Archive for December, 2009
Thursday, December 31st, 2009
Fudging numbers to please the pencil pushers. The NHS in Great Britain has a goal that no one waits to be treated in “casualty departments” (better than calling them “emergency rooms“, I guess) for more than 4 hours. According to the records, a “vast majority” of patients are seen within 3 hours.
Data collected from other sources shows that patients are often moved out of the departments and into other units prior to evaluation which stops the “four hour clock” from ticking. For example, some patients are put in “emergency assessment units” where the average wait is 17 hours and some patients are put in “medical assessment units” where the average wait is 22 hours.
A representative quote from the article: “Labour’s insistence on forcing doctors to focus on ticking boxes ahead of looking after patients means that more time is spent on devising elaborate schemes to satisfy the bureaucrats rather than making sure unwell patients get better.”
Quick care, quality care, free care. Pick any two.
In other news, as a result of this story, JCAHO is now requiring that hospitals close their emergency departments as a patient safety measure.
Paging Dr. Cheech. Paging Dr. Chong. Emergency physician testifies in Pennsylvania about the medicinal use of marijuana. From an emergency physician’s perspective??? Yeah, I see patients in emergent need of a bong hit just about every shift I do [eye roll].
Woman sues hospitals after waiting too long for care. Roshunda Abney went to a Las Vegas acute care clinic complaining of abdominal pain. She was transferred to a hospital for “higher care.” She waited in the hospital waiting room for six hours before leaving and going to another hospital. There she was “treated rudely” and told that she could face a similar wait in the second emergency department. She left that emergency department and went home where, 20 minutes later, she delivered a 1 pound 6 ounce 26 week old baby girl who later died. Six employees at the first hospital have been suspended pending termination proceedings. Miss Abney is suing the hospital for the death of her daughter, Angel.
Paging Dr. Scumbag. Delaware pediatrician rapes and sexually exploits multiple young children – one as young as 3 months old – and videotapes himself doing so.
In other news, the Delaware town’s department stores suddenly sold out of meat cleavers after this article was published.
Threatening to kill a doctor and his family, the EMTs that bring you to the emergency department, and the police that come to subdue you isn’t the way to get faster care. It is a way to get yourself tazed and thrown in the Greybar Motel, though.
P.S. Grabbing for the police officer’s gun is a dumb idea, too.
Mike Tyson cousin causing trouble in Connecticut emergency department? Probably not, but biting an EMT’s ear during a brawl in the department isn’t going to get you seen any quicker, either.
JCAHO mandates strike again. JCAHO requires that negative strep throat screens be confirmed with a strep culture. The increase in cost is approximately $200 per case. The clinical effects of strep cultures? Aside from added costs, more time reviewing paperwork and more time making patient callbacks … nothing. The disease is self limited. Strep goes away on its own. Yet hospitals that don’t perform strep cultures are being cited with a JCAHO “deficiency.” Rick Bukata addresses some of the issues regarding treatment of strep throat and “follow up cultures.”
See also this previous post about antibiotics for strep throat and this Annals of Internal Medicine article on Appropriate Antibiotic Use for Acute Pharyngitis in Adults.
Sometimes headaches are contagious. Especially when they’re caused by carbon monoxide poisoning.
Primary care physician shortage is coming to Michigan … and probably to the rest of the country. The lack of primary care physicians is what torpedoed the “insurance for all” directive in Massachusetts. Now we’re on the verge of replicating the Massachusetts experiment nationwide, and apparently expecting different results. Didn’t someone once define that behavior as “insanity“?
Guess it’s time to sue the bacteria, then. A study published in the American Journal of Therapeutics showed that the increasing numbers of MRSA infections are in part due to physician’s fears about the potential for being sued if they do not prescribe antibiotics. Researchers noted that “some medical decisions may be made not on the basis of the best medical advice, but instead to avoid legal tangles.”
Oh, and the researchers also found a correlation between the number of MRSA infections and the density of attorneys in a given area. Hmmm. Virulent destructive parasites that maim and kill their hosts. You draw your own inferences from that statistic.
P.S. In case you were wondering, I was talking about the bacteria.
Posted in Healthcare Update | 9 Comments »
Wednesday, December 30th, 2009
 With health care reform being heavily debated about the country, trial lawyers are trying to preserve one of their cash cows.
Medical malpractice plaintiff attorneys continue to press their argument that lawsuits are essential to the nation’s health care. In fact, the trial lawyers created a web site called 98000reasons.org and are putting ads for the web site all over the Washington subway system to show our legislators some link between tort liability and the alleged 98,000 patients who die each year from medical mistakes. The logic on the front page of the AAJ web site states
“If less people need to seek legal recourse, that means patients are getting safer. Patients that are safer also means lower costs to the health care system. Everyone can support this.”
It will probably take a lawyer to explain that logic to me, but I digress.
The “98,000″ number is taken from a study called “To Err is Human” done by the Institute of Medicine more than 10 years ago.
There are multiple criticisms of the IOM study. The method in which “deaths due to error” were determined was suspect. The patient population was composed of skewed samples. See here, here, and here to learn more about the criticisms of the study.
Regardless of the reliability of the statistics, those with an agenda cite the statistics as hard facts.
“The equivalent of two full jumbo jets are blowing up every day of the year due to medical malpractice and the only thing that can save us is more lawsuits!”
It’s obvious that patients die from medical errors. Whether that number is 98 per year or 98,000 per year, medical providers can always take steps to improve upon the care that they provide. Focusing on the imperfect nature of the humans who provide medical care is not the point of this post. Humans will always make mistakes – even lawyers.
The trial lawyers want us to believe that they are there to help our nation minimize mistakes. The American Association for Justice is pushing the concept that any attempts to reform the nation’s medical malpractice tort system would have disastrous effects upon the safety of our health care.
A quote on the AAJ site states “The simple truth is that any reduction in the risk of civil liability would remove a critical safety incentive.”
Phrase it however you want to …
The threat of liability improves safety.
Making doctors fearful of losing millions of dollars makes doctors practice better medicine.
We can sue our way to better health care.
Lawyers want doctors running scared.
The trial lawyers got their wish. Doctors are afraid of being sued for millions of dollars and getting dragged through a multi-year lawsuit. So a vast majority of doctors have responded by practicing “defensive medicine.”
Health care providers spend hundreds of billions of health care dollars per year on low yield testing that is fueled by the fear of malpractice lawsuits — a fear that lawyers assert is beneficial to create.
Then lawmakers started questioning whether our health care system could put the vast amounts of money spent on defensive medicine to better use.
Suddenly the trial lawyers started singing a different tune.
Trial lawyers created a “report” titled “The Truth About ‘Defensive Medicine‘”
The report contained multiple assertions, including …
“Direct costs associated with medical malpractice are a tiny fraction of health care costs.” Technically the AAJ statement is correct, but it is misleading. Direct costs of medical malpractice litigation and payouts may be a small fraction of the health care pie, but defensive medicine is an indirect cost that, by some estimates, adds hundreds of billions of dollars to health care costs each year. That’s not so small.
“There are little or no savings to be gained from reforms aimed at eliminating such tests.” In other words, tort reform won’t save the system any money. Would you like grape Kool Aid or fruit punch?
“Extra testing provides benefits to patients.” Hey – it’s good for patients when doctors perform expensive low yield testing to protect themselves from lawsuits. Nothing bad happens from all the radiation. There are no complications or extra costs incurred from false-positive testing. Pay no attention to that man behind the curtain.
If you don’t believe any of the above, then the AAJ report tries to convince everyone that defensive medicine is a figment of the imagination of all the doctors who say that they perform testing to protect themselves from lawsuits. Headings in the “Defensive Medicine” report include “Academics question the existence of defensive medicine” and “President Obama’s Budget Director Doubts the Existence of Defensive Medicine.”
The report states that
One government agency found that doctors chose not to order any tests or diagnostic procedures 95 percent of the time. Doctors who ordered tests almost always did so because of medical indications, and only one half of one percent of all cases involved doctors who ordered tests due solely to malpractice concerns.
If “defensive medicine” occurs in only 0.5% of all medical cases, then obviously the “risk of civil liability” isn’t having its intended effect. All of us doctors are hardly doing anything to protect ourselves from civil liability. We’re not scared enough.
On one hand, the AAJ asserts that we should increase/maintain the threat of liability to maintain the safety of our health system. On the other hand, the AAJ asserts that the doctors are not responding to the threat – which is apparently why 98,000 people per year are allegedly dying from medical mistakes.
If the threat of civil liability makes doctors practice better medicine, the threat of criminal liability would be lead to even better health care. Doctors who allow patients to become ill or die should be considered felons. With doctors so afraid of being thrown in jail, the medical profession would find a way to make patients live forever. The practice of medicine would be perfect.
Problem solved.
Funny, though. If the AAJ assertion that “any reduction in the risk of civil liability would remove a critical safety incentive” is true, I don’t see the lawyers plastering the subways with advertisements advocating legal malpractice suits as a way to improve the practice of law in this country. Or advocating that we implement judicial malpractice to improve the practice of court proceedings in this country.
I know. The Democrats are just waiting to pass health care reform before putting legal and judicial malpractice on next year’s agenda.
Posted in Medical-Legal | 40 Comments »
Wednesday, December 30th, 2009
Our hospital created new order sets to be compliant with all of the new JCAHO patient safety mandates.
One of the JCAHO requirements is that pain medications must be administered according to a patient’s rated pain scale. If a patient complains of pain of “3″ they get one medication whereas if they complain of pain of “7″ they may need another medication.
So the order for pain medications on the order set reads “Administer [chosen pain medication] [chosen dosage] intramuscularly/intravenously every ___ hours for pain rated as _______.”
While writing admission orders for a patient, I just decided to write “administer morphine 5mg intravenously every 4 hours for pain rated as 2.17 or greater.”
The patient went upstairs to the floor. I forgot about her amongst the multiple other admits throughout the evening.
The following morning as my shift was ending, I get a visit from the president of the medical staff.
“You know that patient you sent upstairs last night … Mrs. Smith?”
Those are words that usually mean something bad happened.
“Yeah …” I said hesitantly.
“Well there was a big problem with her orders.”
“Like …?”
“What’s with the pain rating of ’2.17′? The secretary didn’t know how to enter it into the system. She called the nurse. The nurse didn’t know how to interpret it. She called the nursing supervisor. The supervisor had never seen someone enter a pain scale like that, so she called me – the attending – at 4 AM to clarify your order.”
“You’re kidding me.”
“No. But I kind of laughed, though. I’m actually surprised that no one has done that before. I just wanted you to know that you had the whole medical floor up in arms with that order.”
“Great. Sorry about that.”
Next time I’m going to write for medications when a patient rates their pain as “π” or above.
Then again, the symbol for “pi” looks too much like a Roman numeral “II” which could cause people to get pain medication when they rate their pain as a 2 instead of when they rate their pain as a 3.1415 or higher. That could result in patients getting pain medication for a rating 1.1415 points sooner than they actually need that pain medication and could compromise patient safety.
I will therefore write out the word “pi” when making this entry.
Then again, a sloppily written “pi” could look like the number “61″ which could make it so that some patient has to complain of pain of 61 or greater in order to receive pain medication. That could leave patients in pain and could compromise patient safety.
Or the “pi” could look like a “pl” which might be mistaken for a shorthand form of “please” so that a patient could be given pain medications for any pain rating in which they say “please.” That could result in overmedication and could compromise patient safety.
I think I see another patient safety mandate on the horizon.
Dang.
Posted in Joint Commission | 9 Comments »
Wednesday, December 23rd, 2009
This guy must have been really naughty this year. An assailant brutally beat a man who was stacking wood near his home, leaving him with gashes and bruises over most of his body. Emergency department staff were amazed that the patient was not in worse shape. Police are on the lookout for one of Santa’s reindeer.
Beating a 5-week-old infant to the point that she has to go to the emergency department won’t garner you much sympathy in the comments section of a newspaper post.
Could this be why Michael Jackson liked using propofol as a sleep aid? Studies have shown that up to 50% of patients sedated using propofol have a sexually-orientated dream. Apparently some patients actually believe that they have engaged intercourse when they awaken and some have even complained to state medical boards about the sexually inappropriate actions of physicians treating them. Wow.
Former news anchorman Tom Brokaw involved in motor vehicle accident that kills another motorist.
Is David Hasselhoff becoming a frequent flyer? His daughter called 911 after he had a seizure. According to the article, Hasselhoff has been hospitalized for alcohol poisoning “more than five times in the past few years.”
Miami Thrice. South Florida tops the list of ATRA’s judicial hellholes yet again.
Will looming pharmacy reimbursement cuts affect Medicaid recipients’ access to medications? The Deficit Reduction Act mandates $8.4 billion cut in Medicaid spending – most coming from decreases in reimbursement to pharmacies for prescription drugs. A Government Accountability Office study showed that if those cuts were implemented, pharmacies would lose an average of 36% on every prescription they filled. Expert testimony in a lawsuit seeking to prevent the cuts showed that 10,000 to 12,000 pharmacies, most in underserved areas, would close because of the cuts. Many other pharmacies would likely stop participating in the Medicaid system. Access to prescription medications for Medicaid recipients would be significantly decreased.
But at least those patients have insurance, right?
Michael Woods’ Rhode Island children may be “financially secure” for the rest of their lives, but now Rhode Island’s governor Don Carcieri is proposing to cut almost $4 million in payments to hospitals that treat the poor. If the proposal becomes law, hospitals will likely have to lay off staff, which will naturally decrease the services available to everyone. The government that has the power to provide everything to you has the power to take everything away from you.
House votes to postpone 21% physician payments cuts until March 2010. Hey. Good work! Substandard payments for two more months before a lot of doctors leave Medicare. Woo hoo!
Obama extends COBRA subsidy another two months. Now anyone laid off before February 28 will be eligible to receive the subsidy – which pays two thirds of COBRA premiums for 15 months.
Given the above, is anyone beginning to wonder why the government is waiting until March to implement these decisions that would diminish access to medical care? Is there some decision everyone is going to have to vote on in February?
Another example of someone with “insurance” unable to obtain medical care. A patient has a hemangioma in his brain, but no doctor will perform surgery on him because the reimbursements that his Medicaid insurance pays are so low. “Doctors tell him that his condition is operable — but that they can’t accept him without conventional insurance.” Even with insurance, his family is being crushed by medical bills.
Hospitals that spend the most on end-of-life care may be penalized under the new health bill. Medicare pays UCLA an average of $50,000 during a patient’s last six months of life, while Medicare pays Mayo Clinic only half that much. The health care bill would create a study on how to reward hospitals for providing “cost effective” care (read that as “low cost care”) and possibly penalize “high-cost” centers through lower payments.
Should rural specialty hospitals with less than one patient per day coming to their emergency departments be required to have emergency physicians on site 24 hours per day? Rural hospitals say that it is a waste of resources. Would such a practice amount to a slippery slope?
Posted in Healthcare Update | 12 Comments »
Tuesday, December 22nd, 2009
Should medical personnel be forced to help people in need of medical care?
Two EMTs were asked to help someone who had collapsed at a donut shop. They told shop owners to call 911 and then left.
Mayor Michael Bloomberg blasted the EMTs, stating that “there’s no excuse whatsoever” for their actions. Now the EMTs have been suspended from their jobs without pay.
Set aside the moral arguments that everyone “should” help their fellow man. Should we be required to do so?
If the EMTs were on duty, there are certain procedures they must follow. We don’t know if they were called out to another emergency.
But if the EMTs were off duty, isn’t saying that they are required to perform services without compensation kind of like forcing off duty taxis to provide free rides in an emergency, or like forcing off duty attorneys to provide free legal services in an emergency – at any time, or like forcing billionaire mayors to give money to people in financial emergencies?
Should we suspend people from their jobs for failing to do what is morally correct?
Posted in Medical-Legal, Random Thoughts | 69 Comments »
Tuesday, December 22nd, 2009
Just so no one gets mad at me, don’t read this if you have recently or plan to eat spaghetti or other similar dishes … on second thought, don’t read this if you are eating, have recently eaten, or plan to eat in the near future.
I used to work in a garage. All the mechanics used to complain that no one ever seemed to call them to ask them over for dinner. People only seemed to call the mechanics when they had a problem with their cars.
Same thing tends to happen a lot with Mrs. WhiteCoat and me. Just got a call from someone we haven’t seen in over a year wanting me to call in a prescription for antibiotics … to a friend we’ve never met … who has a cough.
Um … no.
Last week Mrs. WhiteCoat got a call from Melissa – one of our close friends – who didn’t want to engage in small talk. The concern in her voice was evident.
“We have a situation here.”
“OK …”
“Junior just pooped in his diaper … AND THERE’S A WORM SQUIRMING AROUND IN THERE!”
“You mean a live worm?”
“YES!!!”
“Eeeeewwwww. What does it look like?”
“You want me to get the diaper out of the garbage and bring it over to your house?”
“NO! Was it one of those little white pinworms?”
“NO! It was six inches long and wiggling all over the place!”
“Eeeeeewwww!”
Then I get a phone call at work asking for advice about the wiggling worm.
“Did it smile?” I asked, chuckling at the description my wife gave me.
“That’s gross.”
“Did they see worm babies?”
“Stop being disgusting. What should they do?”
“Um … put it out in the garden?”
“You’re going to make me puke.”
“OK. Prescribe him some Vermox.”
“What if they see more worms?”
“Twirl them up with a fork and put them in the garden … er … um … flush them down the toilet. Seriously, if there are more worms up there, then they will come out in the stool – dead, hopefully.”
That day, Mrs. WhiteCoat fielded a half a dozen more calls from our friend.
“Can these things get into his liver?”
“I read on the internet that they can go to the lungs and Junior has a cough. Could he have worms in his lungs?”
“The other kids had stomach aches this week. Should I test them for the worms, too?”
I feel bad for the family and it is kind of gross, but come on – relax a little.
If you’re curious, you can read more about nematode (worm) infections here and here and here and here (including pictures). Bottom line in the US is that most infections are asymptomatic, but various nematode infections can cause rectal itching, skin rashes, bowel obstruction, pancreatitis, unexplained anemia, muscle aches, lung problems, and even fetal problems in pregnant women. To minimize your chances of getting infected, wash your hands frequently, don’t walk in sewage (some worms can penetrate skin), avoid contaminated food, don’t eat dirt, and wear insect repellent in areas where certain types of worm infections are endemic (filariasis can be spread by mosquitoes). Interesting tidbit for docs is that nematode infections are a consideration in patients with persistent unexplained eosinophilia.
Eventually, Melissa calmed down and the worm freakout subsided.
Because it is Christmas break at the schools, a select few kids get the honor of taking the science pets home for the holidays. Daughter WhiteCoat got the privilege of taking home the class turtle whom we named Master Oogway (pictured above) after the character in Kung Fu Panda.
Once we got his habitat set up at our house, we needed to feed him, so we used the internet to find out what turtles eat. Carrots, grapes, strawberries, insects and crickets. For a special treat, they really like mealworms.
After reading the last sentence, I couldn’t keep a straight face when I asked Mrs. WhiteCoat:
“Hey … so how’s Melissa’s kid doing?”
Posted in Random Thoughts | 20 Comments »
Thursday, December 17th, 2009
What is wrong with us?
In December 2008 alone, Americans sent 110 BILLION text messages. That amounts to more than 3 billion text messages per day. My thumbs hurt just looking at those numbers.
I’m guessing a good few hundred thousand of those messages were probably sent from our emergency department … and this whole texting thing is getting on my nerves. A LOT.
One guy comes in worried about abdominal pain. I’m trying to get a history from him and his eyes are fixated on his CrackBerry. He repeatedly hesitated answering my questions so that he could read his 27th urgent text message taking precedence over his abdominal pain. I tried to give him the hint a couple of times and repeated the questions when he hesitated with his answers. No clue.
Finally, I asked him “Should I just text you the questions?”
He looked up at me with bewilderment. “Oh. Sorry.”
Then there was a mom who apparently was putting Red Bull in her kid’s sippy cup. He was bouncing all over the room opening drawers, pulling supplies out of the drawers, stepping on the sink pedals, climbing up and down off the bed, back flips, opening and closing the door to the room, that kind of stuff. The mother, who wanted to find out what was causing her severe chest pain, was deep into a textersation and was apparently oblivious to all of her child’s antics. When I asked her questions, she would give me mostly yes or no questions, then would shake her head and change her answers after hitting the “send” button on her phone. She was even reading messages while they had her breasts exposed to do an EKG.
Her kid was annoying me to the point where I told him not to touch things inside the drawers because there were things inside that could hurt him.
His mom pulled him away from the drawers, gave him one evil eye while keeping her other eye glued to her phone, and told him to “stop it.”
Did he stop? Of course not. The sudden yank on his arm just refocused his attention to another object in the room.
He walked over to the garbage can and started stepping on the pedal that opens and closes the lid. I stopped and furled my eyebrows at him. Mom was texting away. Then the kid put his head in the garbage can and stepped on the pedal so the garbage can lid opened and closed on his head. I gritted my teeth. Mom was again oblivious. I was going to tell him to get away from the garbage when he stepped on the pedal and started picking through the contents.
“You probably don’t want to touch the gauze pads with pus and the blood in there. They smell kind of bad and could get you really sick. And that clear thing that looks like a gun in there is called a speculum. It has some really yucky white stuff all over it, too.”
Mom looked up in horror. She slammed her phone shut, yelled the kid’s name, picked him up, and rubbed his hands under the running water.
And here I was thinking that mom wasn’t listening to me.
Posted in News Commentary, Patient Encounters | 19 Comments »
Wednesday, December 16th, 2009
According to this Article from the Atlanta Journal Constitution, a court has ruled that at least some health care is not a right.
In October, I linked to an article about how Grady Memorial Hospital in Atlanta was closing its dialysis clinics due to the significant financial burden. Grady has agreed to pay for the patients to receive dialysis at a private dialysis clinic until January 3, 2010, but after that, the patients are on their own.
After Grady’s announcement, approximately 50 illegal immigrants sued to keep the clinic open, alleging that closing of the clinic “violated their constitutional right to the health care service” and that closing the clinic amounted to “medical abandonment.”
The court held that the plaintiffs had neither a state nor a federal constitutional right to outpatient dialysis services and that Grady Memorial was not legally bound to provide those services.
The attorney representing the patients stated that she realizes that some people don’t believe the patients are entitled to such care because they are illegal immigrants. “They are human beings, and we all have the right to live.” The attorney also stated that “these people are going to die without this.”
The lawyer misrepresented the plight of the patients. Under current federal law, renal failure patients will always have access to hemodialysis, and that access will likely be more expensive than the current system that Grady uses. I called this one seven months ago.
High levels of potassium in a dialysis patient is an emergency medical condition. Under federal EMTALA laws, hospitals are required to provide stabilizing treatment to anyone with an emergency medical condition that seeks medical care in an emergency department. All the patients have to do is call “911″ and they will get door-to-door service to the hospital via ambulance, will get a bunch of expensive testing done to document their elevated potassium, will likely be admitted to the hospital, and will still get their dialysis.
The situation raises a second question, though: Should we be providing uncompensated care to illegal aliens?
I think that the answer should be “yes” – with an asterisk.
If people are violating federal laws, they should suffer the same consequences as anyone else who violates any other federal law. In this case, provide the patients with dialysis, contact police, take the patients into custody, and then initiate deportation proceedings – or whatever other action is appropriate under federal law.
If hospital personnel become aware that a patient has committed a crime, we already call police from the emergency department.
A patient has a gunshot wound? We call the police to report it.
A patient may be the victim of domestic abuse? We file a police report.
A patient in a car accident has an elevated blood alcohol level? We notify the police.
How hard would it be to contact the police to verify someone’s identity if a patient is unable or unwilling to provide a state-issued identification? Not only would doing so determine whether or not a person is in the country legally, but it would cut down significantly on health care fraudsters who obtain care in the emergency department using a fictitious name and fictitious address and then stiff the hospital for the bill.
If we don’t want to enforce our laws, that’s fine.
Then we need to stop complaining about providing care to those who violate the laws.
Posted in Access to Care, EMTALA, Medical-Legal | 24 Comments »
Tuesday, December 15th, 2009
Remember this skit from I Love Lucy?
Lucy and Ethel worked on an assembly line and were responsible for wrapping all of the chocolates that came down the conveyor belt. At first, things were easy, but as more and more chocolates came faster and faster, eventually Lucy and Ethel became overwhelmed and the whole process fell apart. The result was a classic comedic moment.
In emergency medicine, things aren’t so funny. The chocolates are our patients. At times, patient flow is manageable. At other times, patient volume becomes so high that we have difficulty providing good medical care. When things get too busy, usually there is a relief valve called “bypass”. Hospitals have to meet certain criteria to go on bypass, but once a hospital declares bypass, no ambulances may bring additional patients, giving the emergency department time to stabilize patients already there and to open up beds to accept new patients.
Massachusetts is pushing the envelope in medical care and, in January, created a statewide policy that hospitals could not go on bypass. According to this article from the Boston Globe, the law seems to be having its intended effect … for now.
By refusing to allow hospitals to go on bypass, the state forces busy hospitals to keep accepting ambulance runs. It is then up to the hospitals to find a way to make room for the additional patients. Kind of like pushing a kid into the deep end of a swimming pool and telling him that he better figure out a way to stay afloat.
Hospitals are now opening up additional units and are hiring additional staff to get floor patients discharged earlier in the day. However, wait times haven’t changed much – still an average of about 5.5 hours for admitted patients and 2.5 hours for discharged patients since the rule went into effect.
So is forcing hospitals to work at above capacity a good idea or not? Is necessity the mother of invention? Or will we start to see a bunch of hospitals floating to the surface at the deep end of the swimming pool?
I seem to remember a lawsuit that stemmed from emergency department not providing prompt enough care to a celebrity …
Posted in Access to Care, News Commentary | 9 Comments »
Monday, December 14th, 2009
 A couple of weeks ago, I posted a survey about patient satisfaction surveys. To this point, 642 people responded to the survey, which is outstanding.
Some of the responses were surprising. I’m getting the impression that the surveys really are more about satisFICTION that satisfaction, but you can judge for yourselves.
Health care providers
Of the health care providers that responded to the survey, 82% of their hospitals/employers/practices collected patient satisfaction data.
57% of those collecting data used a paid service such as Press Ganey or Rand. 23% used in-house surveys.
More than two thirds of respondents did not know their survey response rate. Of those that did know, most had a response rate between 2% and 10%.
65% of respondents said that their satisfaction scores correlated below average or poorly with the opinions of the patients they treat.
Regarding treatment, more than 40% of respondents had altered treatment due to the potential for a negative patient satisfaction survey. Of those that altered treatment, 67% gave treatment that was probably not medically necessary more than half of the time. Eleven percent of respondents described adverse outcomes from performing such treatment, including kidney damage from IV dye, allergic reactions to medications, hospital admits for “oversedation” with pain medications, and Clostridium difficile diarrhea.
Because of the effects of patient satisfaction surveys, more than 25% of respondents performed testing and gave medications that were probably not indicated, 18% admitted patients who probably did not require admission, and 20% wrote work notes for patients that were probably not warranted. Others mentioned that they did not perform patient education that they feared would anger patients and that they spent “prolonged” amounts of time in rooms selling a treatment plan.
More than 75% of respondents felt that patient satisfaction scores decreased the quality of care that they provided and nearly 90% of respondents believed that patient satisfaction scores decreased the efficiency with which they were able to evaluate and treat patients. More than half stated that patient satisfaction scores increased the amount of testing they performed.
Eighty one percent of medical providers were aware of instances in which patients intentionally provided inaccurate derogatory information on a satisfaction survey and 84% felt that patients used the threat of negative satisfaction surveys to obtain inappropriate medical care.
Nearly one in eight respondents had their employment threatened due to low patient satisfaction scores.
Administrators
Administrators seemed to agree that patient satisfaction scores do not correlate well with general opinions of patients treated in their facilities. All administrators answering the question rated the reliability of patient satisfaction scores from average to below average. The importance of satisfaction scores varied. 25% felt that scores were very important while 75% felt that scores were mildly to moderately unimportant. Administrators seemed to feel that satisfaction scores had little effect on efficiency or amount of testing performed. However, in contrast to answers given by the providers, a vast majority of administrators felt that the effect of patient satisfaction scores made it significantly less likely that providers would render inappropriate medical treatment.
All administrators wanted their percentage/percentile of “excellent” scores on satisfaction surveys to be 90% or greater.
Only one administrator would discount or ignore low survey scores from specific patients and only one administrator reviewed the medical records of patients who provided low satisfaction scores.
Patients
More than half of patients responding to this survey did not fill out satisfaction surveys after visiting a hospital or medical practice.
Of those that did complete surveys, 70% did so to provide complimentary information, 23% did so to complain about care received or a specific provider, and about 7% did so to provide suggestions for improvement. 73% never received follow up after completing a satisfaction survey despite the fact that nearly 60% expressed a desire for feedback.
Of the patients that did not complete satisfaction surveys, 40% stated that the facilities they visit do not offer them. 18% felt that surveys were a waste of time. 21% did not believe that anyone would act upon their responses. Many other respondents noted that they felt the surveys were irrelevant to the care they received and that they find it “insulting” for medical professionals to be graded on their medical care by laymen knowing little about medicine.
The responses about what question respondents would add to a satisfaction survey were quite insightful. Many advocated for shorter surveys. Several suggested asking about the one best experience and one worst experience they had at the facility. One suggested asking whether the amount of money charged was worth the care received. Several asked about the one thing a facility could do to improve. Many asked about the effectiveness of the communications.
There always have to be some smart asses in the crowd. One suggested a question asking why “the porridge-bird lays his egg in the air.” I’ll leave that one to all of you to figure out.
Probably the biggest surprise to me was the number of medical providers who stated that patient satisfaction surveys caused them to provide inappropriate medical care while administrators seemed to believe that just the opposite would occur. I also found it statistically interesting that all administrators wanted their facilities to be in the 90% or above club when only 10% of a given survey population can ever be in the 90th percentile.
I plan to leave the survey open for another week or so to see whether any extra responses are generated by this post. If you haven’t completed the questions, please give them a look. It shouldn’t take more than 5 minutes.
Once the survey is closed, I’ll analyze the data a little further and see whether EP Monthly will publish the results. If not, I’ll post a .pdf of the results for everyone to download.
Thanks again for participating!
Posted in Medical Studies | 3 Comments »
|
|
Text THIS
Thursday, December 17th, 2009What is wrong with us?
In December 2008 alone, Americans sent 110 BILLION text messages. That amounts to more than 3 billion text messages per day. My thumbs hurt just looking at those numbers.
I’m guessing a good few hundred thousand of those messages were probably sent from our emergency department … and this whole texting thing is getting on my nerves. A LOT.
One guy comes in worried about abdominal pain. I’m trying to get a history from him and his eyes are fixated on his CrackBerry. He repeatedly hesitated answering my questions so that he could read his 27th urgent text message taking precedence over his abdominal pain. I tried to give him the hint a couple of times and repeated the questions when he hesitated with his answers. No clue.
Finally, I asked him “Should I just text you the questions?”
He looked up at me with bewilderment. “Oh. Sorry.”
Then there was a mom who apparently was putting Red Bull in her kid’s sippy cup. He was bouncing all over the room opening drawers, pulling supplies out of the drawers, stepping on the sink pedals, climbing up and down off the bed, back flips, opening and closing the door to the room, that kind of stuff. The mother, who wanted to find out what was causing her severe chest pain, was deep into a textersation and was apparently oblivious to all of her child’s antics. When I asked her questions, she would give me mostly yes or no questions, then would shake her head and change her answers after hitting the “send” button on her phone. She was even reading messages while they had her breasts exposed to do an EKG.
Her kid was annoying me to the point where I told him not to touch things inside the drawers because there were things inside that could hurt him.
His mom pulled him away from the drawers, gave him one evil eye while keeping her other eye glued to her phone, and told him to “stop it.”
Did he stop? Of course not. The sudden yank on his arm just refocused his attention to another object in the room.
He walked over to the garbage can and started stepping on the pedal that opens and closes the lid. I stopped and furled my eyebrows at him. Mom was texting away. Then the kid put his head in the garbage can and stepped on the pedal so the garbage can lid opened and closed on his head. I gritted my teeth. Mom was again oblivious. I was going to tell him to get away from the garbage when he stepped on the pedal and started picking through the contents.
“You probably don’t want to touch the gauze pads with pus and the blood in there. They smell kind of bad and could get you really sick. And that clear thing that looks like a gun in there is called a speculum. It has some really yucky white stuff all over it, too.”
Mom looked up in horror. She slammed her phone shut, yelled the kid’s name, picked him up, and rubbed his hands under the running water.
And here I was thinking that mom wasn’t listening to me.
Posted in News Commentary, Patient Encounters | 19 Comments »