American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, February 14, 2013

How might doctors avoid killing or hurting people in their care?

Hospitals are very focused on avoiding harming patients lately. They have been moving in that direction for a long time, but with health care reform legislation, payments are on the line, which makes something that was a very good idea into an imperative.

In the year 2000, the Institute of Medicine, a non-profit organization that monitors various aspects of medical care, reported that 44,000 to 98,000 people died each year due to medical errors. This began a nationwide focus on patient safety that has had some, but not enough, impact on outcomes. Hospitals already do not get paid for care of a patient who gets a blood stream infection from their central venous catheter or a urinary tract infection from their bladder catheter, so they have to eat the costs associated with these things.

When a hospital is paid a lump sum for a diagnosis (say a patient is admitted with appendicitis) and the patient gets some complication that makes their care longer or more expensive, the amount of money the hospital makes on the whole episode is less. But at some point in the not too distant future all payment will be based on good outcomes and having some event in the hospital that makes things more complicated (and the patient sicker) will hurt the hospital almost as much as it does the patient.

We call the bad things that happen to patients "adverse events" and we try to eliminate all "preventable adverse events."

Some of these adverse events are really obviously our fault, and others are so preventable that we consider not preventing them to be unconscionable. Our fault would be doing the wrong procedure or the right procedure to the wrong patient or body part, leaving a sponge in a patient's wound, causing infection of a procedural site by not using sterile technique, giving the wrong medication or the wrong dose, or a medication to which a patient has an allergy.

MRI machines have powerful magnets and occasionally make metal objects brought into the room into deadly or injurious projectiles. We have foul, evil bacteria in hospitals, and if we don't wash our hands between patients we will transmit bugs such as methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile from patient to patient. We know that patients who are bedridden or have had orthopedic procedures get blood clots in their legs that can go to their lungs and kill them, so we give them medications that prevent clotting and sometimes contraptions that massage the blood in their legs. We know that patients on ventilators with tubes in their tracheas will develop pneumonia if kept lying flat, so we elevate the heads of their beds. We know that delirious and elderly folks who are weak are liable to fall and break bones so we watch them very carefully. We know that fragile skin on the bottom can break down and cause pressure ulcers if we don't turn a bedridden patient regularly.

Hospitals are carefully monitored and soundly disciplined if they have too many of these bad things happen, so we really do pay good, and progressively better attention to this sort of thing.

What we don't necessarily recognize is the huge burden of adverse events that happen in hospitals just because patients are in hospitals, despite or because of the fact that they are being treated by our best and brightest physicians with our best evidence based medicine and fancy technology.

Patients are usually admitted to the hospital because they have something wrong enough that they can't safely stay home. Sometimes they are admitted because we aren't sure whether this is true, but want to be on the safe side. When we make the decision to hospitalize a patient, we take on a huge responsibility and expose the patient to very significant risks.

We almost always put an IV in the patient. This is a small sterile tube that goes into a vein and is held in place by something sticky. We then hook the IV up to some sort of fluid with a pump which goes "beep beep beep beep ..." when the little tube gets kinked or displaced. We sometimes give the patient various medications through the IV, maybe diuretics to take off some fluids, sedatives to calm them down, antibiotics to kill real or imagined infections, solutions of various salts to increase the blood volume, or drugs for nausea, pain and high blood pressure. The beeping wakes them up, but the sedatives make them sleep. They become sleep deprived. The pain medications make them goofy and constipated. The fluids discombobulate their own electrolyte levels or overload them causing swelling and oxygen deficiency. The diuretics, if we went in that direction, cause kidney injury, which is strongly associated with in hospital death. They are not fed because we do tests that require that they not eat, so if they are diabetic their blood sugars drop, and then go too high when they finally get a giant tray of food which is much different than what they eat at home.

Much of what we do to patients is based in our culture of infinite health care resources. We don't necessarily even need the IV, but put it in anyway, just in case. There is a perverse incentive to do this, since a patient on IV medications of certain types is felt by payers such as Medicare to need hospitalization, and one without an IV is not. We are paid for a higher level of care if a patient is getting opiate pain medications by the IV route. We don't do these things just to make more money, but we are also not immune to perverse incentives. We sometimes do tests without thinking whether they are necessary. We try to avoid fluid overload or dehydration but we don't necessarily watch people as closely as we should.

Being in a hospital is dangerous. It is also sometimes necessary, and sometimes more dangerous to not be in a hospital. Still. The science of patient safety could link itself more effectively to cost effective care. I would bet that there is actually not one patient admitted to the hospital who does not have a health care associated complication, if we keep in mind that things as seemingly trivial to providers as damage to veins from IVs and blood draws and financial ruin related to hospital costs are truly significant to the patients in our care.

We need to be attentive to the fact that every little thing we do, from ordering a medication to ordering a test, carries with it a significant risk, and notice that some portion of our patients' medical problems stem directly from our best intentions.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health care so expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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