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Healthcare Update Satellite — 06-26-2013

Wednesday, June 26th, 2013

See more HealthCare Updates at my other blog at http://drwhitecoat.com.

UK Accident and Emergency Department criticized for multiple failures after going into “crisis” mode from January through March due to a surge in patient volumes. Of course, all the investigators go and pick through the hospital’s policies four times in April after things have calmed down, rather than going and trying to address the problems in real time while they’re happening.
Want to see me faint? Give me a story about an inspector going to a hospital during a crisis, and making a specific real-time recommendation on how to improve the crisis. None of the vague doublespeak about doing something to “make sure a proper system was in place to identify and manage any risk to the health and safety of people using the hospital.”
Inspectors like this seem to have no problems criticizing other peoples’ solutions – especially after the fact – but they’re hard-pressed to come up with their own innovative solutions during a crisis.

The MERS virus is the latest deadly virus to hit the circuit. The reported mortality rate is 65%! Outbreaks in one case were spread from one dialysis patient to seven others in the same hospital.
One vector was hypothesized to be contaminated dates from Saudi Arabia. Next month’s celebration of Ramadan in Saudi Arabia will be a big test of the infectivity of the MERS virus.

The US isn’t the only country experiencing difficulty managing psychiatric patients from the emergency department. Some Australian hospitals seeing excessive wait times for placement. At Calvary Mater Newcastle Hospital, one in every 15 patients is mentally ill.

Georgia Supreme Court set to hear case challenging Georgia’s emergency medical care statute. Fifteen year old boy undergoes arthroscopic knee surgery to repair a football injury. Eight days later, he comes to the emergency department with chest pain. Labs, EKG, CXR show nothing and he is diagnosed with pleurisy. Two weeks later, he died from bilateral pulmonary emboli.
Georgia’s statute states that emergency medical providers can only be liable if clear and convincing evidence shows that the providers actions showed “gross negligence”.
Two nationally-recognized emergency medicine experts are apparently prepared to testify that the physician’s actions were grossly negligent, which I think is a total crock of an opinion.

140 million patient visits this year and soon to rise even higher with implementation of the UnAffordable Insurance Act. Fewer emergency departments. Higher acuity. Oh, and so what if you don’t get paid for your services. Now to avoid government penalties for patients who are re-admitted too soon, emergency physicians will be expected to provide “observation care” in their limited beds. What could go wrong?
This author says emergency physicians need to be “at the table”. More like we need to fight back before we’re “on the table.”

Patients having pain in the emergency department? Don’t give them 2mg of Dilaudid all at once! Give them 1mg now and 1mg in 15 minutes because according to this Annals of Emergency Medicine study, by the second dose, 42% of the patients have already experienced “adequate anesthesia.”

Oh, and in case you didn’t hear, yours truly is officially going to have his work overseen by one Judith Tintinalli. As in the Emergency Medicine Tintinalli. Talk about pressure …
Dr. Tintinalli has been named as EP Monthly’s new Editor-in-Chief, replacing Dr. Kevin Klauer who is moving over to ACEP News. Welcome aboard! And if you need some pithy commentary for the next edition of your book, you know where to find me.

Healthcare Update Satellite — 06-15-2013

Saturday, June 15th, 2013

More HealthCare Updates from around the web are at my other blog at http://drwhitecoat.com.

What’s the highest sodium level you’ve seen? These docs saved a patient with a corrected sodium level of 196 which is the highest I’ve ever heard of. Lower 170s is the highest I can remember. The patient drank a quart of soy sauce on a dare, then started having seizures a couple of hours later. Some quick thinking docs gave him 6 liters of free water over 30 minutes and the patient survived and was neurologically intact! Amazing. The docs from University of Virginia in Charlottesville deserve a lot of credit for saving this fellow.
Another story about the case is here.

$5 heroin killing many New Jersians. Ocean County, NJ has lost 53 people to drug overdoses this year alone.

California man enters hospital, walks into emergency department restroom, pulls out gun and shoots himself dead.

Are CT scans useful for evaluating dizziness in the emergency department?
This study showed that there was a 1 in 50 chance of a significant finding. Some people had bleeding in their cerebellum, some had hydrocephalus, some had cancers. When patients received a follow up MRI, 13% of patients had significant findings – most of which were strokes that had gone undiagnosed on the initial CT scan. I’m betting that if the testing was negative, certain groups of people [cough cough Consumer Reports hack cough] would label the tests “unnecessary” and state that the testing shouldn’t have been performed.
What would you want if it was your family in the emergency department?

An unfortunate case of “crying wolf”? UK patient takes overdose of pain medications then is taken to the emergency department (A&E department). There, she denies taking any medications to cause her lethargy. She was assigned to be watched by “unqualified” Healthcare Assistants, and was believed to be faking a coma because she was a “frequent flyer.” She stopped breathing and died from a narcotic overdose 12 hours later.
Now the Secretary of State for Health is being petitioned to prevent Healthcare Assistants from observing seriously ill patients and requiring that only nurses do so.
With more patients, fewer facilities, and lower reimbursement for care, we’re moving toward the system already present in the UK. Can we learn anything?

Another interesting article from the UK. When one hospital closes its emergency department, the domino effect on nearby hospitals is significant. Waiting times to be seen skyrocket: There is a five-fold increase in numbers of patients waiting more than 4 hours to be seen. The number of cancelled elective surgeries doubles. Patients die in ambulances waiting in the hospital parking lots just to get into the emergency departments.
Take note of these types of problems as the United States heads closer to a socialized system.
But at least their care is free.

Healthcare Update Satellite — 06-06-2013

Thursday, June 6th, 2013

More HealthCare Updates from around the web are at my other blog at http://drwhitecoat.com.

Remember the case where hospital administrator Bruce Mogel allegedly planted a gun in a doctor’s car then called the police to frame him because the administrator didn’t like the doctor’s criticisms of the way the hospitals were being managed? The doctor sued the hospital and won $5.7 million.
Well a judge just threw out that judgment. Employers can’t be liable if the employee/officer’s actions are not reasonably related to the job or reasonably foreseeable.

Patients gone wild. Combative New Jersey patients gets beat down by police, then causes officer to dislocate his ankle. Now charged with aggravated assault on an officer.

UK hospital emergency department director states that there is “toxic overcrowding” and that hospitals are at a “crisis point.” Notes that the EDs are “simply not equipped to safely care for such numbers of patients, an increasing proportion of whom are elderly and frail with complex medical, nursing and social needs.”
More patients, sicker patients, “substandard conditions” … what could go wrong?

Missouri Clinic sued for failing to drain an allegedly nonexistent perirectal abscess. The patient was instead placed on antibiotics, instructed to use sitz baths, told to see the surgeon the following day, and instructed to return to the emergency department if his condition worsened. Four days later when the next surgery appointment was available, the patient was determined to have had necrotizing faciitis which by that time had spread from his buttocks to his knee.
Experts in the case allege that immediate lab tests, CT scans/ultrasounds were required and that the patient should have been admitted to the hospital. The emergency physician plaintiff’s expert testified that it is a deviation from the standard of care to discharge a patient with such an abscess from the emergency department.

Canadian politicians demanding an inquest into death of a patient who fell and hit her head, then left emergency department after waiting six hours to be seen. She was found dead the following day. According to statistics in the article, the number of patients leaving hospitals without being seen by physicians increased nearly 10% between 2011 and 2012.

Brainiac Democratic Nevada politician Marilyn Kirkpatrick tries to amend the Nevada constitution to cap costs for anyone receiving treatment in a hospital emergency department.
Changing the CONSTITUTION to reflect how much people should have to pay when someone else renders private services to them? How much more idiotic can legislators in this country get?
Why stop at emergency services? What’s next? A constitutional amendment to limit the charges in Nevada for fast food hamburgers? Pints of alcohol? Attorney’s fees? How about capping Nevada lawmaker’s salaries?
Fortunately, this colossal example of poor judgment died without even coming up for a vote.

Two thirds of Americans aren’t sure that they will purchase coverage required by Obamacare by the January 1, 2014 deadline. More than 60% of people believe that the UnAffordable Care Act will lead to higher health care costs. It already has.

Healthcare Update Satellite — 05-29-2013

Wednesday, May 29th, 2013

More HealthCare Updates from around the web are at my other blog at http://drwhitecoat.com.

Next on the FDA hit list … sleeping pills. Number of ED visits related to Ambien prescriptions triples between 2005 and 2010.

Connecticut emergency department declares influx of intoxicated patients from nearby concert venue a “scheduled mass-casualty situation” and a public health issue as sometimes more than 90 patients are taken to local emergency departments in various states of drunkenness.
I used to work at a trauma center near a concert venue. The worst concerts during those days were “OzzFest” and Jimmy Buffett. The worst for this Connecticut hospital are reportedly country/western concerts.
How times change.

Unintentional ingestion of medical marijuana sending more children to emergency departments. To make things safer for our children, I’m having trouble deciding whether we should outlaw it, throw doctors in jail for prescribing it, or call it an “assault drug” and wage a media war against it.

Patients Gone Wild goes international. Egyptian doctors go on strike after registered convict beats one doctor and tries to shank an orthopedist while security guards stand down. One Egyptian doctor’s rights group wants people who attack hospitals to be charged with attempted murder.
I have a feeling that attack rates would drop precipitously if that ever happened.

Australian university is trying to figure out why rural adults use the emergency department for dental problems almost 3 times as often as their urban counterparts.
We really need to do a study to figure this out?

Top medical malpractice case in New York for 2012: $8.6 million judgment after ENT doc allegedly misdiagnosed sinus infection for 2 years which allegedly led to pituitary gland infection, which allegedly caused patient to develop diabetes insipidus and seizures.
And I shake my head.

It’s been almost 50 years since JFK was assassinated and now we’re learning what happened to the emergency department where he was treated. Ten years after the incident, workers chopped the room up into little pieces and put it into barrels. Now the Kennedy library reportedly doesn’t even want the material.
Odd.

Healthcare Update Satellite — 05-15-2013

Wednesday, May 15th, 2013

More HealthCare Updates from around the web are at my new digs at http://drwhitecoat.com.

“Dear ER staff. Our friend is drunk. Fix him.” Unconscious Arizona college student who was “turning blue” left in hospital lobby with Post-It note stuck to his body after losing “drinking contest” at frat house. Nice friends.
If you decide to follow the link, turn down the volume on your computer. Gannett’s KSKD.com has an auto-start video ad that will blow your ears out.

Irish emergency department so crowded and busy that it has to pull an ambulance up to the front door to act as an extra resuscitation room for a patient. To be fair, there were five patients all needing resuscitation at the same time. I actually think that the doctors were pretty resourceful in coming up with the idea.

Nice article on how University of Michigan is decreasing medical malpractice expenses by disclosing errors and compensating patients before lawsuits are filed. Open claims have declined to 63 from 262. Lawsuits have declined to 0.75 per 100,000 patients per month from 2.13. Claim resolution time also has declined to 0.95 years from 1.36, costs to defend lawsuits have dropped to less than $1 million per year in 2009 from $2.2 million in 2001, and the amount needed for reserves has fallen to less than $16 million in 2009 from $72 million in 2001.
They seem to be on to something.

Nice article in the Atlantic about the decline of emergency care. Emergency department visits have increased by 44% while emergency departments have closed at a rate of 11%. In addition, 339 trauma centers have closed. A 10% increase in the number of African Americans treated correlated with a 41% increased risk of the emergency department closing.

If you’ve got nothing to do for a few hours, you can read the 4951+ comments on Reddit that were posted after an emergency physician offered to answer any questions that the readers might have.

The UnAffordable Care Act may leave cancer patients requiring “specialty drugs” with a hefty bill. Some states will require patients to pay up to 30% of the cost of their medications – which could total thousands of dollars each month.

Wisconsin hospital offers machine that dispenses prescription medications. Bad news is that patients need a credit or debit card to pay for the medications … no cash allowed. In addition, you have to visit the hospital’s own ED or acute care clinic – no other prescriptions work in the machine.

Interesting social experiment in New Zealand proves the obvious. Patients don’t use the the emergency department because they can’t afford to see a primary care physician – they use the emergency department because it is convenient. Patients were eligible to receive vouchers to obtain free appointments with primary care physicians for non-urgent complaints. Not one voucher has been handed out this year.
There was a wide belief that people used the emergency department because it was free, but the “clinical head” of the ED stated “that’s probably not as strong as a driver as you might think.”
Bullhokey. Institute a $20 co-pay for each emergency department visit and see how quickly ED patient volumes decrease.

Healthcare Update Satellite — 05-07-2013

Tuesday, May 7th, 2013

More HealthCare Updates from around the web are at my new digs at www.drwhitecoat.com.

Annals study shows clinical signs that necessitate admission in patients with ALTE (when newborns appear to stop breathing): “obvious need for hospitalization (they used persistent hypoxia as one example of this), significant medical history, and more than one ALTE in 24 hours.

Dual energy CT scan can diagnose knee ligament tears more effectively in the emergency department.
Is it necessary to definitively diagnose ligament tears in the emergency department, though?
And how long will it take until government officials blast doctors for ordering these tests?

You know all of those hospitals that advertise their emergency department wait times? Now those ads may end up biting hospitals in the rear. Nevada patient chooses hospital based upon advertised average wait time of 17 minutes, then waits five and a half hours before getting treatment. Newspapers publish statements suggesting that the signs may be “false advertising.”
Will consumer fraud cases against hospitals based on these advertisements be too far behind.

Florida House tries to improve medical malpractice environment by passing bill that would require experts to be in the same specialty as the physicians about whom they are testifying and that would allow ex parte communications between lawyers and a patient’s treating physician.
I still wouldn’t practice medicine in Florida.

Conditions at California’s Contra Costa Regional Medical Center are endangering patients according to the emergency department staff. Examining patients in the lobby and behind screens in the hallways are alleged as the emergency department is seeing twice as many patients as it was designed to accommodate.
So what do hospital administrators do in response? They hire a consultant to tell them the same things that the staff is already telling them.
What? Did you expect rational thinking?

Hospitals finding that they can cut costs by catering to emergency department “superusers”. For example, homeless patient Dennis Manners was treated in the emergency department 337 times in less than two years, amassing charges of more than $626,000. The hospital found him an apartment, assigned him a primary care doctor, and enrolled him in a drug treatment program.
I think that what the hospitals are doing is great, but why should this financial burden fall on the backs of private enterprises when government should be providing the services for its citizens?

Social media strikes again. Picture from Cumberland Infirmary in England shows that the hospital isn’t meeting the government targets for patient throughput.

Healthcare Update — 04-23-2013

Tuesday, April 23rd, 2013

More HealthCare Updates from around the web are at my new digs at www.drwhitecoat.com.

Diagnostic errors account for most paid claims in medical malpractice cases. Errors in diagnosis were the most common type of claim and also amounted to the highest proportion of total payments. The total inflation-adjusted amount of diagnosis-related payouts was $38.8 billion over 25 years.
Remember, these statistics represent just the payouts. On average, two of three medical malpractice lawsuits end in no payment to the plaintiff.
And we still wonder why doctors do so many “unnecessary” diagnostic tests?

Missing bamblance. University of Virginia is on the lookout for a stolen ambulance after the driver left the ambulance unlocked with the engine running.

Another missing bamblance. This one was from University of Alabama Birmingham ED ramp. The ambulance company executive said that it “wasn’t clear how or why someone took the vehicle.”
How – The driver obviously left the keys in it.
I agree with him on the “why” part.

Ex-boyfriend kidnaps patient from hospital room. Waited until she was called back to the treatment area from the waiting room, then stuck a gun in her ribs and made her leave.
I can’t make this stuff up.

Another application of federal EMTALA law. Everyone coming to the emergency department must be evaluated and treated – even if they just bombed the Boston Marathon.
Cases like this come up every once in a while and it is very difficult for the emergency department staff to set aside their feelings.
Another story on the topic here

Surgical complications good for a hospital’s bottom line. With insured patients, hospitals made an extra $39,000 per patient who had post-surgical complications. Medicare patients with post surgical complications earned the hospital about $1750 more. Hospitals lost money on Medicaid and private pay patients with post-op complications.
Don’t believe people who try to draw the conclusion that “errors” and “complications” are the same thing – they aren’t.

Healthcare Updates — 04-15-2013

Monday, April 15th, 2013

See more HealthCare Updates from around the web at my new digs at www.drwhitecoat.com.

More of a free market approach to medical care. Australian private hospitals noting a large uptick in emergency department patients as patients opt to pay for emergency services rather than wait for care at the public hospitals. Some emergency departments are recruiting highly regarded specialists to further increase patient demand for services.

Another article about Australian medical care. Patient goes to hospital complaining of the “worst headache of his life.” In many cases, that translates into doctor speak for “order a head CT scan to rule out bleeding”. The patient had a head CT nine days before going to the emergency department which showed the presence of an aneurysm. He was discharged from the emergency department and died the next day.

More arrests for oxycodone prescriptions. In this case, a physician wrote prescriptions for more than 500,000 pills over 2 years. The prescriptions were filled in New Jersey – even though they were written in New York. Other allegations surfaced as well.
The investigation was sparked by an overdose death where a prescription bottle bearing the doctor’s name was found at the scene.

More Unaffordable Care Act follies. Smoking is considered a “pre-existing condition” under the Act and smokers therefore can’t be charged higher rates than non-smokers for insurance. Which means that non-smokers will be charged even more to cover the cost of treating smokers.
I’m getting the impression that the government wants the insurance industry to fail.
Get your healthcare now while you still have insurance, folks.Final Text

Sounds good my man, seeya soon, ill tw …” The University of Northern Colorado student sending this text message never got to finish it. He was driving while texting, drifted into oncoming traffic, jerked the steering wheel, and rolled his car. He died from the resulting injuries.
His parents published pictures of his phone with the message hoping that they can keep others from texting and driving. I hope that every parent prints this article and discusses it with their children.

Healthcare Update — 04-08-2013

Monday, April 8th, 2013

Columbus, OH paper compares hospital wait times from 15 different hospitals throughout central Ohio. Metrics include minutes until diagnostic evaluation, minutes until pain medication, minutes until admission decision, and minutes from admission to room placement. I just wonder how accurate the metrics are. It isn’t like self-reported data like this can’t be manipulated.

Evanston Northwestern Hospital in Chicago suburbs also making news because of its wait times – nearly twice the national average.

The problem with providing patients with insurance: When the insurer cuts payments, what happens if providers won’t take your insurance? Government cuts payments to providers so that it costs more for cancer clinics to provide chemotherapy to some Medicare patients than the government reimburses. To stay afloat, some cancer clinics have now begun turning away Medicare patients needing cancer infusions. Now patients go to hospitals where the charges for cancer treatment are higher and the waits for treatment will likely be longer.
But we’re going to be insured! And we can keep our doctors, too!

Patients gone wild. Two brothers in Lebanon “attack” an emergency department, smashing windows and insulting the doctors and nurses on duty. In other words … a normal day in a typical American emergency department. And their Press Ganey scores probably stink for that day, too.

What a great story. Six year old Long Island kid treated in emergency department raises $275 with a fundraiser and uses the money to buy coloring books for other emergency department children.

Remember how CMS promised to give incentive payments for “meaningful use” of electronic medical records? Not so fast. Rules changing. Now it is doing random audits of 5-10% of all applicants to see whether they should actually get their bonus payments. Self-reporting isn’t good enough any more.
Wouldn’t it be interesting to see what would happen if all providers went back to paper records?

Canadian paramedics visiting patients with “non-urgent” issues to keep them out of emergency departments. The only question I have is who determines whether the issues are “non-urgent”?

A second interesting Medical Economics article. What are the tech trends that will affect how doctors practice medicine in the future? Interesting to consider. Remote patient monitoring. Personal health records with biometric security. Cool stuff.

More than 25% of Oklahoma patients enrolled in Medicaid. Of those, about a quarter used the emergency department a total of 528,000 times at a cost of $170 million. Oklahoma is now trying to determine how to deal with the high utilizers – those who use the ED more than 15 times every 3 months.

Speaking about Oklahoma … Oklahoma Dentistry Board officials are deciding whether to pursue criminal charges against a dentist. Officials found rusty instruments, “potentially contaminated drug vials” and “improper use of a machine designed to sterilize tools” in the dentist’s office.
The Oklahoma Dentistry Board accused the dentist of re-inserting needles in drug vials after their initial use and using the same drug vials on multiple patients. This happens often in medicine. The dentistry board also stated that a sterilization machine hadn’t undergone monthly testing in six years. Concerning, but when the Board officials tested the machine was it not properly sterilizing equipment? They did test the machine, right? Were the rusty instruments used on patients? Where was the rust located – on the handles or on the surfaces that come into contact with patients?
In addition, the dentist allegedly allowed dental assistants to administer IV sedation when only dentists are allowed to perform such acts.
For each charge, the dentist could face up to four years in prison and a $10,000 fine.
Are the alleged actions above worth throwing someone in jail for 8 years over?

Rhode Island emergency department reportedly one of few in country to have an MRI available in the department. Wonder how MRI use at this hospital compares to national averages.

Remember … fast care, quality care, free care – pick any two. Patient upset because she was treated quickly in a freestanding emergency department, but her bill was too high and included a $1,500 “facility fee” typically used by hospitals. Some of those costs to go complying with governmental regulations.

One British Columbia hospital emergency department is in a “state of emergency” due to understaffing and high patient volumes.

Emergency department personnel don’t routinely ask suicidal patients about availability of firearms in the home. Will patients admit to having guns and if so, will intervention make any difference in suicide rates?

Woman with double uterus told not to have any more children due to possibility of dying from complications. Goes for abortion and learns several days later that the abortion was unsuccessful. Instead of going for repeat procedure, keeps pregnancy. Now, after delivering healthy 6 pound girl, woman sues abortion clinic for the pain, suffering, and emotional distress of having undergone an improperly performed abortion.

Healthcare Update — 04-01-2013

Monday, April 1st, 2013

This case report is entirely bizarre. Patient gets awarded more than $800,000 after visit to doctor resulted in incorrect diagnosis of cancer when the patient really had pneumonia and caused patient to have amputation of her foot. A trial was held on the case four years ago with a verdict in favor of the doctor, but the judge declared a mistrial because Washington State jurors were referring to the plaintiff’s Japanese attorney as “Mr. Miyagi” and were making other racist comments against him.
Then, the article notes that the doctor had been disciplined by state regulators for making “erroneous diagnoses” and for prescribing methadone to drug-addicted patients. So now Washington State physicians’ licenses can be on the line for failing to perfectly diagnose patient symptoms and for prescribing medication for one of its intended uses.
I admit we don’t have all the information behind the license actions, but the article makes the Washington State Medical Board sound a little overeager to discipline physicians.

Congratulations! You delivered a healthy 6 month old! 15 lb 7 oz baby delivered vaginally in UK. More than 20 doctors reportedly assisted in the delivery.

Curing patients gone wild? Australian hospital emergency department guards petitioning to carry guns at work. Medical workers claim that it will make emergency departments more dangerous.

Australian patient held four days in emergency department waiting for psychiatric bed to open up. Shortage of beds creates high demand. Patient’s mother alleges that his condition worsened because of the long wait.
Not that anything like this could happen in the US. Oh wait. What a coincidence. LSU is closing their mental health emergency department, resulting in other hospital emergency departments having to care for “an additional 2,000 people who are a danger to themselves or others, who are desperately in need of stabilization and potential further hospitalization.”
When medical services are curtailed, the patients needing those services don’t just disappear.

(more…)

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