MAB: Managing Assaultive Behavior - in the Trauma Room

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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.

How has the Patient Satisfaction push effected your practice

In the past 2 years Patient Satisfaction scores have led to a major change in priorities in Emergency Departments. I have written about some of the ways ED’s are changing here. Many feel the patient survey is biased toward the less sick (read Ron Elfenbein's editorial in ep monthly) patient because it excludes admits and transfers and is based on relatively a small percentage of returns from very low acuity patients. Regardless, survey results are on the Web and in the newspaper which can lead to a major competitive advantage or disadvantage depending on where you fall. Perception is more important than reality in our sound bite world. Nothing evidences that more than some of the consulting groups offering seminars on how to change the patients perception (not the care itself) of their experience. Have you been studerized? Another example is the willingness of some hospitals, Sutter Health Alta Bates Hospital in this case, to target 3 employees from each unit who are "Not onboard with our service expectations" for disciplinary action to improve their Press Ganey scores.


Perceptions aside, has this emphasis changed practice for the better or worse in Emergency Departments? Below is an unscientific survey for “Providers” regarding how the patient satisfaction push in Emergency Departments has effected your practice in the past 2 years. I am starting with Providers but will follow-up with Nurses and Managers. I have weighted the score based on things generally considered good practice based on my experience. Do not consider, for the sake of clarity, other factors that have changed in the past 2 years such as new research, guidelines, institutional policies, and legal climate, only consider the effect of the Patient Satisfaction scores in your answers. Only Yes Answers get scored. Everyone starts at 0. Now lets take the test.

1. Do you see patients sooner than you did 2 years ago (quicker door to provider time)? Add 5
2. Do you cut short exams or procedures to achieve seeing new patients sooner? Subtract 5
3. Do you spend more time with your patients than you did 2 years ago? Add 5
4. Are you more likely to keep the patient informed of delays and explain procedures? Add 5
5. Are you more likely to troubleshoot delays in admission and testing to reduce the patients waiting time to admission and improve ED flow? Add 5
6. Do you provide a higher level of personal service to those who are included in the survey as opposed to those who are excluded? Subtract 10
7. Are you more likely to prescribe antibiotics upon patient request when the clinical indications suggest a viral etiology of infection or otherwise are not indicated? Subtract 10
8. Are you more likely to prescribe narcotic pain medication, stronger narcotic pain medication, or a larger quantity upon patient request when the indication is weak or a NSAID would be the better medication choice? Subtract 10
9. Are you more likely to order expensive tests such as CT Scans or MRI’s upon patient request when the indication is weak? Subtract 5
10. Are you more likely to directly dispense take home medications from the ER upon patient request, especially narcotics? Subtract 5
11. Are you more likely to tolerate disrespectful behavior or verbal abuse to avoid a complaint or negative survey? Subtract 5
12. Are you more likely to encourage or pressure Nursing or Ancillary staff to tolerate disrespectful behavior or verbal abuse to avoid a complaint or negative survey* Subtract 10
13. Are you more likely to avoid educating patients about negative health behaviors to avoid offending them and getting a negative survey? Subtract 5
14. Are you more likely to pressure Nursing to avoid educating patients about negative health behaviors to avoid offending them?* Subtract 10
15. Are you less likely to report suspected conditions such as domestic violence, child, or elder abuse to avoid angering patients and risking a negative survey?* Subtract 15

Now add up your score. Here is Murse's take on how the patient satisfaction push has effected your practice.

+5 to +20 – You are the bomb. Come work in my ED. You truly care about doing what is best for your patients and have not been pressured to make bad decisions to get a better score. You are ethical. The Nurses love working with you. Its not very likely that you’re the director of your ED group.

0 – You’re a solid practioner but you probably have been asleep for 2 years or on an extended sabbatical or trek in Tibet. Nothing effects you. Your probably the type that does not even look up from the desk when a patient is totally going off just on the other side. You operate at one speed regardless of the activity in the department. Also not likely influenced by bean counters or Pharmaceutical reps. Probably wears the same type cloths and prescribes the same type of medications you did 15 years ago. You could be an Attending in many academic medical centers riding out your tenure to retirement. The Nurses ignore you except to look at your cool vacation photo’s that you frequently load up on the department computer and show even during busy times.

-5 to -15 – You don’t like confrontation especially from bean counters or demanding patients. Have a little bit of a backbone problem. Perhaps your testicals have not fully descended if your male. Your not dangerous but just a little bit irritating. You give wishy washy answers to keep everyone happy. You like being peoples friend and generally are but are not someone to go to for support.

> - 15 – You would sell your sole to the devil. You sell out your peers for political expediency. Your either trying to impress some bean counter with the bump in scores at the expense of safe practice or you or your ER group is getting a financial bonus for improving their patient satisfaction scores which drives your actions. You probably do unnecessary procedures under the cover of poorly supported guidelines to increase your reimbursement. You likely prescribe every new expensive medication after sucking up freebie trips and dinners from the Pharmaceutical rep. You just might be the Director of your ED group. The Nurses dislike you.

*If yes to any of these questions then mandatory failure regardless of final score. Some Nurse is likely to drop a dime to on you to the State Licensing Board if you ever screw up.

Templated Charting - The Slippery Slope to Fraudulant Documentation

The other day at work I was taking care of a patient that was in an MVC. She was in spinal precautions and complained of neck, and leg pain. Our ED Physician came in and did his exam from the door way holding his Tablet PC marking off items into the Electronic T-sheet while he asked a few basic questions. He was in and out in less than a minute. Out of curiosity, I reviewed his documentation and not surprisingly there was a comprehensive assessment documented. Abdominal findings, lungs sounds, heart sounds, pupils and ocular movements, neuro exam, all beautifully documented in a long paragraph and all normal. Not bad for an exam conducted from the doorway. I watched without comment throughout the day and noticed the same general exam pattern on most of his patients and the same comprehensive documentation of his exams. About one half of the Docs in this ED practice operate in a similar way although he is the worst. Others actually perform the exams they document and coincidental, have the longest door to provider times. They are being pressured to speed up their times. Exams do take time. This same Physician above is the promoter of Triage Bypass policy being promoted at the ED I work. He claims that asking patients the same questions and doing the same exam he will do (or not do) in Triage is an unnecessary delay and negatively effects patient satisfaction scores. So now when beds are open were rushing patients back with nothing more than an eyeball assessment to make them happy and get them to the Doctor who does a 1 minute exam from the doorway and fudges the chart. Guess what, our patient satisfaction numbers are way up and our length of stay is down. Administration is happy.

Fudging charting is not isolated to Physicians and Electronic Documentation. Another ED I occasionally work at I see nurses regularly check off on the paper T-Sheet items that were not done. I even see some make up phony discharge vital signs rather than take the time to do them. I recently had a discussion with my Charge Nurse who audits charts prior to the end of the shift. She was all over me because I was not checking off the boxes which said ID Band confirmed, Bed in low position, Side rails up x 2, patient gowned, blanket provided, and including discharge vitals. I told her, the patient was a Fast Track patient and discharged within minutes of arrival, I didn’t do all those things. Doesn’t matter she said, “Just check the boxes or we get dinged”. I told her to go ahead and ding me, make my day. I’d rather get dinged for not checking boxes than falsifying a chart. My stand is being viewed as I'm just being difficult.

The question that this begs is whether the problem is with the individuals or the tool. My opinion is a poorly designed tool facilitates shortcuts in certain individuals who are either lazy, dishonest, or very uninformed about what they are charting. Templated charting, either paper or electronic, can cross the line rapidly into fraudulent charting in those individuals. I don’t think they view it as fraud and are able to rationalize their actions because they feel they are only documenting to satisfy a regulatory requirement. In the case of documenting items not done to obtain a higher billing level there is no question in my mind that fraud is occurring.

A good article, here, at AIS Health.com list some of the issues with templated electronic documentation.

"Physicians love electronic medical record (EMR) templates because they make documentation faster and easier, but abuses, such as cloning and "exploding" notes, are jeopardizing reimbursement and compliance, experts say. If too much information is replicated from one EMR to the next, there is little to distinguish patient encounters, and that undermines physician attempts to establish medical necessity — the foundation of Medicare reimbursement — and perhaps implicates quality of care."

My first example I listed is an example of an exploding note. Basically, an electronic template is pulled up for a specific complaint, a few mouse clicks is all it takes to default all values to normal and a beautiful paragraph is produced based on programming code behind the scenes listing all the elements of a comprehensive normal exam. To change the defaults you need to click a few more times either selecting common abnormal values or free text the abnormal finding in. The path of least resistance is the former.

"Cloning can work for elements of the history, but cannot and should not be used for the history of present illness, the exam or the medical decision-making portion," the compliance officer says."

Cloning refers to pulling data forward from previous visits or from another persons note, usually via copy and paste, into your note and signing it as yours. Very helpful for a long history which does not change but problematic for a physical exam that you did not do. In Academic Medical Centers its common for the Student to do the exam, the Resident pulls forward the note as theirs and on rounds the Attending does the same and signs it electronically.

Templated charting both paper and electronic has caught the attention of many in the HIM community. The American Health Information Management Association has a good paper on Guidelines for EHR Documentation to prevent Fraud. The article list many types of documentation problems and recommendations and the appendix gives real case examples.

“Electronic documentation tools offer exciting new time-saving and validity checking features designed to enhance communication for all health record users. They address traditional, well-known requirements for documentation principles, while supporting expansive new HIM capabilities. However, use of these features without appropriate management and guidelines may cause invalid auto population of data fields, manufactured documentation to enhance expected reimbursement, and other undesirable outcomes”

What is the solution? It’s certainly not to stop using templated charting or electronic charting. It won’t be long before everyone is doing it. A strong set of standards for EMR design and training is essential. Charting tools that require structured data for most exam documentation would help. Rules against copying notes of others and calling them yours and the clear understanding that if you have charted something you did not do you have committed fraud. You can report fraud here. Templated charting, if used correctly, prompts the individual to perform complete exams and documentation and can enhance patient safety.

Change of shift at Emergiblog

Some great posts included including my most recent on patient satisfaction scores

http://ermurse.blogspot.com/2007/09/ed-patient-satisfacion-scores-out-of.html

ED Patient Satisfacion Scores - Out of Balance

A few months ago I ran a post titled Top Ten ways to improve your Patient Satisfaction Scores where I listed some of the disturbing methods being undertaken to improve patient satisfaction scores in Emergency Departments. Is anyone else bothered by the constant drum beat from administration that seems to have a single minded focus on satisfaction scores to the exclusion of almost everything else? I have seen Managers in tears when the monthly report cards come out and their scores for their departments have not risen or perhaps even dipped a point or two. Many Managers who until recently were at the top of their careers suddenly are pushed out over the issue. Why is this so important now? Easy, it’s being tied to reimbursement, CEO bonuses, and it’s now listed on the web which gets featured in many community newspapers. In the typical 2-4 Hospital town it can become a major competitive advantage or disadvantage. That would be fine if the scores reflected the critical mission of an Emergency Department. I do not believe they do.

Now before everyone gets their panties in a bunch I am not advocating against a satisfied patient. That would be like being against mom and apple pie. What I am advocating for is balance. The surveys focus seems to lack balance and does not recognize that Emergency Departments primary focus should be emergencies. Lets look at the survey and who it targets, and more importantly, who gets excluded. The National Quality Measures Clearinghouse forms the basis of the Press Ganey or other organizations who produce patient satisfaction surveys sent to ED Patients. Here is a survey section on ED satisfaction and who gets excluded is described below.

“Patients with an emergency department (ED) visit during the reporting period who answered at least one question in the "Overall Assessment" section of the Emergency Department Survey. Deceased patients, patients admitted to hospital through the ED, patients who leave the ED against medical advice, patients who leave the ED without being seen, and patients transferred to another hospital/institution are not eligible”

So the Critical Care patient who you and half the department bust your ass to stabilize, admit, or transfer does not get surveyed, at least for their ED stay. Some hospital surveys do include these patients for their own purposes but they are excluded from the reported scores used for like hospital comparison of Emergency Department questions. In fact, putting a lot of resources into your critical patient can detract from and increase waits for the non-critical patient, the ones who get surveyed, many of which don’t need to be there. We all know that wait times are highly correlated to patient satisfaction. That is why Hospitals have changed their focus and are catering to the lower acuity patients with programs such as expanded Fast Tracks, Provider is Triage, Triage Bypass, liberal prescription practices, and other sometimes short sighted practices that sacrifice solid principles and safety for expediency. Critical care and educating staff to do well at it in many ED's has assumed a lower priority.

I have a suggestion. The survey should be weighted based on the patients acuity. Critical patients surveys would be weighted heavily and patients with clinic conditions should receive much less weight. So if I get high rating from one acute MI that should mean as much as 5 clinic patients. If that were to happen you would see administration put much more emphasis into expanded training and education with a focus on critical thinking and skills rather than over serving a patient population who want boutique treatment with no waiting.

Remote CPOE error and the relationship to Critical Thinking Nurses

In recent past post on several blogs I, along with numerous others, engaged in some back and forth banter about the appropriateness of Nurses questioning Dr’s treatment orders. I remember one of the quotes of someone, I presume an MD, who expressed strong feelings about having his judgment questioned by a Nurse, “Because I’m the Doctor, that’s why” and other comments to the effect of What Medical School did you go to blah blah blah. A couple examples of this attitude mostly in the comments on posts here, and here. I have had similar discussions in my various workplaces over the years with a few MD’s who expressed similar opinions. Fortunately they are in the minority. Most Physicians value Nursing input and recognize the benefits to themselves as well as patients.

I ran across an interesting article in the newsletter from the Institute for Safe Medication Practices that puts this argument in perspective for me.

From the May 31, 2007 issueProblem: ISMP received a report from a hospital where a medical resident had prescribed a NORCURON (vecuronium) infusion for the wrong patient via a computerized prescriber order entry (CPOE) system in a remote location. She meant to order the infusion for a ventilated patient in ICU but accidentally prescribed the drug for a patient on a medical unit.

ERMurse’s opinion on how this could of happened. Most EMR systems have features called Patient Lists which are very valuable for staff seeing patients in multiple locations especially in large facilities. For example, all patients assigned to a particular admitting service populate the Service List and individual practitioners can create their own lists adding patients manually. They work from these list extensively. In the electronic world a lot of work can be done remotely from the patients location. I suspect the Resident simply picked the wrong person from the list and the system did not have enough strategically placed visual cues in the list or on each screen of the patient record for the Resident to recognize the error. The placement on the list of appropriate patient identifiers and location can help in orientation to what patient you have accessed. Once in the record, did each screen have a prominent view across the top that displayed the patients name and location. Some EMR systems do, others once you pick a patient and begin wading through the various order and documentation screens you loose orientation of which patients record your on. Busy people get interrupted frequently and can resume work thinking they are on one patient and are actually on another. Simple design decisions and consistency of design in an EMR can keep the clinicians oriented to the correct patient or not.

An inexperienced resident pharmacist processed the order and prepared the infusion, failing to recognize that a neuromuscular blocking agent should never be sent to a medical unit where patients are not intubated and on ventilators. The resident pharmacist affixed two labels to the bag: one noting that the infusion was a high-alert medication, and the other stating that the drug was a “paralyzing agent.” The pharmacy technician who delivered the infusion did not think to question why the medication had been pre-scribed for a patient on the medical unit. An independent double-check was required for this medication before administration, so two nurses verified the drug, pump settings, and patient.

You think those 2 Nurses left something out? They did the 5 rights of med checking, well sort of. You can verify the order, route, patient, dose, and time and make this error if you do not possess the critical thinking skills to understand (or research) what your giving and why your giving it. My initial gut reaction is that all the people involved in the chain are incompetent. That may be the case but knowing the culture of the institution or floor is an important consideration in determining how this happened. Do the Nurses view themselves as independent licensed professionals with a duty to know their patients conditions and reasons for treatments and feel free to question Physicians on care issues or do they view themselves simply as being there to follow orders without understanding or questioning. A surprising number of Nurses practice this way. I do believe there is a cultural element in Nurses who do not critically think. In some cases it is the culture of the institution that discourages critical thinking, in others I believe it is a reflection of the culture of the Nurses and where they were trained which in my experience is more common among some foreign trained Nurses.

The infusion was started, after which the patient began walking to the bathroom. He fell to the floor once paralysis began to set in, but fortunately, he was able to call out for help. The resident physician was called, along with the rapid response team. When the team arrived and asked what happened, one of the nurses questioned whether the “new drug” she had just hung could be responsible. Realizing the problem, the physician immediately stopped the infusion.

Talk about a Shit your pants moment when that Doc looked up and saw Vec hanging on a Med Surg patient. I would have loved to have been a fly on the wall to see the expressions on the faces in that room.

The prescribing error escaped the attention of at least five staff members–the physician, pharmacist, pharmacy technician, and two nurses. The error was also able to get through the system despite safeguards such as warning labels and double-checks. It is also likely that the nurses working on the medical unit, where the drug had never been used, had little knowledge of Norcuron, its indication, its paralytic effect, and the need for mechanical ventilation, despite the warning label…..

Most likely, the problem was not that the nurses did not carry out an independent double-check according to a typical process used in many hospitals–independently comparing the “five rights” against the physician’s orders or a verified MAR.In fact, the nurses followed the physician’s orders perfectly. What is missing in the double-checking process is a cognitive review of the appropriateness of the drug, dose, and route of administration.

That’s why you look up meds your not familiar with and question any order that does not fit the picture. Getting back to the “Because I’m the Doctor” attitude I have only one thing to say, Be careful for what you ask for in how you would like Nurses follow your orders and not question your judgment. The result might not be in your best interest or the patients.