Monday, March 12, 2007

clinical innovtions, telling patients what to expect, How to Become a Physician Hero:

“In guerilla country a handcar, light and expendable, rides ahead of the big lumbering freight train to detonate whatever explosives might have been placed on the track.”

Peter F. Drucker, The Age of Discontinuity, Harper & Row, 1968

Many health care safety innovations fill gaps in a system supposed to be continuous. Doctors can become heroes by serving as early-warning systems for patients, forewarning what lies ahead.

This blog is for doctors. Its purpose is to ensure safety of patients by informing them what to expect.

• Begin by giving patients written information about common hospital dangers. In the 1999 Institute of Medicine’s report To Err is Human hospital errors were reported to cause as many as 100,000 deaths a year in hospitals.

• Follow by “prescribing” patients online information for filling care gaps with interactive videos. The videos tell patients what surgical procedures and chronic disease episodes entail. They explain in simple, clearly illustrated, empathetic language possible dangers and complications.

Health Care Gaps

“Gaps” personify health system “fragmentation.” Gaps occur at multiple junctures, inside and outside hospitals,

• when patients are transferred from one location to another within the hospital;
• when seriously ill patients are left unattended in hospital wards;
• when patients are relocated to rehab facilities;
• when patients leave hospitals to go home,
• when patients go to pharmacies with illegible prescriptions,
• when patients are not properly instructed how to remove or insert urinary catheters or give IM injections, use bronchodilators, or perform other procedures;
• When patients are not taught to recognize complications, like gaining weight in heart failure.

Many gaps happen during “hand-offs” or transfers, within hospitals, from hospitals to other facilities, from doctors to hospitals, from doctors to care sites outside their realm, in short, in gaps between settings.

Filling Gaps in Young Patients

For pediatricians and those who give anesthesia or operate on children or adolescents, the process of filling gaps is important, Because of smaller size, children may experience special anesthesia problems and adult doses of antibiotics or pain killers may endanger them.

I have a young friend in his 30s. Twenty years ago, a cardiorespiratory arrest after a routine cosmetic jaw procedure permanently disabled him. In the recovery room, a nurse gave him a dose of Demoral. After being transferred to a pediatric ward, a second nurse gave a second dose of Demoral, a respiratory depressant. The second dose caused a cardiorespiratory arrest with prolonged oxygen deprivation and irreversible brain damage, with ensuing gait disturbances and inability to read.

Preventable Medical Errors

I thought of my young friend, an invalid for life, when I read these paragraphs in a March 7, 2007 New York Times story, “Medication Errors are Studied,”

“Young children are the most likely victims of surgery-related medication mistakes, a new study has found, and poor communication as the patient moves from the operating room to recovery is the most likely culprit.”

“The study was confined to errors made on patients undergoing surgery, and the rate of harm, 5 percent, was much higher than is typical for medication errors. Among children it was 12 percent.”

“Most of the errors involved painkillers and antibiotics. Four resulted in deaths, and one death was of a child.”

“Problems typically arose when a patient was handed off from the preoperative team to the operating room to the recovery room to the regular ward nurses.”

A Preventable Triple Tragedy

My friend was disabled. The surgeon and hospital were sued. The settlement requires an insurance company to pay for lifetime care, which may last 70 years after the event. Both the disability and malpractice suit were tragic enough. But also tragic was the fact that the hospital and the surgeon had no systematic way of preventing the tragedy.

The patient fell through three care gaps.

• Lack of communication between nurses in separate hospital units.
• Giving two adult doses of Demoral, a known respiratory depressant to a young patient whose jaw was wired shut who could not communicate.
• Placing the patient on a pediatric unit, ill-equipped to handle a respiratory arrest. He should have been held longer in the recovery unit.

Six Most Common Hospital Safety Gaps

Today, such tragedies may be prevented. Hospitals are beginning to focus on six common mishaps.

Donald Berwick, MD, founder and leader of the Institute of Healthcare Improvement in Boston, outlines six steps, which may prevent 100,000 deaths each year:

1) prevent ventilator-associated pneumonia (VAP);
2) prevent IV-catheter infections;
3) stop surgical cite infections;
4) respond rapidly to early warnings;
5) make heart attack care reliable;
6) end medication errors.

On the sixth point, Berwick advises: “Reconcile medications whenever patients move from one care setting to another, even if it occurs within the hospital.”

Preventing these mishaps falls mostly on hospitals’ shoulders. But informed doctors and alert patients can help too. They can insist ventilator patients be sat up in bed with mouths cleansed; remind nurses catheters need to be changed frequently; advise hospital personnel not to shave surgical sites; stay with critically patients and carefully watch for distress; insist heart attack patients be placed on aspirin and beta-blockers; and make sure medications are re-checked during in-hospital transfers. Safety requires eternal vigilance by all every step of the hospital stay.

The Surgeon as Victim

In the case of my young friend, the surgeon was a psychic and monetary victim. Many disillusioned doctors retire after losing malpractice suites. The malpractice attorney maintained the surgeon should have anticipated what might happen and should have spelled out the complications forcefully in the informed consent process prior to surgery. But, of course, the surgeon, though he had the parent perfunctorily sign an informed consent form, expected nothing to happen. He probably felt he should not have been held responsible for post-operative nursing mistakes outside the OR. The problem, he might have said, was in the system, not with him.

Power of Advance Patient Engagement

Which brings me the subject at hand – the power of patient engagement before the time of need, before the patient enters the hospital, before the procedure, when the patient and his family are focused on the impending event, when they can be told what is to happen and what might happen.

How can this “engagement” be facilitated and rendered relevant? Emmi Solutions, Inc, for purposes of disclosure, is a Chicago company with whom I am affiliated as an industrial advisory board member, engages the patient by developing online, simple, relevant, personal, three-dimensional, interactive videos.

Doctors “Prescribing” Advance Explainations for Patients

Doctors “prescribe” by giving Internet access to videos to patients and families, who, in turn, download videos in advance of surgery and study them.

The videos are three dimensional -- they feature a soothing voice leading them through what’s about to transpire, provide medical illustrations to visualize , and explain events in 6th grade language.

In chronic disease management, the videos have three purposes:

1) Engaging and educating patients before or during a very personal experience;

2) Changing patient behavior by informing them in advance of adverse consequences;

3) Measuring outcomes of engagement, education, and changed behavior.

A Fundamental Difference – Taking the Initiative

These videos may seem like just another layer of unneeded information to those already reeling from information overload.

But there is a fundamental difference.

In this consumer-driven age, patients often take the initiative by presenting the doctor with downloaded information from the Internet – information the doctor may not be aware of and which the doctor may regard as irrelevant or misleading.

Information gaps between patient and doctor may create tensions between patient and doctor. They may circle each other, struggle to define what each other knows, and pit their knowledge against one another.

In the case of doctor “prescribed” information, the doctor takes the initiative by presenting relevant, simple-to-understand, three- dimensional information when it is most needed, before the clinical event – real-time in time.

The patient may react by saying, “My doctor told me exactly what to expect, what to be prepared for, and what complications to avoid.” That leaves little room for misunderstandings, builds trust, and makes the doctor a hero rather than the villain.


Peter Lucash said...

Excellent post, Dr Reece! You make an excellent case for physicians once again being proactive for their patients. Physicians should be the ones driving patient education and information. In my blogs, I advocate the same, and promote websites for each practice that includes patient information. I'm intrigued by the Medem offering, as it is simple, cheap and a great start. I'll be posting about your comments on Tues, Mar 13.

Peter Lucash said...

Oh, yes. I write the Physician Business Blog over at All

Peter Lucash

Richard L. Reece, MD said...

Thanks, Peter, for you comments. I appreciate them. Physicians, indeed, should drive physician education and,for that matter, patient safety. I will spread the word about your blog

Richard L. Reece, MD