of an ED.)  What they have is a culture where patients are fully worked up and all avenues are explored before a patient is admitted.  Let’s call this ED “A” (for armpit!) and the second ED at the fancy HMO ED “F” (for fancy.)

Differences:

ED A values disposition, looking at hospital admission as a last option.  This is based on the fact that with such a significant homeless population, hospital A would go out of business if ED A admitted everything. 

ED F, on the other hand, values through put.  ED F will get paid on every patient they see, and the hospital will get paid by the HMO for every patient that is admitted.  There is no incentive to not admit patients.  Rather, there is incentive to clear the decks of the ED and move patients through to the hospital.

ED A must complete work ups so they can dispo patients effectively.  ED F frequently will call and say, “Mr. Oldtimer can’t walk, and I don’t know why, so he needs to come in.”  Work ups stop as soon as patient is admitted because, for ED F, it is easier just to admit patients than work them up and attempt a disposition.

Hospital A has a powerful hospitalist group that has a lot of clout.  The hospitalist group and hospital don’t want to admit patients for social reasons.  Again, finances play a large part in this culture of disposition.  Hospital F has a hospitalist group that has no clout, and is viewed as a baby sitting service by the ED.  ED A will hear about it from the hospitalist group if work ups are incomplete.  ED F will hear nothing.

So, if you are looking for an efficient, effective ED group, don’t look at the fancy ED with the fancy EMR and state of the art equipment.  Look at the ED group who understands that a hospital is not a hotel, and that it is for sick people only.  This is how to save health care dollars!

Okay, I admit, the whole JCAHO thing just makes me laugh.  What I find laughable is the fact that hospitals and clinics rush around to become JCAHO ready, pass the inspection, and then revert to all the old habits and ways of doing things.  However, in interest of being fair minded, I poked around their website, and tried to mine a few pearls that would be helpful.  The pickings were slim.  But for those who need a laugh, I culled some goodies.

JCAHO has the following directives on things you never even thought of:

Hand cleaner dispensers: yes, there is a regulation on alcohol based hand rub dispensers, known in JCAHO-speak as ABHRs.  According to the busy folks at JCAHO, you may place an ABHR  in corridors 6 feet or wider, and dispensers must be at least 4 feet apart.  And don’t mount them over outlets.  No word on keeping them filled, however.

Thermometers in refrigerators vs. a frozen penny:  no, you can’t freeze a penny and see if it melts and use this as a standard to see if your ‘fridge is cool enough.  If your practice is dumb enough to do this, you deserve the JCAHO thump on the head!

Staff only refrigerators: these don’t require monitoring, so go ahead and set up that petri dish we call the staff refrigerator!

Computers on wheels: (COWS we called ‘em, but now known by a more politically correct term WOW–work on wheels.)  Any way, yes you can use computer on wheels, but don’t clog up the hall ways.

“Reducing waste and improving efficiency.”  There is an entire section on this and an “initiative.”  In this section of the website, JCAHO states, “Ironically, in the face of the growing hue and cry for improved efficiency, confusion reigns over the definition of this term and how improved efficiency might actually be realized.”  The true irony is that efficient health care is not necessarily effective health care, and this is the crux of the matter.  JCAHObians need to realize that health care efficiency with out effectiveness is meaningless.  At this point, I ask, is this an oxymoron–improving efficiency and JCAHO?

I’m off to check and make sure the hand cleaner dispensers are at least four feet apart.  I’ll keep you posted!

I was going through all the paper work from my husbands recent stay in the hospital and decided to tally up how many hand outs/papers/brochures he had been given.  (And, I must note, he read none of it.)   Here is a list of all the papers  the hospital was either required to give him, or thought would be helpful:

1. “Your right to make health care decisions.” Brochure, 7 pages.
2. “Remember your hero book mark.”  Patients were supposed to write the name of a caregiver they really liked on it to remember the caregiver in the future.  Surprisingly, my name was NOT filled in by dear Hubby.
3. “Notice of Privacy Practices”–HIPPA junk, 8 pages long.
4. “Need Help Paying for Your Health Care”–4 pages.
5. “Welcome to our hospital” –from the CEO. One page, single spaced.  Now I know who he is–and I’ve worked there 8 years!
6. “Our mission”–from the CEO.  One page single spaced.  (Do I care?)
7. “Stop smoking” –2 pages.  (My husband doesn’t smoke.)
8. “Make your health care safe”–2 pages.
9. “What if I have concerns about my care”–1 page.
10. “Is it a side effect or Allergy?”–1 page.
11. Hospital admission agreement, small type single space one each for pre-op and surgery, total two pages.
12. “Important Health Care Decisions” one page, signed by God knows who.
13. One folder with a pretty picture of a helicopter on it to hold the 31 pages of “important material.”

I didn’t include all the paper work for discharge.  Sheesh, who reads all this?  And can’t we do better?  How much of this is government mandated, “best practice” mandated and out right unnecessary?  This is not the way to  make health care more transparent, this is the way to make health care more confusing.

Today I received an email warning me that JCAHO was expected to visit one of the hospitals where I work.   The headline on the email was “JCAHO Site Visit Imminent.”  Shivers immediately ran down my spine.  I hate the fact that hospitals turn themselves inside and out for JCAHO, and that hospital administration basically has a JCAHO cam to keep track of where JCAHO may appear next.  God forbid that there could be a violation and the hospital get dinged.

I think we should all be mindful of patient safety, “effective communication between caregivers”, safe use of medications, and clean hands.  (The email states it pertly:  “gel in, gel out, every patient, every time.” )  If we as care givers aren’t cleaning our hands we DESERVE to be sanctioned!  Since when do we only care about clean hands, patient safety, signed orders and effective communication ONLY when JCAHO is about to come?  The email even reminds us that there is a special hand book we can carry around with us in case the JCAHO examiners pin us to the wall and interrogate us.

So why do I care?  Because I care about patients.  There needs to be SYSTEMS in place to insure patient safety and excellent care.   Sending an email is not a system, it’s a quick fix with out substance.  I am cynical because such emails pay lip service to these important standards, and do nothing to create long term change.  It is the Hawthorne effect: change will occur briefly, but then revert to the norm once the attention is removed.  So Mr. Hospital Administrator, here are five  steps you need to take LONGTERM:

1. Insure there are FILLED hand gel dispensers EVERYWHERE.  How many times have I tried to use an empty gel can?  It needs to be part of house keeping’s job to check these dispensers two times per day!
2. How many times have I asked for a sitter for a patient to avoid falls, poseys and over medication, only to be told it costs too much?  If you are serious about reducing these never ever events, provide the resources, not just an email reminding me to keep patients safe.
3. Have pharmacists review every medical reconciliation.  One of the hospitals I work at has no system what so ever to fill the medical reconciliation out.  The physicians usually end up doing it, close to discharge sometimes! Identify WHO is to fill out this valuable paperwork, and put in a system to make sure it is completed AT admission or the next day.
4. Hold surgeons to the same standards as the rest of us.  Yes, the surgeons bring in the money, but how many times is there a pre-op h and p on the chart?  One hospital I work at has a hospitalist assigned to each elective joint surgery.  The hospitalists make sure there is an h and p, and follow the patient through out.  The idea is that the hospitalist will make sure there are less medication errors, and prevent problems before they occur.  I think it is a great system, and hopefully my perception is reality.
5. Institute check lists on patient handoff at every level.  Yes, radical that I am, I think physicians should have to follow a standard hand off system too.

Well, I’m sure that hospital administrators every where are racing to implement systems just as I described.  (What are you smoking?!)  In the mean time, I suppose I should tuck a copy of the “Survey Readiness Guide” into my white grey coat with the dirty sleeves.

It was a tough week in Pookieville.  I worked all week at one of my favorite hospitals.  I like working there because the specialists I work with are hypercompetent and always willing to help.  Furthermore, they like to chat. Well, they like to chat about interesting cases.

I was particularly challenged this week because I had to think out of the box.  I will not share the details of the case, as I don’t intend this blog to be about medical cases per se.

When I picked up  my service, I  assumed care of a very complicated patient, with a disease process that was appropriately handled.   Unfortunately, there was an outcome that was unexpected and completely unpredictable .  It was also quite serious.  What I want to share is how hard it was to think out of the box, which was what was required.  Medical statistics and medical science can not predict all outcomes, which is when the “art” of medicine comes in to play.

I walked in to the room to discuss the latest bump in the road, and the various treatment options to remedy the latest bump.  Now, before I went in the room to talk to the patient, I had done my home work.  I had reviewed the latest bump in the road with the surgeons, specialists,  the sub-specialists and several of my co-hospitalists.  There was no clear consensus as to what should be done about this problem, just a general agreement that this problem was indeed, a big problem.  Most of my colleagues were glad they were not me, because it felt as if all options were fraught with danger to the patient.  “Glad I’m not the one that has to write those orders,” was the general feeling.

Great.

I explained to the family what the issues were, and that we were now in rock and hard place territory.  I explained that there were no randomized, double blinded placebo controlled studies for where we were at.  I explained the options, risks, benefits and side effects of each option.  I explained that  I had done my home work.

“Do you just fling sh– at the wall and see what sticks?”  One incredulous family member asked.

It must appear that way, when we can’t quote studies, and cite statistics and supply comfort from numbers.  We must appear like idiots when we have to use our experience, and our colleagues’ experience to make a decision when there is no clear cut decision, and when the road is paved with ill feelings and anger at an outcome only God could have predicted. 

But none the less, a choice on treatment had to be made. 

Here is how I made my decision on how to treat the problem:

1. Identified the problem.
2. Said “@#%*!”
3. Asked everyone involved in the case their opinion, including the PharmD, and the head of the department of medicine.
4. Came up with three options, and picked the one I felt was the safest with the best outcome.
5. Reviewed options with the patient and family.
6. Realized that there may be MORE options, once I talked to the family.  (Interestingly, the family was the most creative in looking at solutions.)
7. Walked out of the room, made more phone calls, and finally came upon the solution that we ended up going with.
8. Called a renowned specialist at the local University and got the specialist’s opinion, who was in concurrence with the ultimate solution I had crafted.
9. Went back in the room (a bit demoralized, as I had said there were no other options, but now had come up with one.)
10. Heard the family’s  intense relief at the more moderate, middle of the road option that we ultimately agreed to implement.
11. Went for it.

So why I am writing about this?  Because it took me TWO hours to do all of this.   It took two hours for me to think and explore every option, and to finally come up with an option that seemed workable, and the least dangerous.  I took the time because I wanted to do what was best.   It was the family that was most able to think outside of the medical box, and who encouraged me to explore further.

Now, was this the right choice?  Only time will tell, and yes, sometimes as physicians we just have to throw sh– against the wall, and then throw some more, and then consult our colleagues, and then think again to find the answer when there is no right answer.

I just hope that in the future, I have enough time to think out side of the medical box.

How do you think out side of the box?