Wednesday, November 29, 2006

A Blooper at Children’s

The health department of the City of Boston recently sent a letter to Children’s Hospital Boston, chiding it for failing to report an outbreak of whooping cough last September that eventually sickened 33 hospital employees.

Although state law requires that such events be reported within 24 hours, the Boston health authorities did not learn of it until several weeks later, and then by accident (The Boston Globe, November 28, 2006).

There was no report of any apology on Children’s part. A spokesperson assured reporters that the hospital was taking steps to strengthen its reporting procedures.

The requirement that infectious disease outbreaks be reported to public health authorities has been around for as long as anyone can remember and ought to be routine. It is a sad commentary that a hospital like Children’s is so loosely managed that such a thing could happen.

Tuesday, November 21, 2006

Medication Reconciliation An Example

The posting on medication reconciliation brought the following example from Jim Walworth; friend, former colleague, and retired CEO of Health Alliance Plan, the HMO of Henry Ford Health System in Detroit.

Your note on medication reconciliation brought back the memory of one of my mother's hospital discharges. She was a 92 year old, insulin dependent diabetic with long term congestive heart failure. Her hospitalization was to regain an appropriate fluid balance. On discharge by the consulting cardiologist, she (I) was given several prescriptions to get filled, each of which was for a different drug than she had been on at admission. The floor nurse pointedly said that the "doctor" wanted only these new prescriptions to be given my mother. I told her these were all the equivalent what she'd been on but I would, nevertheless, get them filled as soon as possible. I also told her that because there was no written prescription for insulin I would just keep her on the pre-hospitalization dosage. She rather adamently told me that "If the doctor wanted her on insulin he would have given you a prescription!" Fortunately, I knew enough that such a direction was clearly erroneous. While I knew that I would just keep her on the insulin, I couldn't resist asking for the nurse's name so, as I told her, I would know who to sue when my mother was readmitted through the ER in a coma.

Saturday, November 18, 2006

Medication Reconciliation

Anyone who believes that picking the right doctor is all there is to maximizing the odds of a good outcome needs to learn about medication reconciliation.

We all know about those little plastic boxes that hold the pills to be taken at various times throughout the week. For we seniors, it seems like being on a half dozen or more medications at any one time is now par for the course.

But when we are admitted to the hospital, we aren’t allowed to bring our medications with us (maybe somebody ought to re-evaluate that one of these days). We are given the meds ordered by the doctor, issued by the hospital pharmacy, and administered by the nurse. Then when we leave the hospital, we are given a handful of prescriptions intended to continue the course of care we were on while hospitalized.

So there are two “handoffs” there, one from ambulatory status to hospitalization and another from hospitalization back to ambulatory status (or transfer to another facility). It doesn’t take much imagination to see the opportunities for mistakes – misinformation about the drugs the patient had been on before, failure to match the discharge prescriptions with the inpatient drug regimen, misunderstandings on the part of the home going patient about whether to resume the drugs being taken prior to hospitalization, etc. etc. etc.

Medication reconciliation is the term used to describe a formal program that traces drug usage before, during, and after hospitalization to prevent drug errors occurring during those handoffs. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has adopted medication reconciliation as one of its patient safety goals. Hospitals are struggling to comply and grousing because JCAHO gave them only a year’s notice (Modern Healthcare, November 13, 2006).

An effective program of medication reconciliation requires the design and implementation of a system applicable to clinical care. Hospitals are not very good at that. Management is expected to stay out of clinical matters and leave such things to the doctors and nurses.

Clearly, that has to change. The Modern Healthcare article quoted a Seattle hospital pharmacist as saying “It’s things we should have been doing.”

The syntax may be a little awkward, but you can’t quarrel with the thought.

Monday, November 13, 2006

Cultural Paralysis as a Cause of Death

About a third of the 865,000 heart attacks in the U.S. are caused by blockage of a major artery that supplies oxygen to the heart. According to current guidelines, those patients should have angioplasty within 90 minutes of arriving in the hospital Emergency Room. If treatment is delayed a half hour longer, the risk of death goes up by 42%.

At present, less than one-third of all such patients receive angioplasty within the recommended 90 minutes.

According to the November 13, 2006 issue of The Boston Globe, The American Heart Association is launching a program to improve this situation and “hundreds” of hospitals are expected to participate.

The Globe article also reported a Yale University study which analyzed the time saved by certain steps that have been implemented in various hospitals. The results are as follows:

· Letting the ER order the cath lab to get ready rather than waiting for a cardiologist (8.2 minutes)
· Have a one-call system that summons the angioplasty team rather than have an ER clerk call everyone individually (13.8 minutes)
· Let the ER doc order the cath lab to get ready when paramedics report that an EKG taken in the ambulance indicates a heart attack (15.4 minutes)
· Require members of the angioplasty team to show up within 20 minutes of being paged (19.3 minutes)
· Keep a cardiologist on site 24/7 (14.6 minutes)

These are all things that any hospital could do without waiting for a national association to launch a program.

Since lives are at stake, one wonders why they don’t do it. The only reason I can think of is that it remains culturally unacceptable for the management of the institution to become that involved in clinical matters and the professional staff is insufficiently disciplined.

In other words, you could die from cultural paralysis.

Tuesday, November 07, 2006

Bad News for Single Payer

To the extent that Single Payer means Medicare for all or its equivalent, recent economic reports are bad news for its advocates.

Government involvement in the financing of social services is almost always motivated by the need to relieve somebody’s financial distress.

In the private sector of health services, the parties involved are providers, employers, insurance companies, and patients.

Hospitals complain of underpayment, but according to the October 20, 2006 of Modern Healthcare, their profits have been steadily rising, reaching the national level of 5.3% of revenue in 2005, or nearly $29 billion.

Concerns have been expressed about high health care costs harming the competitiveness of U.S. companies, but stock prices are climbing, with the Dow Jones Industrial Average reaching recent record levels above 12,000.

I don’t have figures at hand for health insurance companies, but I believe they are earning healthy profits, as well.

That leaves patients – particularly the uninsured and those who are being asked by their employers to bear a larger portion of their health insurance premiums. That is undoubtedly of concern to them, but apparently not enough to cause them to express themselves politically about it. The big push for the Massachusetts initiative for covering the uninsured came from the already flush providers and insurance companies, not from patients feeling a financial pinch.

It all goes to support my long-held view that any expansion of government involvement in the financing of health services will be incremental (such as the Medicare prescription drug benefit) and that financing care for the employed population will be a private sector responsibility for as far into the future as can be foreseen.

So instead of spending energy arguing about something that isn’t going to happen; i.e., single payer, we ought to be working on things we can do something about, like improving the performance of our inefficient health care delivery system.

Thursday, November 02, 2006

More On Inefficiency

Responding to a recent posting about having to produce insurance cards multiple times in a hospital whose computers don’t talk to each other, long-time friend Bill Busby forwards the following from Albuquerque:

I don't know how many times the same thing has happened to me.

I'll give you another example: When I go to my PCP's office to pick up a prescription, the issuing clerk writes all of the prescription data on a form for me to sign. The form is printed on NCR (no carbon required) paper. Immediately after I sign the form, the clerk obliterates the entry with a sharpy. When I asked why, she told me that they kept only the carbon so the original was unnecessary.

I received no response when I asked why not get rid of the NCR paper and print the form on ordinary paper which costs less than half what NCR costs. While I recognize that the savings derived from making this simple change will not pay the CEO's salary, it will, none-the-less reduce costs (and clerical time).

And this situation leads me to believe that there must be hundreds of other "small" savings a good business systems analyst could make which would have no effect whatsoever on the quality of the medical care provided by this partnership which includes a hundred or more MDs.

Wednesday, November 01, 2006

The Good and the Bad

The below input from Cindy Muggli, Social Worker from Minnesota, suggests that perhaps I dwell too much on what needs fixing in health care and that I should at least occasionally focus on what is good about it.

Wow it’s depressing to hear about all the things that are wrong with healthcare. With so many studies you'd think someone would use that information to fix the problems. Could it be that part of the problem is the studies? I believe it’s nearly impossible to understand the issues unless you actually experience them, and the best way to experience them is to do the jobs. If you want to understand the issues faced by nurses, follow them around for a while; watch what they do, listen to what they talk about. Translate that to any individual job found in the healthcare system. You might even notice some GOOD things about healthcare. Oh and while you're at it, can you figure out why it’s still the norm for interns to work round the clock? That’s got to be resulting in some of the mistakes made in hospitals.

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