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Thursday, September 24, 2009

Write on the incision site: Wrong site wrist/finger surgery

Here is an example of what has been reported and the initial changes made as a result of Massachusetts hospitals' analyses of "serious reportable events," as required in the new Chapter 305 state law.

A Spanish speaking only patient was admitted for surgery to release a left trigger finger, a condition where the finger catches in a bent position and straightens with a snap; instead she had a carpal tunnel release, a completely different operation on the wrist and not the finger.
This mistake was not discovered by the team in the operating room, but by the doctor when he returned to his office and looked at the patient's medical record.

To avoid this error from recurring, the hospital changed its policy from having the surgeon sign the side of operation to requiring the surgeon to sign the actual incision site. Also in this case, not all team members participated in the time out. In response, two more important issues were addressed by the facility: first, the policy was changed to require the presence of an interpreter for non-English speaking patients, so they could answer questions about the operation and verify the site, as required by the Universal protocol; and second, a revised hand-off routine was instituted to accommodate changes in staff immediately before and during the operation.

Advice to surgical patients: Have the surgeon mark the incision site, not just the correct side of your body – or mark it yourself.

Kudos to Dr. Stancil Riley, Tracy Gay of the Betsy Lehman Center, and Elizabeth Daake of DPH to helping this happen and making this available at the Massachusetts Department of Public Health's website.

Read another wrong-site surgery story.

Saturday, September 19, 2009

Visiting Hours Are NOT Over: Innovative Patient/Family Council Hospitals in Massachusetts

In my role as President of the Consumer Health Quality Council, I had the privilege of participating in a training session for Massachusetts hospitals yesterday on starting their patient/family advisory councils. These speakers mentioned specific improvements in partnering with patients that their councils have already inspired:

Susan Shaw of Children’s Hospital of Boston described many changes, e.g., the welcoming patient guide, the redesign of Family Sleep Space, and "Executive Family Walk Rounds," among others.

Karen Conley described how South Shore Hospital has greatly extended its visiting hours, focusing on the Emergency Department, Intensive Care Units (ICUs) and PACU. In the past, every evening the loudspeaker would intone, "Visiting Hours Are Now Over," forcing family members to leave their ill, scared, and vulnerable loved ones at their moment of greatest need. After this announcement was eliminated, the number of formal grievances fell by 94% from one year to the next! South Shore Hospital began using family-initiated rapid response teams in June (I hope to report more on this soon) and has several other very exciting ideas in development from its council.

At my visit a few weeks ago to the pediatric family advisory council of Dana Farber Cancer Institute, Maureen Connor's team mentioned that parents had asked for and received a washer and dryer on the kids' floor so that the parents themselves could help keep their kids' bedding and clothes clean.

BRAVO TO THESE PIONEERING HOSPITALS! It's worth noting that none of these ideas costs hospitals much, if any, money, and yet mean a lot to patients and their families. I hope patients will tell their primary care providers and friends about these practices, so more patients get their care at those patient-friendly hospitals.

At the Consumer Health Quality Council of Health Care for All, we're asking Massachusetts hospitals to send us their plans as they complete them by the end of the month, so we can learn about and publicize more of the innovative ways that hospitals are becoming more patient-friendly.

Advice to patient advocates: Steer your clients to hospitals with productive and imaginative Patient/Family Advisory Councils.

Read our Council's testimony on the new Chapter 305 law that mandates these patient/family advisory councils. Thanks to Paula Griswold and Effie Brickman of the Massachusetts Coalition for the Prevention of Medical Errors, and Tracy Gay of the Betsy Lehman Center, for organizing the series of conference calls as training sessions. Thanks to Marlene Fondrick of the Institute for Family-Centered Care for sharing IFFC's knowledge and resources in the calls. Thanks for the legwork by Linda Burgess, Nicola Truppin, Deb Wachenheim, and Alec Ziss of the Consumer Health Quality Council's work group on Patient/Family Advisory Councils.

For all of them on this Jewish New Year, may they be written in the Book of Life.

Friday, September 18, 2009

David, Goliath, Max Baucus, and Nikki White: The Senate Finance Committee's plan for national health insurance

Nikki White was a slim, young and athletic college graduate. She had a job, and health insurance. At 21, she had been diagnosed with systematic lupus erythematosus, a chronic inflammatory disease that gradually weakened her to the point where she could not work. When she lost her job, she lost her health insurance. She tried everything to get medical care, writing letters for months, but no insurance company would accept her because of her costly pre-existing condition.

Finally, she collapsed when at her home in Tennessee, and was rushed to the Emergency Department. She received plenty of free care, including six months in an intensive care unit (costing taxpayers hundreds of thousands of dollars). It was far too late, and she died in 2006 at age 32.

Every 12 minutes, an American like Nikki dies. You read it right, and I’ve checked the math. That's the key finding of a study that determined that 45,000 Americans die each year from the lack of health insurance.

The same day the study was released, the value of insurance company stocks rose on the news that Sen. Max Baucus submitted the Finance Committee's health insurance plan. Investors believe that Baucus' scheme would be highly profitable for insurers, who will gain millions of paying customers. Insurers would not have to compete against a public program. Instead, these highly experienced, financially stable Goliaths would compete against nonprofit co-ops, i.e., young start-ups. Insurers are adept at cherry-picking the healthiest, least expensive people to insure, likely leaving the sicker, more costly uninsured people for the nonprofit co-ops. It's easy to guess who'll profit in that marketplace. That's why insurance stocks rose.

Here in Massachusetts, we don't have this problem. Here, Nikki would be alive. We have some excellent insurers – and near-universal health insurance.

Advice to non-Massachusetts residents: Move here. If you don't want to do that, call your senator or congressman and insist they support a public option for health insurance.

Read how universal health insurance saved someone’s life. Thanks to Nicholas Kristof for the source story in the New York Times of Sept. 13, and Dr. Andrew Wilper et al in the December 2009 [sic] issue of the American Journal of Public Health.

Saturday, September 12, 2009

If you can fix me, please do: A living will

Here's Dr. John Dykers Jr.'s end of life plan, in a letter to Annie's Mailbox:

I'm glad you brought up the end-of-life plan dilemma faced by 'Aunt Thelma, Uncle John, and my Marie.’'I am a doctor, and my patients have embraced my own end-of-life plan as follows:

"If you can fix me, please do. If you can't fix me, please help me avoid pain, fear, lack of air, hunger, nausea, thirst, loss of dignity, and prolonging the dying process. I understand it might take a few days for you to figure out whether you can fix me or not."

This format helps facilitate conversation between generations without the feeling of abandonment. Most of us old folks don't fear death as much as the process of dying or prolonged disability.

Advice: Send this to your parents, suggesting it as a default living will. If they want to revise or discuss it, so much the better.

Read another living will story. Thanks to Dr. Dykers, whose letter appeared in the Boston Globe on Sept. 9.

Friday, September 11, 2009

The best way to spend September 11: Rapid response teams

Eight years later, today on Sept. 11, I still feel the impact of the terrorist attacks.

I had the pleasure of spending much of the day in planning how to greatly improve the health of people in Eastern Massachusetts. Babra Rabson of Massachusetts Health Quality Partners and Prof. Stuart Altman are leading a large-scale collaborative called Aligning Forces for Quality (AF4Q), and I'm participating on its Leadership Team.

In today's meeting we discussed broad goals we might pursue. My own vote was to encourage the use of rapid response teams in hospitals to prevent cardiac arrests in the hospital. Cardiac arrests in the hospital are very common; there are hundreds of thousands of them in the US each year, according to an article by Dr. Kerry Voorhis and Dr. Tina Willis in Pediatric Clinics of North America in 2009. Resuscitation attempts are made on roughly 30 hospital inpatients a day in Massachusetts, but they usually fail to save the patient's life. Warning signs like a change in the breathing rate, blood pressure, or confusion usually appear several hours before the cardiac arrest. Doctors and nurses can be trained on the hospital's process for intervening before a resuscitation (a code team) is needed. Family members can be informed that they can urge a rapid response team if they notice their family member's condition has deteriorated suddenly. This is a new law in Massachusetts; it's a requirement by the Joint Commission on Accreditation of Healthcare Organizations, and is a recommendation of the Institute for Healthcare Improvement.

The wide use of these rapid response teams should save many people's lives. The cost of doing so is slight. There may even be a financial reason to do this, as surviving inpatients will live on to keep paying insurance premiums.

The leaders of the AF4Q collaborative will choose an ambitious goal that will save lives of Massachusetts residents. They may well choose a different focus. In any event, I feel grateful to contribute to the discussion, and I feel this was the best way to spend September 11.

Advice for September 11: Spend the day in community service to make life better.

Read another story about rapid response teams.

Thanks to Helen Haskell of Mothers Against Medical Errors for emailing the source articles, and for inspiring South Carolina's Lewis Blackman Act.

Tuesday, September 1, 2009

Now that he has fallen: Teddy Kennedy's contribution

As author John James says, "I remember the days early in my adult life when I believed that a more socialized system of healthcare was overdue in America. Ted Kennedy was a hero of that vision, and I bought one of his books. Once I became a 'responsible' adult my personal wellbeing trumped any social goals I had at a more equitable healthcare system...until that healthcare system took my son's life."

Ted Kennedy starts his 1972 book: In Critical Condition - The Crisis in America's Health Care with this:

"I am shocked to find that we in America have created a health care system that can be so callous to human suffering, so intent on high salaries and profits, and so unconcerned for the needs of our people. American families, regardless of income, are offered health care of uncertain quality, at inflated prices...Our system especially victimizes Americans whose age, health, or low income leaves them less able to fight their way into the health care system...It is an industry which strongly protects the profits but only weakly protects the healing and rights of people."

John James continues, "This was published 37 years ago and the pages on my copy of this book are turned a dingy yellow. Sadly, very sadly, the words of Senator Kennedy are more true today than they were 37 years ago. He ran the good race, but we must carry on now that he has fallen and the finish line is more distant than ever."

I'm also missing Teddy, who I increasingly realize was one of our greatest public health heroes. Here is a list of the healthcare laws he was influential in shaping, courtesy of the Massachusetts Hospital Association's Monday Report: The National Community Health Center Program; The Family Protection of Medicine Act; Meals on Wheels and the Women, Infants, and Children Nutrition Program; National Military Child Care Act; Ryan White CARE Act; Mammography Quality Standards Act; Human Services Reauthorization Act; Health Insurance Portability and Accountability Act (HIPAA); the Mental Health Parity Act; Children's Health Insurance Program; Minority Health and Health Disparities Research and Education Act; Pediatric Graduate Medical Education Act; Family Opportunity Act; and Genetic Information Nondiscrimination Act. In addition was his sustained strong support of funding for cancer research.

Advice to public health advocates: Take heart from Teddy's example.

Read another story about Teddy’s encounter with cancer.