Managing  patients with multiple monitoring wires & tubing, and infusion lines constitutes a nightmare on tree street!  Astonishingly, not an anachronism.   I suggest we develop a system that incorporates wireless monitors, color coded pressure tubing, color coded intravenous lines, and methods to cable together multiple lines to create one  or two  input cables of infusion lines with power strips on IV poles to minimize cables on the floor and clotheslined power cables to wall sockets.     Also we need LARGE medication labels on the IV bags, color coded for important drugs like epinephrine, but large enough to read from 6 feet.  Lets get organized and decrease the entropy of patient transport.

Why is it in 2012 that we still occasionally encounter patients found unexpectedly dead in bed in a modern hospital?   Such incidents of delayed discovery create difficulty with successful resuscitation and if successful the patient may not wake up.  Moreover, if a patient is transferred recently from ICU or he/she is triaged, then litigation can be problematic.   We need to invest in buying or developing wireless monitors on all nonICU patients in the hospital which will reliably detect hypoxemia/malignant arrhythmia .  The system will page or otherwise notify the nurse when something is amiss so a rapid code or rapid response team can be called

 The health system should maintain a  program to evaluate and fund QI ideas from front line care givers.   These would be detailed proposals directed to either process or quality.   For example, a physician might propose an evaluation of the use of dexmedetomidine for delirium in the ICU, evaluating cost savings and morbidity.  An RRT might suggest a different staffing model to deal with transports of ventilated patients to improve efficiency.  An RN might suggest the approach that stops UTIs.  The health system  would provide resources to conduct the study and provide ethical oversight, which is especially needed for cost containment protocols.

Every day I walk into the very large hospital  complex and encounter family members and visitors bewildered and mesmerized with the complexity of getting around the medical center.  I suggest development of an in house GPS system.      Issue gps units to visitors and families in the lobby (swipe a credit card or something for deposit),  use their smart phones or issue free apps.  It should increase family and visitor satisfaction and make the medical center seem like a top ten futuristic place.  It may also enable security to track whereabouts of all visitors and help us find family for consents to also improve efficiency.

Observation:  Patient undergoes anesthesia with 1:1 constantly-present anesthesiologist/CRNA with ETCO2 monitored.   Case ends; patient goes to ICU, often with continuation of the same anesthetic or neuromuscular blockade or gets put on  an opioid infusion.  The patient  is  now 1:2 to 1:4  or so nursing with no expectation of continuous nursing presence.  But now ETCO2 is rarely done.  How does this make sense?  I propose that every intubated or trached patient in the hospital have mandatory ETCO2 monitoring and that it be recommended for any patient receiving oxygen.  The technology is available; let’s use it for patient safety.

Gawande in his recent checklist book discusses the role of emergency checklists for pilots.  We need this approach for medical emergencies.  Change the culture from one expecting caregivers to pridefully remember all aspects of managing a given emergency.  Create a set of the first five things that need done for common and uncommon emergencies.   For example for apparent anaphylaxis: 1. Give oxygen, 2, apply monitors, 3. Give epi, 4. Give H2 antagonists, 5. Call for Help.  Put on all PCs in the health system. Make an emergency checklist manual.   Make a smartphone app.  Sell the book and sell the app.

Larry Chu and colleagues at the Stanford AIM lab are proposing just that.  Modeling after the emergency checklists that pilots use for emergencies, they are introducing the notion that we in anesthesia and critical care should do the same.  Evidence for this notion was recently published in the NEJM:     Arriaga AF, etal: Simulation-Based Trial of Surgical-Crisis Checklists. N Engl J Med 2013;368:246-53.

You can get the cognitive aids by visiting Anesthesia Illustrated or clicking on this link (http://www.cognitiveaids.org).

"Search your feelings, Lord Vader. You will know it to be true.

Our earliest experiences in anesthesia are marked by the intense onslaught of feelings. We do not know how to focus our  attention; we don’t have the experience to parse what is relevant and what is extraneous. So we suffer from extreme anxiety, sensory overload, and become easily exhausted. Soon we become comfortable, and our anesthetic thinking dwells in the realm of information; physiology, pharmacology, do’s and don’ts.

If we are to progress to excellence, we need eventually to contend with our feelings about the craft and our feelings within the craft.

In past years, I have written regarding emotions within anesthesia. Most importantly, this includes establishing empathy for each patient so that the outcome matters more than just our own liability or reputation. When we are doing 6 cases a day or more, or spending long hours with inert patients, having that personal connection enhances vigilance and enhances our sense of meaning or purpose. This is accomplished as part of the pre-op interview.

Anxiety is an important component of anesthesia and must be cognitively addressed and titrated. Anesthesia is, by its nature, a tense undertaking. Anesthesiologists or anesthetists who don’t have that sense of tension get in trouble more often, or so I have observed over three decades. On the other hand, excessive tension leads to fatigue, unhappiness, and burnout (whatever that is.) We tend to become blind to the tension inherent in our jobs; I call this emotional adaptation, and liken it to sensory adaptation; that’s the term-of-art for the phenomenon that causes you to not smell the roasting turkey on thanksgiving after a few moments.

Emotional adaptation contains hidden dangers. We often manifest our clinical judgments through feelings. If you asked me to do a pediatric heart right now, I would be pretty anxious and rightly so, since I haven’t done one in over 20 years, and I have no business doing so now. In my experience, after impulse control issues (themselves frequently a manifestation of anxiety) the most common way in which an anesthesiologist gets into trouble is by getting in over their head, typically because they aren’t acknowledging their anxiety, they are over-adapted to tension or are just too fatigued. Fatigue manifests as judgment errors, and those errors are frequently insidious. Fatigue causes a practitioner to not put in a better IV for an arm tucked patient, or to not check the position before the drape goes on. As well, we are conditioned to downplay our tension as part of our training and culture. I certainly was never encouraged to express my feelings in training; just the opposite. Admitting tension or anxiety was (and is) a sign of weakness...

Our nature as anesthesiologists is to intellectualize. It is our legacy and our pride, and has served us well over the centuries in our battles with surgeons and with the struggle to relieve the suffering of our patients. Medicine has greatly benefitted as a result. But our careers and practices would be better served if we allowed ourselves and taught our trainees to legitimately engage feelings in the clinical environment.

My hospital recently ran an innovation tournament. over 1700 ideas but only one of them won to get implemented. So I share what I submitted in this and a series of posts to share my suggested innovations with others; perhaps some good will come out of the effort.

CRM Training

Only 17% of in-hospital cardiac arrest patients survive.     Simulation-based crisis resource management (CRM) teamwork training may help. However, cost constrained hospitals are reluctant to commit the necessary resources to sustain recurrent CRM training of hundreds of housestaff annually. RRT ICU nurses are permanent staff who can be trained once.  I propose a QI study to determine the impact on team practice performance, patient outcomes, and measures of institutional efficiency when simulation-based CRM trained first responder ICU nurses leverage this CRM knowledge by teaching housestaff in a real-time in-situ interprofessional education-facilitator paradigm associated with imminent and actual cardiopulmonary and respiratory arrests.

My hospital recently ran an innovation tournament. over 1700 ideas but only one of them won to get implemented. So I share what I submitted in this and a series of posts to share my suggested innovations with others; perhaps some good will come out of the effort.

Blog and ListServ monitoring

The health system needs to support a program to monitor blogs and email/facebook  discussion groups that focus on various diseases.  In particular people subscribing to these services may be searching for physician and hospital resources and if appropriate the blog-discussion group monitor could suggest  health system physicians or services.  In addition, some questions might be referred to  health system experts to provide public answers.  Blogs are easily found.  Email discussion lists can be found at http://www.lsoft.com/lists/LIST_Q.html.  Simply entering melanoma produces three discussion lists.  It seems a good way to develop international grassroots awareness, provide accurate public education,  and support for the health system.

My hospital recently ran an innovation tournament.  over 1700 ideas but only one of them won to get implemented.  So I share what I submitted in this and a series of posts to share my suggested innovations with others; perhaps some good will come out of the effort.

Ambidextrous Organization

The Innovators Dilemma(Christensen)  describes   failure of well-run companies to stay atop their industries when they confront  disruptive  technological change and is thought to be a reproducible phenomenon in all organizations.    Examples include Geisinger-like integrated health systems, emerging independence of advance practice nurses to displace MDs, & global healthcare competition.   Does the health system have a way to deal with the now small, but potentially disruptive low cost services offered in India?  I suggest that the health system create an administrative structure, a so called ambidextrous organization, which will facilitate and support development of potentially disruptive technologies without interfering with current cash cow services.   

Corruption

First, it seems that, in spite of all of the prior law enforcement reported here and elsewhere, massive fraud continues to be perpetrated against the federal government via Medicaid and Medicare. It’s impressive - 91 people and over 400 million dollars. Once again, South Florida appears to be an epicenter for this kind of criminal activity.

http://www.reuters.com/article/2012/10/04/usa-healthcare-fraud-idUSL1E8L4EY420121004

At least the US takes an interest in investigating and prosecuting fraud.....

Corruption or Incompetence?

This news item from the BBC should hardly be a surprise, as the previous posts covering misconduct related to the allocation of organs for transplants made it clear that this too is a ‘feature’ of Great Britain’s NHS.  The scope of the problem is unknown, likely because there has been little or nothing in the way of investigation. I would bet that the scope is far greater than this news item from the BBC suggests:

http://www.bbc.co.uk/news/health-19789397

This item does point out the existence of a class of ‘medical tourist’ that has been largely ignored in public discourse and press coverage: relatively indigent patients who bribe their way into a public health system. This is not a problem unique to Britain’s NHS.  Everyone understands that this happens at county hospitals all over the USA, and that most of the recipients are illegal immigrants here. 

It is worth noting that at least a third of the hospitals that England’s NHS queried didn’t even try to ascertain whether their patients were entitled to care.  Why? They may be driven by high ethical standards. They might be constrained in the kinds of documents they can request patients to produce. They might be afraid of getting caught as those described in this story were. I do wonder if the administration of the NHS has ever broached this as a topic in any discussion with their public. My guess is that most Britons would be distressed to learn about the scope and expense of this diversion of their tax dollars.

I-told-you-so

Finally, in what should not be news to anyone who has read my previous posts here, there is growing bi-partisan concern about both the costs and consequences of the federal mandate for the electronic medical record, as this recent story documents:

http://www.publicintegrity.org/2012/10/05/11189/top-house-republicans-demand-suspension-electronic-medical-records-program

Remember, you probably heard it here first.

If it bleeds, it leads.  This dictum drives much of the modern news media, shapes what is regarded as news, and slants the coverage of everything you see, hear, and read.  Going by the news, you would think that many US cities resemble the towns depicted in old-time westerns, and that hospitals are slaughter houses. ‘Medical accidents kill hundreds of people every day!’ is the inescapable conclusion of anyone who reads the hype in the media that followed, and continues to follow, the fabled IOM report.  ‘It’s like a 747 crashing every day’ is a common refrain in these discussions. 

A colleague pointed me to this article recently:

http://www.dailymail.co.uk/news/article-2090332/Four-patients-die-thirsty-starving-EVERY-DAY-hospital-wards-damning-new-statistics.html?ito=feeds-newsxml

Once again, we have a news item that casts the NHS in a very poor light.  But is this a reasonable interpretation of the data?  The short answer is no.  Almost every hospital in the US admits patients with dehydration every day.  Dehydration is a common feature among elderly patients who fall ill in a nursing home, and is almost invariably accompanied by urinary tract infections/urosepsis, mental status changes from their previous baseline, and bedsores.  The mortality rate of patients admitted with these problems is high.  Attribution of cause of death is a social construct, even when an autopsy has been performed (the certainty of television shows not withstanding).  Most practitioners would represent that these patients died of urosepsis and their underlying condition. Most would list the dehydration as a contributing cause, but not the major cause.  If you read the above item from the Mail Online carefully, you see that a much smaller number of patients are alleged to have died from dehydration while in hospital, the majority (>70%) seem to have it listed as a contributing cause.  My guess is that there is a coding error here, and that at least a few, and likely a majority of the patients who are alleged to have died of dehydration died of some other cause. The database itself is somewhat suspect, because I would contend that admission with dehydration occurs more commonly than this report represents.  The British numbers, are too low to represent an accurate accounting of the patients admitted to their hospitals with dehydration, and simultaneously overestimate the number that die with dehydration as the primary cause. More than anything, the Mail Online story is a lesson in the perils associated with using database information for making any kind of inference.

The commentary that follows this article is informative.  There is clearly a lot of frustration with the NHS, or there are at least a lot of people willing to make comments in the Mail Online about this problem.  I do wonder how the comments would read about a similar story in the USA.

Don Berwick is out as the Director of CMS, and one of his deputies is in-line to be his replacement.

Here is a nice article about his efforts to transform healthcare in the US from the New York Times:

http://www.nytimes.com/2011/12/06/opinion/nocera-dr-berwicks-pink-slip.html

Here is a nice item from the Washington Post:

http://www.washingtonpost.com/blogs/ezra-klein/post/cms-administrator-don-berwick-steps-down/2011/11/23/gIQAdXs2oN_blog.html

Here is a nice article from Boston about his priorities:

http://www.boston.com/Boston/whitecoatnotes/2011/12/don-berwick-five-principles-for-change/qWyl3sMa8yXCFd97qKLF0H/index.html

It is clear that it was his ambition to do a lot of good at CMS. There is no disputing that a year is too short a time to understand an organization so vast, let alone transform it. The consensus is that he hoped to replicate the NHS in the US. If all of this were easy, he would have done it all in a year, and we would be talking about all of the great things he accomplished.

Here is a recent item about the status of the NHS:

http://apnews.myway.com/article/20111211/D9RID8800.html

Ignore the inflammatory anecdotes in the article.  They’re data, but they’re not especially useful data.  I could generate equally emotional anecdotes to support the other side, but these would still not constitute useful data.  Pay attention to the real systematic numbers, which are the real crux of the debate.

They are in a pickle. There is no easy way out of the difficult situation in which they find themselves. It is ironic that the British have as much trouble predicting the consequences of changes as we in the US do, in spite of the widespread belief that they actively control every aspect of care. Well meaning people come to opposite conclusions about the consequences of change, with the Docs and nurses at odds with government, just as in the US.  I see it this way: if you spend less, you are likely to get less.  Worse, in a command economy, the free market does not seize every opportunity to reduce costs.  Medical inflation has many costs, but regulation is likely a major unrecognized driver. If you read this article, it is hard to avoid concluding that the British spend too little on health care.  It is also hard to reconcile the details of this article with the representations of many who advocated for the Affordable Care Act.

John Goodman wrote this recent item about health care:

http://townhall.com/columnists/johncgoodman/2011/12/17/is_liberalism_a_religion

In it, he makes a convincing case that efforts to improve access to care have had the opposite effect in Massachusetts, and draws the expected analogy to Canada and Great Britain, where there are now explicitly two standards of care: that for those who can afford to get out of the national system, and that for those who are stuck with it.  In Great Britain, something like 10% of people seek their care outside the system.  This fact is critical in its importance. First, the money these people spend out of pocket is not included in the estimates of overall or per-capita expenditure, which is likely far more substantial than widely reported.  This would suggest that the Brits spend more on health care than widely believed, and with less, not more efficiency, as widely alleged. These same people also shorten the wait times for a variety of critical services, and reduce the demand for resources in every dimension, including hospital and ICU beds.  The gap between what the NHS provides and want the population demands is thus larger than widely represented.

Finally, this recent report from NCEPOD

http://www.ncepod.org.uk/

represents their usual outstanding work in understanding the failures of the NHS.  In a sentence: patients who would go to the ICU in the US often go to the wards in the NHS, and a large percentage of those patients die.  It is worth noting that a large percentage of patients admitted to the ICU in either system die, and that the devil is in the details of the differences. 

I have a new truck.  It has a little video camera that comes up on the navigation screen when I put the car into reverse. I don’t know how to use it.

Huh? you say. It turns itself on and off. What’s to know?

But of course, that’s not the point. For going on half a century, I have used a combination of looking over my shoulders and in my rear view mirrors to guide my vehicle’s course in reverse. The technique changed when passenger side rear view mirrors came into vogue. It changed a little again sometime in the past few years, I realize lately, as shifting in my seat to peer over my right shoulder became less useful, because of the high rear window in my old Sequoia (or maybe I just got lazy?) Now I’ve got this whiz bang video image. Do I watch it while moving. Do I consult it for an instant before I begin? How close am I really to that police car?

I just haven’t integrated it into my technique yet. It’s awkward. New technology is like that. It takes time. And new technology takes many forms.  New monitors like the BIS; that’s easy to see. Sevoflurane replacing Isoflurane? Not so obvious, but new technology nonetheless. Integrating Sevo took a little while, and going back to iso for say, a hernia would require some conscious readjustment until I had the slower pharmacokinetics hard-wired back into my implicit memory. Kind of like swinging a heavier bat or something.

Simple changes can have a subtle impact. I remember when disposable gloves basically appeared. For years, anesthesia, like early baseball, was a bare-handed affair. We intubated without gloves, started IV’s, put in NG tubes, for pity’s sake! Herpetic whitlow was an anesthesiologist’s malady. To be sure, we used sized sterile gloves for spinals and epidurals and Swans, but that was about it. Then, Bang! Gloves. NG tubes became a lot easier-you just stuck a finger back there and guided it in. Who knew?

Smart phones are important anesthesia technology. I remember when there was talk of putting reference books on line at anesthetizing locations. Seems quaint now. Try this; “Siri, what’s the starting dose for milrinone?” Post a comment and let me know what she says.
Not to mention Angry Birds at 02:30 AM.

Oh, and Pandora. Huge.

My career has seen a steady stream of new technology, some subtle (rocuronium). Some dramatic (echocardiography). It took me a decade to notice how the technology altered the care, another decade to appreciate how the technology altered the art, and a third decade to appreciate the aesthetics of that continuous transformation. Anesthesia is pretty much fun aesthetically. A real dance, every bit as artful as surgery, at least to my sensibilities. But, hey, I’m biased.

So, it’s midnight and thanksgiving and I’m on call at the trauma unit. Maybe this post is a giving thanks for having found a lifetime of meaningful artful compassionate work. Who knew indeed?

First, it seems that presumed consent is going live on the other side of the pond. 

The language in the body of this BBC item is more moderate than the headline and lead:

http://www.bbc.co.uk/news/uk-wales-politics-15625285

It will be interesting to see how this plays out over time.  Will the language of the final legislation reflect the intent of its authors? Will the details of implementation increase the supply of organs without impinging on the rights of individuals and their families? 

Meanwhile, the NHS continues to struggle with its system-wide electronic medical record:

http://www.guardian.co.uk/society/2011/sep/22/nhs-it-project-abandoned

As with all news items about this topic, it is hard to know what actually has happened or will happen.  It is also impossible to divine exactly what the cause or causes of this problem are or might be.  Previous news items have alleged poor management on the NHS side. If the NHS is anything like the DoD, it is quite plausible that the government struggles to marshal the resources necessary to manage an undertaking of this scale. Also like the DoD, it is almost inevitable that there has been specification creep over the lifetime of the project, and that the program now envisioned is far more extensive in its intended scope than the original concept.  Regardless, any official recommendation to terminate a program after such a massive investment is a serious blow, even if not a fatal one. Sadly, we are unlikely to learn anything from the NHS experience; finger pointing and politics make truth and learning the first casualty of these kinds of failures.