Musings of a Highly Trained Monkey: Change of Shift: Volume Two, Number Three
Great collection of posts including mine with a nice touch of color.
Thursday, July 26, 2007
Tuesday, July 24, 2007
A Vital Sign with concerning unintended consequences
Great post over at Aggravated Surgery Doc about the on the Downside of the 5th Vital Sign on how the PC infiltration of pain management policy caused poor patient outcomes and placed patients at higher risk. He makes valid points that political pressure has lead to more aggressive use of IV narcotic pain management instead of IM or other management thus putting patients at risk.
“In that milieu, a physician who prefers to prescribe IM narcotics can be accosted for using up valuable nursing resources, and assailed for not being sensitive enough to patients' pain. Of course, given that scenario, it was only a matter of time before some self-important regulatory agency got involved in the business of pain management”
“Fast forward a few years to 2001, when the Death Star of American Medicine decides it should be the arbiter of all things pain-related --- JCAHO published its report on Pain Management Standards. Basically, it mandated that hospitals establish policies for assessing and treating pain, particularly postoperative pain“
In my mind the crux of the issue is whether the pain scale is an accurate means of pain assessment (that’s a big NO!!!!!) and are people being harmed from more aggressive pain management (YEP!!!). A study published in the May 2007 Journal of the American College of Surgeons titled Kindness Kills: The Negative Impact of Pain as the Fifth Vital Sign documents cases of preventable death directly related to pain management in surgical patients and how they have increased in the period after JCAHO’s rules. More concern here from Anaesthesiologist.
The study and experiences above relate mostly to surgical patients. My experience has been in the ER. I have seen numerous near misses (patients needing reversal) and am aware of a few clean kills related to over aggressive pain management in a busy ED without the depth in Staffing to provide sufficient monitoring of the practice. I have seen numerous people who “Have a Ride” lie or sneak out and drive after being well medicated. I call in a report and turn in a DMV form when I see it happen. How do we measure how many people that has knocked off over the years on the roads by one of these "Customers". Wont ever be measured and the reports will be anecdotal so it will be ignored in the pain management debate.
I see this problem as getting worse and now being driven by the desire to produce high patient satisfaction scores which is reflected by improper intervention in medical decisions by non medical Hospital Administrators. Kim wrote about that recently here and couldn't’t have said it better below. When a patient does not get their fix, I mean, appropriate pain management, that being IV or IM Demoral or Dilaudid with a mixer x 2 and Rx of Vicodin #30 as well as a six pack of Vicodin to go being they came in after the Pharmacies are closed, they tend to complain.
“The patient is pissed. Excuse me, I mean the patient is experiencing anger at the unwillingness of the physician to administer what they want to be given. The patient is so angry that they take it all the way up to the head administrator of the hospital. In person.The administrator is concerned. Although the Admin is neither an RN nor MD, they do see an unhappy patient/client/health care recipient who feels they were treated inappropriately. This needs to be addressed. A meeting is called to address the patient’s issues. The bottom line: the patient gets what they want. Every time they come in, from anyone who happens to be on duty. This message is relayed back to the ER and the physician who did not treat the patient per the patient’s request is reprimanded. The patient is now given exactly what they ask for every time they come in by every doctor in the department”.
I may add that if the Nurse shows the least bit of a perceived judgmental attitude when carrying out the fix, I mean the order, they can expect a complaint and a negative evaluation, or worse from managers who are running scared over complaints. A judgmental attitude could be the Nurse inquiring about daily use of other medications, legal or illegal, that may potentate their ordered fix, I mean pain management, giving the big whopping dose of Dilaudid to slow (I put anything more than 1 mg IV on a pump over 20 min which has been called punitive), pressing the "Customer" to show they have a driver, or any type of attempted discharge education or suggestion related to their pain management practices.
If this practice has not hit your ER yet, consider yourself lucky for now.
“In that milieu, a physician who prefers to prescribe IM narcotics can be accosted for using up valuable nursing resources, and assailed for not being sensitive enough to patients' pain. Of course, given that scenario, it was only a matter of time before some self-important regulatory agency got involved in the business of pain management”
“Fast forward a few years to 2001, when the Death Star of American Medicine decides it should be the arbiter of all things pain-related --- JCAHO published its report on Pain Management Standards. Basically, it mandated that hospitals establish policies for assessing and treating pain, particularly postoperative pain“
In my mind the crux of the issue is whether the pain scale is an accurate means of pain assessment (that’s a big NO!!!!!) and are people being harmed from more aggressive pain management (YEP!!!). A study published in the May 2007 Journal of the American College of Surgeons titled Kindness Kills: The Negative Impact of Pain as the Fifth Vital Sign documents cases of preventable death directly related to pain management in surgical patients and how they have increased in the period after JCAHO’s rules. More concern here from Anaesthesiologist.
The study and experiences above relate mostly to surgical patients. My experience has been in the ER. I have seen numerous near misses (patients needing reversal) and am aware of a few clean kills related to over aggressive pain management in a busy ED without the depth in Staffing to provide sufficient monitoring of the practice. I have seen numerous people who “Have a Ride” lie or sneak out and drive after being well medicated. I call in a report and turn in a DMV form when I see it happen. How do we measure how many people that has knocked off over the years on the roads by one of these "Customers". Wont ever be measured and the reports will be anecdotal so it will be ignored in the pain management debate.
I see this problem as getting worse and now being driven by the desire to produce high patient satisfaction scores which is reflected by improper intervention in medical decisions by non medical Hospital Administrators. Kim wrote about that recently here and couldn't’t have said it better below. When a patient does not get their fix, I mean, appropriate pain management, that being IV or IM Demoral or Dilaudid with a mixer x 2 and Rx of Vicodin #30 as well as a six pack of Vicodin to go being they came in after the Pharmacies are closed, they tend to complain.
“The patient is pissed. Excuse me, I mean the patient is experiencing anger at the unwillingness of the physician to administer what they want to be given. The patient is so angry that they take it all the way up to the head administrator of the hospital. In person.The administrator is concerned. Although the Admin is neither an RN nor MD, they do see an unhappy patient/client/health care recipient who feels they were treated inappropriately. This needs to be addressed. A meeting is called to address the patient’s issues. The bottom line: the patient gets what they want. Every time they come in, from anyone who happens to be on duty. This message is relayed back to the ER and the physician who did not treat the patient per the patient’s request is reprimanded. The patient is now given exactly what they ask for every time they come in by every doctor in the department”.
I may add that if the Nurse shows the least bit of a perceived judgmental attitude when carrying out the fix, I mean the order, they can expect a complaint and a negative evaluation, or worse from managers who are running scared over complaints. A judgmental attitude could be the Nurse inquiring about daily use of other medications, legal or illegal, that may potentate their ordered fix, I mean pain management, giving the big whopping dose of Dilaudid to slow (I put anything more than 1 mg IV on a pump over 20 min which has been called punitive), pressing the "Customer" to show they have a driver, or any type of attempted discharge education or suggestion related to their pain management practices.
If this practice has not hit your ER yet, consider yourself lucky for now.
Wednesday, July 11, 2007
Stroke Centers, Marketing or Medicine
You are out shopping on a hot summer day when you suddenly become a little dizzy. It comes and goes and you start having a minor headache and then your vision gets a little fuzzy. Your getting worried. In the back of your mind you remember that health fair you went to and the people at the booth sponsored by the local Hospital talking about signs and symptoms of stroke. Could this be a stroke? Possibly heat related or a migraine? You also remember what they told you. You must get to the hospital within 3 hours of the start of your symptoms to get the miracle clot busting drug if it is a Stroke. You tell your spouse and off you go to your local Hospital which has been certified as a Stroke Center by JCAHO.
Once in the Emergency Room your taken right back, people crowd around, off come your cloths, someone puts an IV in your arm and you’re rushed off for a Head CT. When you return you get an EKG, more blood tests and a lot of questions. A cheery young lady comes in and says she is the Stroke Coordinator. She talks with you and gives you some handouts and asks more questions. Then someone brings a big machine into the room and does an ultrasound of your heart and neck. Your symptoms seem to have subsided but you are admitted to the Hospital just as a precaution. The ER Doctor is still not sure if you had a TIA or some other problem. Since your better you don’t need the miracle clot buster drug. Good thing.
The response to a potential stroke patient is modeled much like the response to a trauma patient entering a Trauma Center. These patients go to the top of the priority list and command the resources of the facility. The goal initially is to identify rapidly if the potential stroke patient is a candidate for TPA. A wide net is cast where most every patient with any acute neurological presentation gets entered into the Stroke Protocol. Some communities have implemented EMS destination protocols so potential Stroke patients are routed to a Stroke Center. San Francisco did this and the response of the hospitals was the all became or have applied to be Stroke Centers.
So is all this good medicine or marketing to increase patient volume and charge for a lot of expensive procedures? The good medicine argument is subject to much debate just as TPA’s use for ischemic strokes is controversial. Grunt Doc in recent posts here and here sheds light on the controversy, mainly in response to a recent Wall Street Journal Article that promotes TPA. The main Emergency Medicine organizations have taken positions that TPA not be considered standard of care for Ischemic Stroke but be an option in certain cases. AAEM’s position statement can be viewed here The movement towards Stroke Centers seems to have steamrolled over the concerns of Emergency Physicians and is moving ahead at a brisk pace. A list of current Stroke Centers can be viewed here. The ED I work at is a Stroke Center. Some of the ED MD’s are very reluctant to give TPA but know its not a good career move for them or their ED group to not give it on a qualified candidate. So they do it. ED Physicians are in a no-win situation. They are likely to get sued for giving or not giving TPA if the outcome is not good.
The “Stroke Center” paradigm provides a way to segment hospitals by their treatment patterns and shed light on how to overcome barriers to treating with TPA. Source:Genentech Stroke Assessment Market Research, 02/2003 – 07/2003
Genentech also offers educational grants to assist Stroke Centers in defraying the cost of educating their staff in stroke care. The American Heart Association, long criticized for recommending TPA’s use due to conflicts of interest of its Leadership, some with financial ties to Genentech and weak supporting data for TPA use in stroke, also is very involved in the Stroke Center concept and assists hospitals in getting Stroke programs started.
Genentech knows that promoting Stroke Centers will increase the use of TPA. One study showed an dramatic increase in TPA use at Stroke Centers versus non centers but no decrease in mortality or length of hospital stay associated with TPA. The real data out there does seem to support a modest decrease in long term disability when TPA is used according to strict criteria although some studies have actually shown an increase in mortality with TPA use. My suggestion would be to place this illustration on the TPA consent form which basically says, you may have less disability but your likelihood of a fatal hemorrhage is increased, and if your symptoms are not due to a stroke but some other neurological disorder you assume all the risk and none of the benefit, you make the call.
Once in the Emergency Room your taken right back, people crowd around, off come your cloths, someone puts an IV in your arm and you’re rushed off for a Head CT. When you return you get an EKG, more blood tests and a lot of questions. A cheery young lady comes in and says she is the Stroke Coordinator. She talks with you and gives you some handouts and asks more questions. Then someone brings a big machine into the room and does an ultrasound of your heart and neck. Your symptoms seem to have subsided but you are admitted to the Hospital just as a precaution. The ER Doctor is still not sure if you had a TIA or some other problem. Since your better you don’t need the miracle clot buster drug. Good thing.
The response to a potential stroke patient is modeled much like the response to a trauma patient entering a Trauma Center. These patients go to the top of the priority list and command the resources of the facility. The goal initially is to identify rapidly if the potential stroke patient is a candidate for TPA. A wide net is cast where most every patient with any acute neurological presentation gets entered into the Stroke Protocol. Some communities have implemented EMS destination protocols so potential Stroke patients are routed to a Stroke Center. San Francisco did this and the response of the hospitals was the all became or have applied to be Stroke Centers.
So is all this good medicine or marketing to increase patient volume and charge for a lot of expensive procedures? The good medicine argument is subject to much debate just as TPA’s use for ischemic strokes is controversial. Grunt Doc in recent posts here and here sheds light on the controversy, mainly in response to a recent Wall Street Journal Article that promotes TPA. The main Emergency Medicine organizations have taken positions that TPA not be considered standard of care for Ischemic Stroke but be an option in certain cases. AAEM’s position statement can be viewed here The movement towards Stroke Centers seems to have steamrolled over the concerns of Emergency Physicians and is moving ahead at a brisk pace. A list of current Stroke Centers can be viewed here. The ED I work at is a Stroke Center. Some of the ED MD’s are very reluctant to give TPA but know its not a good career move for them or their ED group to not give it on a qualified candidate. So they do it. ED Physicians are in a no-win situation. They are likely to get sued for giving or not giving TPA if the outcome is not good.
The marketing aspect of Stroke Centers is closely tied to the marketing of TPA. The creation of, or at least the illusion of, TPA as the Standard of Care for Ischemic Stroke seems to be the strategy with an aggressive media campaign as well as involvement with the American Heart Association in setting standards. Genentech who makes TPA has promoted the establishment of Stroke Centers and has made it one of their marketing goals.
The “Stroke Center” paradigm provides a way to segment hospitals by their treatment patterns and shed light on how to overcome barriers to treating with TPA. Source:Genentech Stroke Assessment Market Research, 02/2003 – 07/2003
Genentech also offers educational grants to assist Stroke Centers in defraying the cost of educating their staff in stroke care. The American Heart Association, long criticized for recommending TPA’s use due to conflicts of interest of its Leadership, some with financial ties to Genentech and weak supporting data for TPA use in stroke, also is very involved in the Stroke Center concept and assists hospitals in getting Stroke programs started.
Genentech knows that promoting Stroke Centers will increase the use of TPA. One study showed an dramatic increase in TPA use at Stroke Centers versus non centers but no decrease in mortality or length of hospital stay associated with TPA. The real data out there does seem to support a modest decrease in long term disability when TPA is used according to strict criteria although some studies have actually shown an increase in mortality with TPA use. My suggestion would be to place this illustration on the TPA consent form which basically says, you may have less disability but your likelihood of a fatal hemorrhage is increased, and if your symptoms are not due to a stroke but some other neurological disorder you assume all the risk and none of the benefit, you make the call.
The Hospital I work holds Stroke Fairs catering to senior citizens. They have speakers go to community events and organizations. More than once I have seen or read material distributed or articles in the local newspaper or directly heard reference to getting to the hospital early to get the “miracle clot busting drug”. Is this information helpful? accurate? The education on lifestyle changes and symptom recognition is very helpful but I have big concerns about the promotion of TPA and minimization of risks. Again, perhaps the above chart which was produced by AAEM should accompany the handouts.
So are Stroke Centers good medicine or marketing? My opinion, some good medicine (the education and rehab portion) and a lot of marketing and optimistic claims. The whole thing kinds of smells bad to me. As a Nurse when tasked to give TPA for stroke I make sure that the patient and family are fully informed, repeated several times, that while the treatment may eventually reduce disability it also might kill you. As far as the Stroke Center cheer leading, I just hold my nose.
So are Stroke Centers good medicine or marketing? My opinion, some good medicine (the education and rehab portion) and a lot of marketing and optimistic claims. The whole thing kinds of smells bad to me. As a Nurse when tasked to give TPA for stroke I make sure that the patient and family are fully informed, repeated several times, that while the treatment may eventually reduce disability it also might kill you. As far as the Stroke Center cheer leading, I just hold my nose.
Tuesday, July 3, 2007
Should the University of California Invest in Nurses or Lawyers…. Hmmmm!! Updated Aug 07
Dan Walters, a columnist with the Sacramento Bee has a reputation for calling government on the carpet for its wasteful spending and misdirected priorities. California corners the market on government waste and misdirected priorities and the University of California tops the list within California government. Their mis-management of public money is infamous. Just a few examples, here, here, and here.
Walters comments here on the recent decision of the University of California at Irvine to open a new law school despite a recommendation by the California Post secondary Education Commission’s not to citing an ample supply of lawyers in California, approximately 200,000. Roughly the same number as practicing Registered Nurses in the State. The full report of the Commission can be viewed here. Walters suggests Nursing education would be a better use of public resources.
It's another illustration of the fundamental dysfunctionality of California's government, its chronic inability to relate to real-world issues and prioritize its limited resources. UC's regents and administrators want to establish a new law school at Irvine because it would, in their view, enhance the school's prestige and, by extension, their own, not to meet any true educational or societal need…….
The Legislature's budget analyst, Elizabeth Hill, issued a report on the state's looming shortage of nurses in May, noting that the University of California, in a study by its San Francisco medical school, forecast a demand for registered nurses in 2014 that's 40,000 higher than the current forecast of supply, given retirement and other factors.
Hill recommended several steps, including supplemental funding to expand nursing education programs and removal of artificial barriers to expansion. The issuance of her report was virtually simultaneous with another event -- a vote by UC regents to authorize UC Irvine to hire a founding dean for its proposed law school at an annual salary of $233,200 to $364,300. It was the regents' figurative thumb of the nose to CPEC and its position
Some would argue the University is not tasked with “vocational education” which is normally handled by the States Community College System. Without even addressing the Vocation vs Profession argument the Nursing shortage in California is closely related to the number of Nursing programs available to students which is closely related to the number of qualified advanced degree Nurses to teach those students. Would it not be a better use of taxpayer money for the UC system to try to address the real issues facing the public rather than producing a surplus of Attorneys and building their Ivory Towers.
I cant wait for the sequel. The inevitable audit of how UC spent its millions of Stem Cell monies.
UPDATE August 07: UC Davis just announced the start-up of a new Nursing Program. Could I be wrong about UC liking lawyers more than Nurses. Nahhhh. They got a 100 million dontation to get it started. Regardless of the motives I'm glad to see more training in the pipeline.
Walters comments here on the recent decision of the University of California at Irvine to open a new law school despite a recommendation by the California Post secondary Education Commission’s not to citing an ample supply of lawyers in California, approximately 200,000. Roughly the same number as practicing Registered Nurses in the State. The full report of the Commission can be viewed here. Walters suggests Nursing education would be a better use of public resources.
It's another illustration of the fundamental dysfunctionality of California's government, its chronic inability to relate to real-world issues and prioritize its limited resources. UC's regents and administrators want to establish a new law school at Irvine because it would, in their view, enhance the school's prestige and, by extension, their own, not to meet any true educational or societal need…….
The Legislature's budget analyst, Elizabeth Hill, issued a report on the state's looming shortage of nurses in May, noting that the University of California, in a study by its San Francisco medical school, forecast a demand for registered nurses in 2014 that's 40,000 higher than the current forecast of supply, given retirement and other factors.
Hill recommended several steps, including supplemental funding to expand nursing education programs and removal of artificial barriers to expansion. The issuance of her report was virtually simultaneous with another event -- a vote by UC regents to authorize UC Irvine to hire a founding dean for its proposed law school at an annual salary of $233,200 to $364,300. It was the regents' figurative thumb of the nose to CPEC and its position
Some would argue the University is not tasked with “vocational education” which is normally handled by the States Community College System. Without even addressing the Vocation vs Profession argument the Nursing shortage in California is closely related to the number of Nursing programs available to students which is closely related to the number of qualified advanced degree Nurses to teach those students. Would it not be a better use of taxpayer money for the UC system to try to address the real issues facing the public rather than producing a surplus of Attorneys and building their Ivory Towers.
I cant wait for the sequel. The inevitable audit of how UC spent its millions of Stem Cell monies.
UPDATE August 07: UC Davis just announced the start-up of a new Nursing Program. Could I be wrong about UC liking lawyers more than Nurses. Nahhhh. They got a 100 million dontation to get it started. Regardless of the motives I'm glad to see more training in the pipeline.
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