Drinking the RME Kool-Aid at ENA’s annual conference

Just got back from the Emergency Nurses Association’s annual conference in Minneapolis. Overall a pretty good conference if you avoided the Keynote addresses. A disappointment was the numerous presentations and posters touting the wonders of the process being pushed by several ED groups and Hospital bean counters called RME. Rapid Medical (Mediocre) Evaluation which also goes by several other names such as Triage Bypass, Provider is Triage, Door to Doc, among others depending on which ED Physician group is pushing it. All are basically the same thing. While pieces of the process can streamline care (immediate bedding, bedside registration) here are the claims that are made by the RME’ers that any thinking Nurse should question.

If we adopt RME we will be able to pay for more Nurses with the all the money we Save. Right!!!!! Well, that’s not my experience. I work in one of these facilities and staffing has stayed the same and the moment there is a lull the manager is trying to send staff home because the census is low. So, reduce your standards to move people through, stack them in chairs to utilize more space, pressure the Doc's to do a substandard exam, and as soon as you discharge them go home your not needed. Now that’s efficiency. Remember, work smarter not harder. I have an idea. How about not counting patients who dont get a Nurse in the Nursing hours of care. Most patients are alotted around 2 hours of care credit for budgeting. What if they never get a Nurse. No, that would be way to honest.

Patient should not have to tell their story more than once. Don’t trouble the patient with having to repeat their story more than once. This is team Triage and we get all the facts on the first try because the Story Never Changes!!!!! More Kool-Aid please. What do you call the Nurse in Team Triage? Scribe

You don’t need to have a Primary Nurse assessment. What the heck for. They don’t do that down at the Wall Mart Clinic, why should the ED. And what a wonderful way of dodging the Nursing ratios in California.

Patients do not need to get undressed. What the heck for. You never find anything when you examine the skin, back, or any other covered part. What a waste of time. Yum, Good Kool-Aid. I cant wait for our next round of survey results. Can you say Bump!!

Nurses are more satisfied. Which ones? The ones who view Nursing as a series of tasks rather than a process and don’t assess their patients or understand a Nurse Patient relationship probably will. You know them, the ones who make up discharge vital signs and always have their chart complete even though you never heard any of those questions asked. Yep, that’s them. There are certainly plenty of them around. Managers will also like it. Nothing makes them tingle like good numbers.

Patients can be quickly categorized with minimal or no triage. Put on your Blinders and only focus on the complaint they tell you. It keeps the problem simple. Patients always articulate an accurate complaint and totally understand their symptoms. Easy Peasy. You have an ear ache – Done, Your back hurts – take these, Done. Our Door to Provider times are awesome. Wow, why didn’t we think of this model 20 years ago.

Patients are more satisfied. Some probably will be. Most don’t recognize crappy care as long as its delivered with a smile and done quick. The Customer is always right.

So there you have it. Our professional organization (ENA) pumping up a process that shortchanges patient assessment and treatment from both Nurses and Physicians and cuts out important parts of the Nurses role to make the numbers look good. Brilliant recruiting strategy. I am so thrilled I think I will join for life right after I finish this Kool-Aid.

Annoying Consultant Speak

In the past week I have sat through several process type meetings and must reflect on some of the most irritating consultant speak. Here are a few examples.

Rapid cycle process improvement
The model of improvement is applied in short test periods, using small samples of patients, and measures the effectiveness of the changes being tested. Based on what is learned, successful interventions are applied to other patients or other organizational activities or settings and unsuccessful ones are revised and tested again for effectiveness. You usually hear it when a new manager or director takes over from the outside or your existing manager goes to a conference. Murse’s Translation. I went to this cool seminar and heard this great idea and since I don’t really know anything about statistics or study design and we don’t have time to do a real study were going to implement this new process and if by the end of the day it works were going to do it throughout the hospital. Then were going to put it in a power point and present our great success to the CEO. I love the smell of a bonus in the morning.

Perfect is the enemy of Good Enough
The origins of this phrase are from the French Philosopher Voltaire. In modern times it seems to appear during crunch time of hospital IT projects. Go-Live is just a few months out. The team is feeling nervous and wants changes. The CIO calls a big meeting and gives a power point pep talk to get everyone "on the same page". Then it comes out, “You know, when it comes to rolling this out, Perfect is the Enemy of Good Enough. Murse’s translation: “Lets put some lipstick on this pig and roll her out. Stop you’re bitching, the users will just have to deal with the issues”. Ok, we know its never going to be perfect but can I ask: Did you use that same term when applying for your job when asked to describe yourself? How about when you proposed to your significant other, or do you say it to your kids just before finals or the big game? Doubt it. I’ve decided that at the next EMR Go Live that I support I will wear a team t-shirt that says, Perfect is the enemy of good enough! How about that on a team shirt. The users will be impressed.

Studerized
Being Studerized is similar a baptism in the Studer Group philosophy. I suspect there is Cool Aid being served at this baptism. Hospitals thought-out the country are sending their staff to various vacation resorts for $1200 a pop, not counting lodging and travel for the 2 day Studerization. By the end you are a customer service expert. Patients become Customers. You become experts in scripting the survey and how to change the patients perception of the visit. You are eager to go back to your hospital and implement the Three Levels of Studerizaiton. When you get back you will be filling out report cards on each other and identifying your departments high, middle, and low performers. Hope I’m not in the low group. Wow, I’m pumped. Pass the Cool Aid.

I'll update this list from time to time, shouldn't be hard I have more meetings this week.

Spike in medications deaths. Could it beeeeeee ……. Satan – or perhaps “The Fifth Vital Sign”

In a article to be published in the Archieves of Internal Medicine next week an alarming spike in the number of accidental deaths from prescription drug use related to “medication errors" is reported. The Article by David P. Phillips, a sociologist at the University of California, San Diego is the most recent in a series of research he has done on the subject of drug abuse, suicide, and societal trends.

“Deaths from medication mistakes at home increased from 1,132 deaths in 1983 to 12,426 in 2004. Adjusted for population growth, that amounts to an increase of more than 700 percent during that time. In contrast, there was only a 5 percent increase in fatal medication errors away from home, including hospitals, and not involving alcohol or street drugs”

"By 2004, fatal medication errors were responsible for far more years of potential life lost than were all accidents from firearms, falls, fire and flames, drowning and non-medication poisonings combined," Phillips said

So what type of medications are we primarily talking about here. You guessed it, Opioid pain medications like Methadone, Oxycodone, Vicodin, and Fentanyl. Throw in a benzo, an antidepressant, perhaps a glass of wine and out go the lights.

Similar data is being reported by the Centers for Disease Control. According to the federal Centers for Disease Control and Prevention, unintentional poisoning deaths – 95% of which are drug overdoses – increased from 12,186 in 1999 to 20,950 in 2004.

During testimony at a Senate Judiciary committee in March of 2008 Leonard J. Paulozzi, M.D., M.P.H stated


When these more specific drugs were tabulated, we found that street drugs were not behind the increase. The increase from 1999 to 2004 was driven largely by opioid analgesics, with a smaller contribution from cocaine, and essentially no contribution from heroin. The number of deaths in the narcotics category that involved prescription opioid analgesics increased from 2,900 in 1999 to at least 7,500 in 2004, an increase of 160% in just 5 years.[1] By 2004, opioid painkiller deaths numbered more than the total of deaths involving heroin and cocaine in this category.


He went on to say

All available evidence suggests that these deaths are related to the increasing use of prescription drugs, especially opioid painkillers, among people during the working years of life. A CDC study showed a correlation on the state level between usage of opioid painkillers and drug overdose death rates.[2] Perhaps because of differences in marketing or physician prescribing practices


What can be done

It is important that state prescription drug monitoring programs share data with law enforcement officials for the purpose of investigating the unlawful diversion or misuse of certain controlled substances. For example, some state prescription drug monitoring programs are administered by a law enforcement agency in conjunction with a state board of pharmacy


This recommendations falls in line with what California is implementing through the CURES program which will give providers instant online access to all scheduled drugs obtained via prescription by a patient. Law enforcement also has access to this data as needed. I recently posted about that program here

What is going on here is a direct result of politicizing medicine by the pain rights movement and the organizations (Joint Commission and others) that have mandated liberal pain management into guidelines and enforcement standards. More recently the push to promote patient satisfaction in Healthcare organizations has resulted in liberalizing of prescribing opioid medications to make patients happy. Whatever happened to do no harm? Medicine has lost its way. These numbers should serve as a wake up call and re-examination of pain management practices and the whole concept of pain as the fifth vital sign.

California takes a big step forward in fighting prescription drug abuse

In 2005 California expanded the CURES program to include all Schedule II-IV prescriptions dispensed. These medications have to be reported to the State Attorney Generals office who maintains a database of medications dispensed. This includes controlled substances directly dispensed from, Pharmacies, Doctors offices, clinics, and Emergency Departments that give out the to-go six pack of Vicodin when patients present after pharmacies are closed. Reports to the CURES program are done using a direct dispensing log that is faxed weekly to the CURES program.

Medical Providers and Pharmacist have been able to tap into this database by requesting an activity report on patients under their care. What they get is a print-out of every controlled Rx filled by the patient regardless of the source. In the past this report took several days to weeks to obtain. It was little use for the Provider who is trying to figure out if the person in front of them is filling multiple scripts from multiple sources. It worked well for ongoing care of repeat patients. I have seen it work well with some of our regular patients who return like clockwork to the ED several times a month. When confronted with the report of scripts they have filled recently and neglected to mention when listing their medications most give up knowing they have been had and you don’t see them again.

Soon the availability of activity reports will be online instantly via the California Attorney Generals web site. Instant access to a patients controlled substance prescription activity will give providers knowledge if they being lied to, used, played, to feed a habit or supply someone with an income who is reselling their meds. For those with legitimate pain conditions who are not seeking medication from multiple sources it should help them by removing the cloud of suspicion that follows them when seeking pain relief.

This effort is being funded partially by the Troy and Alana Pack Foundation founded by Bob Pack who’s 7 and 10 year old children were killed by a driver under the influence of prescription drugs obtained from multiple doctors. The Wall Street Journal recently had an article about the program.

Its about time.

Disparities in Healthcare and Staff Discipline at UC Hospitals

The University of California Hospitals have been involved for many years in studying and pointing out the Disparities in Health care delivery and access in America between ethnic groups, genders, and other perceived disadvantaged groups. All have the same theme, disadvantaged or people of color get worse health care given the same conditions. All one has to do is Google “Disparities in Health care” and UC California and you will be treated to a whole host of studies, articles, talks, or seminars where UC researchers, mainly physicians, point out these disparities. UC seems to have taken the lead in many respects in pointing out the problem. That being said, one would think they would set an example within their own institution on equality. The tremendous body of research and the recent revelation about the disparities in disciplinary action between UC Physicians and non physicians for patient privacy breaches at UCLA Medical Center reminds me of that old saying about people in glass houses and throwing stones.

In case anyone missed it, a number of employees at UCLA Medical Center were caught recently peeking into the electronic records of Britney Spears and other celebrities. This has not been an isolated event as media reports and the citation and plan of correction from the California Department of Public Health revel that it has been going on for some time on a rather large scale. In regards to the Spears case, California Health Line reported ..

The Department of Public Health said 53 employees, including 14 doctors, at UCLA Medical Center breached Spears' records on two occasions. None of the physicians quit or were fired, while 18 other employees resigned, retired or were dismissed after the violations were discovered, according to UCLA data.

I guess I am not surprised by hypocrisy in one of the ivory towers of Academic Healthcare but I am surprised that they would hand a gift to the cases of workers that were fired. If the fired workers unions cannot capitalize on the inequity in treatment to the benefit of those fired then they are not representing their workers well. For a disciplinary action to prevail in arbitration with public or unionized employees it must be based on “Just Cause”. Over the years Arbitrators in hearing disciplinary cases have agreed that to establish Just Cause there are 7 tests that should be met. One of the 7 tests is equal treatment or discipline for similar offenses. It also can open Pandora’s box to a discrimination case if the person treated less equal is a member of a minority group or other protected class.

UC has an explanation for the treatment inequity. Physicians are peer reviewed in disciplinary cases. Everyone else deals with HR. They acknowledge that Physicians historically have been treated more leniently. Should they be? One could make a case that the the expectations and thus penalties for physicians should be higher than less educated staff.

David Feinberg, CEO of the UCLA Hospital System, said, "Historically, doctors have been treated in a way that may be more lenient than nonphysicians, and we will address that."

In their attempt to address the problem of privacy breaches and how to respond equitably to all offenders Gene Brock, UC Chancellor, has set up a committee of 11 people from various UC campus to come up with recommendations. 7 of the 11 are Physicians leaders, the rest are HR or Public Information staff. No Nurses or ancillary staff leaders. More stones for their glass houses.

RME: Rapid Mediocre Evaluation

Rapid Medical Evaluation is one of the latest buzz words for programs promoted used by ED Physician groups to promote faster ED throughput and market their groups to hospitals. Its similar to “Provider is Triage”, “Triage Bypass”, and “Door to Doc” programs some of which I have written about before and so have others here. RME is proprietary to a California ED group, California Emergency Physicians (CEP).

The premise goes something like this. Patients presenting to the ED can be rapidly divided into 2 groups the sick and less sick based on a quick look rather than a full triage. This is done by bringing every patient upon presentation immediatly back to a intake area staffed with a physician or more commonly a PA and a Nurse or in some cases only a PA, tech, and unit clerk. After a quick focused interview by the provider the patient is put into one of the 2 categories. The sick group goes to the main ED for treatment. The less sick group may either be discharged on the spot or sent off to various areas for lab or radiology studies. The less sick group does not own a bed and rarely gets undressed. The less sick group is not assigned to a Nurse in most cases. They move about the hospital similar to the way you would move from area to area in a clinic setting basically on their own and once all the results are in they are dispo’ed. The benefits reported are quicker door to provider times, fewer Left Without Being Seen patients, and more revenue for the hospitals and ED groups.

Some of this sounds good but lets peel back the onion and look beyond the marketing aspects and flashy improvement of ED metric’s that some of these programs report. Since these programs are primarily focused on the low acuity patients do they really do anything about ED overcrowding. The primary reason ED’s are in crisis is not a large volume of low acuity patients. If there is a back up of low acuity patients waiting to get into fast track is that a crisis that endangers patient safety, usually not. It’s the high acuity patients and the difficulties in dispositioning those patients that is the majority of the problem. Lack of inpatient beds or staff, lack of specialist coverage, lack of primary care, and an aging population being the main culprits. ENA has a well refrenced position statement on ED overcrowding that examines the issue.

None of these programs are consistent with national standards for Triage which usually gets eliminated or stripped down when RME is implemented. Both ENA and ACEP have endorsed a 5 level triage system. ENA and ACEP have a joint position statement here. ENA at their 2007 meeting specifically endorsed either the 5 level Canadian Triage Acuity System (CTAS) or the Emergency Severity Index (ESI) Historically ED triage systems have been 3 level and the research has shown that the 3 level systems have poor reliability and predictive value where as the 5 level systems have good predictive value. So now were supposed to believe that a 2 level system is the way to go. Perhaps the biggest flaw is the assumption that the majority of ED visits can be can be reduced to a quick look and a 3 minute interview a couple of tests, a quick prescription (likely not indicated) and disposition out the door. Many low acuity presentations are obvious but you will get burned by practicing like most are. Elderly and special needs populations even when presenting with a minor stated complaint need an history, physical exam, vital signs, and Nursing assessment.

Administrators see these programs as a way to reduce Nursing hours. CEP claims in their web site that the less sick patients do not need to be assigned to a Nurse. Kind of an end run around the California Nursing Ratio’s

“A corollary of RME to rapid care is the more efficient utilization of nurses and the elimination of many nurse hours that are required for compliance with many regulated state and healthcare system nurse:patient ratios. For example, by seeing, caring for and discharging a patient directly, and eliminating the need to count that patient as being in a bed in the ED, significant nurse hours may be reduced in the ED. Nurses find professional satisfaction with a career in an efficiently run ED, thus lowering hospital recruitment and retention costs”

So if patients only need ancillary testing they wont get counted in the Nursing Ratio’s? The promoters want it both ways. They want to end the Nurse Patient relationship with the less sick patients but in the real world a Nurse gets assigned many of the tasks to process the patient in and out and most regulatory agencies require some form of Nurse involvement. I have news for CEP. If a Nurse assess, gives medication (even Tylenol), performs a treatment, draws blood, performs a breathing treatment, or discharges a patient a Nurse Patient relationship is established and the patient is counted in the ratio’s, at least in California. You can not reduce Nursing to a series of tasks as much as you’d like to.

But what about the numbers, these programs produce great numbers! Yes, some do, especially if you don’t have a good understanding of statistics and view all patients as equal. The focus in the promotion is 3 primarily ED metric’s, LWBS, Door to Provider, and Patient Satisfaction scores with Patient Satisfaction scores being one of the biggest drivers. Because most high acuity patients get excluded from the satisfaction surveys the scores represents a skewed representation of what an ED does. The published metric's I have seen at the links here and others are relatively short duration measurements with no outcome studies. They avoid the subject of return ED visits rates, missed findings, morbidity and mortality from doing an inadequate exam or work-up or having the patient seen by a PA instead of a MD, or the negative effects of eliminating an effective Triage system. If you discharge patients before they have a chance to leave without being seen your LWBS rate will decline. You can drive down the door to provider time by putting the provider at the front end of the process but what does this do for the back end high acuity patients. Patients generally will be happier if waits are reduced, even if the care is sloppy. And finally, most of these programs are implemented simultaneously with other process changes such as bedside registration, expanded fast track capacity and hours, and immediate bedding which have been shown to be very effective. My experience is that the credit for the improvement is claimed by the RME type processes promoters when it would more accurately go to the bedside registration, expanded fast track, and immediate bedding processes The rest is window dressing and mediocre care designed to sell the services of the ED group promoting it and buff satisfaction scores.

MAB: Managing Assaultive Behavior - in the Trauma Room

This summary is not available. Please click here to view the post.

Who are the real Villains in the Nataline Sarkisyan case.

Ever hear the expression, Don’t let the facts get in the way of a good story. In the case of the well publicized death of a 17 year old from LA who while being treated for Leukemia went into Liver failure and was “denied” a transplant by CIGNA Insurance, that appears have happened. I won’t rehash the entire story as it is all over the media and has entered the health care debate at State and National levels. One candidate, John Edwards, has made it part of his campaign and advocates of “Single Payer” which is code for “Government run and taxpayer financed Health care” are using Nataline’s case as their poster child for the cause. The father appeared at a rally the other day and was quoted as saying “CIGNA killed Nataline”. The family has retained infamous looser lawyer, Mark Geragos, in their almost certain lawsuit against CIGNA. He and others are requesting that CIGNA execs be charged with murder.

Maggie Mahar has written one of the most balanced pieces on this issue titled “Bad cases make bad law” its an eye opener for those who haven't looked at this in depth.

“The fact that Nataline’s case had gone sour on her doctors’ watch might have made them less than objective. I’m not suggesting that the doctors were worried about a malpractice suit: following bone marrow transplants, patients are very susceptible to complications. There is no indication that the physicians caring for her did anything wrong. Nevertheless, at least one prominent palliative care specialist has told me that sometimes she has to protect patients from surgeons who want to try to repair a failed procedure —with yet another surgery. “They can’t bear the failure—they want to make it right. This is what they have been trained to do.” But they are not necessarily thinking about what is best for the patient”.

Two things stood out to me in this story. Those being were, is this patient even a candidate for a liver transplant and if she was why did not UCLA do the operation rather than wait for insurance approval. CIGNA had approved her bone marrow transplant which was unsuccessful. UCLA certainly did not need CIGNA’s approval for the transplant operation, only for the payment. Looking over the exclusion criteria for liver transplants from 2 other facilities that have good reputations in the transplant area I noted that this patient was not a candidate. Sanford who’s criteria is listed here and California Pacific Medical Center in San Francisco who’s criteria is listed here both exclude patients with non-hepatic malignancies. I could not find UCLA’s criteria in any searches.

I nominate the following as the Villains in this case

1. UCLA medical center for raising this families hopes when she would not of been a candidate for the operation at most transplant centers. They get a double nomination for not performing the operation if they felt it could of saved this girls life. A hospital does not need approval from a 3rd party insurer to perform a lifesaving operation. Considering the narrow window of availability of livers and this patients grave condition If UCLA felt she could have benefited they should have performed the operation immediately upon the availability of a donor liver and appealed the denial. Instead UCLA asked the family for a $75000 deposit to do the procedure which they did not have. Most appeals eventually end up getting paid. Even if they were not paid UCLA could have performed the case as charity care and been the good guys. UCLA is infamous for its excessive end of life care with no better results than more conservative like institutions. This is likely being driven by their excess bed capacity and a high percentage of specialist. Its all well documented here in this study by Drartmouth University.

2. The organizations promoting single payer who are exploiting this case and the family for the cause. In particular, one that I am a member of, the California Nurses Association. They have done a lot for nurses at the bargaining table and getting Nursing Ratios but their political agenda is way to Micheal Moorish. I cannot remember CNA ever soliciting its members on whether they even support single payer before devoting our dues money to that cause. Emails to their leadership expressing an opposite point of view are ignored. CNA members are some of the highest paid nurses in the country. That would not of happened under single payer where government sets the reimbursement.

3. Politicians and slimball lawyers led by slimball in chief John Edwards. Politicians do not normally piss me off, Edwards is an exception. He made his millions by suing OB doctors in cerebral palsy cases for not doing c-sections. He used junk science and courtroom theatrics imitating a fetus stuck inside the mother yelling to get out to sway juries. Note to Edwards, most recent research has shown that CP is not related to delayed C-sections but lets not let facts get in the way of a good story, especially when big money is at stake. Edwards, the champion of the poor, is well known for giving speeches on poverty in America for 50,000 a pop. One recently for none other than the University of California at Davis. You’d think the University of California would have better things to do with taxpayers and students money, apparently not.

I hate to be in a position defending an Insurance company. I generally despise them and as Maggie Mahar states

“Meanwhile there are so many clear-cut problems in our for-profit private insurance industry that should be investigated in a court of law. I would like to see states take insurers to court for the way they “cherry-pick” their customers, shunning the sick, and raising premiums on customers who become seriously ill. Often, insurers scour their records looking for some scrap of evidence that the patients’ illness may have been caused by a pre-existing condition. Insurers also write policies in such a way that it is very difficult to know, for certain, what will be covered—and they advertise “super-saver” policies that contain so many holes that they don’t even deserve to called “insurance.”

Another tip for the single payer crowd would be pick your battles. Being wrong and going public with it in such a high profile case and trying to capitalize on other peoples tragedies ruins your credibility for legitimate issues.