Monday, June 13, 2011

Legislators Gone Wild: A Bill Requiring All Operations To Be Recorded

Last month the New York State legislature threatened to pass a law banning doctors from wearing neckties. This was based on some research that showed that bacteria can be found on ties. No link to any disease caused by a tie has been reported. It appears that the proposal did not become law.

Now comes news that lawmakers in Massachusetts are considering a bill that would give patients the right to have their operations videotaped if they pay for it. The story claims that this could be done without a videographer being present in the operating room. And, get this, if a hospital refused to allow the videotaping, it could be fined $10,000.

Who thinks up this stuff? Can you think of any problems with this plan? I can.

It would not be difficult to record laparoscopic and arthroscopic procedures since they are already being performed using video equipment. There would be added expense because many hospitals have not purchased the necessary DVD recorders. However, open surgical procedures are not routinely videotaped and video equipment is not readily available to do so. Even when experienced videographers are present, it can be difficult to see what the surgeon is seeing.

Who would pay for the installation of video equipment in every operating room of every hospital in Massachusetts?

A comment on the article points out that the taping of all surgical procedures would be complicated, distracting and might cause surgeons to perform differently [possibly detrimentally] when they know they are being watched.

Sometimes things happen during a case that might seem untoward to a lay person. For example, due to magnification by the laparoscope, a few milliliters of blood can look like a hemorrhage. Occasionally, gallstones or bile may be spilled. Although this rarely results in complications, it could be construed as a “mistake” by a devious [is there any other type?] lawyer.

This would of course be a boon for plaintiffs’ attorneys. Wait, aren’t most legislators also attorneys? I wonder if there is a connection?

In summary, this plan is misguided, ill-conceived and stupid. Since it is being discussed in Massachusetts, it just might pass.

17 comments:

Elaine Schattner, MD said...

This doesn't seem like a good idea for patients. Others watching can distract the operator. Also, some doctors get nervous (i.e. shaky) on-camera, as on-stage, but are otherwise calm while doing their work.

Kevin B. O'Reilly said...

Thought you might be interested in my recent coverage of these topics.

Massachusetts bill would give patients the right to film surgery:
http://www.ama-assn.org/amednews/2011/06/27/prsb0627.htm

New York bill seeks physician dress code to cut infections:
http://www.ama-assn.org/amednews/2011/05/23/prsa0523.htm

Skeptical Scalpel said...

@Elaine I agree completely

@Kevin Excellent articles. Thanks for posting them.

Martin Young said...

I raised this possibility two years ago on KevinMD as a blog post, saying the advent of cameras into the OR was inevitable.

Now here it is. Doctors might have had two years to prepare a better response than to be caught shortfooted.

But, as I write in a new post to come out next week on the same blog, prophets are never welcome in their own countries!!

Skeptical Scalpel said...

Having thought about this for a month, I am now convinced that the expense of installing and maintaining video equipment in every OR in the country would be prohibitive. It is never going to happen.

Todd J. Scarbrough, M.D. said...

http://bit.ly/PMuY88

Skeptical Scalpel said...

Todd, that's an excellent post. Too bad it will never happen. Legislators aren't into evidence-based anything.

Danny Long said...

2004 Joint Commission mandated basic safe surgery protocols to reduce never events and preventable medical/surgery harm.
2014, surgery never events remain a chronic problem accounting for a huge percent of liability pay-outs.

Surgeons who voluntarily video operating room events, the who is there, time outs, check lists, etc.. all the basics for safe surgery..Deserve to command deep discounts for liability premiums.. let the trouble makers pay their own way..

Soon common surgery procedure outcome will become public information. Giving the public a powerful tool to make better surgery decisions..It will happen.. just like medical device payments to providers will be public one day soon..
Pharmaceutical payments are already public.. the game is changing.. forward thinking surgeons would be well advised to get on board.. improve outcomes asap. They will be made public via big data.

Heck, in today's world, videoing the surgery room could be done with anyone's telephone.. Like they say, it aint brain surgery..

Ill bet if surgeons had a 12 month rehearsal period prior to video becoming part of the medical records.. heck surgery would look like a well orchestrated ballet. Never events in that hospital would be a distant ugly memory, patient harm fall.. provider peace.. going home knowing tomorrow will be better yet.

Skeptical Scalpel said...

Danny, thanks for commenting. I'm sure you mean well but the statement on your website, "Over 10% of patients die after leaving surgery, largely due to behavior in the operating room." is untrue and misleading.

The logistics of videoing every operation would be overwhelming. It's impractical. A cell phone camera would never work. How many phones would you need to tape even one day's worth of surgery in a busy hospital? And who would hold the phone and point it in the right direction? I could go on.

Danny Long said...

Skepical Scapel, thanks for the opportunity to interact here on your blog.. And your concern is one I have head many times.. and every time I'm surprised.. (sort'a)
Here is my base line for establishing the over 10% (adjusted for patient condition at admittance) It is publicly available to anyone..
......................................................................
Establishing the base number of over 10%
Using Medicare data, adjusted for condition pre surgery condition.

This number represents the estimated number of patients that died for every 1,000 people who had a serious
treatable complication. Example here clearly shows 132.9 pr 1,000 = 13.2 percent see link below. (feel free to plug any hospital in to see post-op death rates.. Average is about 11.1 % +- )
I feel sure we can agree that using hospitals own data and billing information. we could trust it..

http://www.hospitalsafetyscore.org/h/duke-university-hospital?findBy=zip&zip_code=27516&radius=50&agree=agree&rPos=444.4445&rSort=distance

Then to get to the chronic concerns I hear about.. disruptive behavior... sleep deprivation, ...unrealistic surgery scheduling.. short staffing.. equipment that does not talk to each other, failure to follow protocols, etc etc.. ..thanks like that..
then (I feel sure you know I was over simplifying the cell phone example) but we can move onto that subject too.. :-)

sound fair?

Danny

Danny Long said...

Skeptical Scalpel, By no means am I saying all surgeries are half-hazard. I am saying the adherence to the basics of safe surgery is clearly not wide spread.

We also need to remember this thread we are on was started/triggered several years ago by someone wanting evidence in court.. Although there is that risk. The greater risk is to medicine's declining provider/patient relationship.

Congress distaste of 750 billion being wasted yearly inside healthcare, while the same healthcare says a camera to reduce costs from preventable harm is too expensive....may be an unfruitful defense..

Not to belabor the subject of post-op death rates, I have made it real easy for anyone to get a national picture of this problem. I loaded a list of what the public are told are "A" rated medical universities onto one page.
It lists the post-op death rate, with a corresponding link to the information source. Big Data.

I invite you to my little site if your interested..
http://shellyskalicky.blogspot.com/p/avera-mckennan-hospital-and-university_50.html

Skeptical Scalpel said...

Danny, thanks for your explanations and the links. I tried to figure out how Leapfrog calculated the death rate from complications scores, but it is not clear to me. Yes the average is 11%, but the range is 53% to 155%. You should be picking on hospitals nearer 155% rather than those whose scores are 13%.

A lot of postop complications are not due to events in the OR. Videoing all operations might cut down on some complications (although that has never been proven). Some complications like wound infections may happen even if everything is done correctly.

Some of the hospitals you listed on your website are not really university hospitals but have "university" in their names such as Staten Island University Hospital, Kennedy University Hospital - Cherry Hill, and University Medical Center of Princeton at Plainsboro. It's a common ploy to make the name of the hospital sound more impressive.

Danny Long said...

Skeptical Scalpel.. thanks for bringing this up, I too asked the same question.. found the same confusion about the death rate scoring.. The numbers are not generated by LeepFrog.. they come directly from CMS.

The scores are adjusted based on diagnosis billing codes at admittance, age, sex, etc. This provides the baseline at admittance to compared to post-op expected survival.
Understanding the numbers Medicare Agency for Healthcare Research and Quality. What are Risk-Standardized Outcome Rates? (PAGE 15)

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Downloads/-Medicare-Hospital-Quality-Chartbook-2013.pdf

Hope that helps.. I have spoken with a lot of folks, Risk Mangers included who had no idea this stuff was out there..

As I understand much of surgery, even surgeons dont really know how they are doing compared a room full of other surgeons.. there simply has been no yard stick yet.
This currently only shows hospitals, one day it will be broke out by surgeon..


PS, Thanks for pointing out the "bogus" universities, I will remove them from the list. I am not picking on these hospitals, I an simply point to the size of the known death rate..
For the sake of easy number, we can just call it 10% post op death rate due to complications..

Now on to the chronic problems surgery team members experience during surgery?

Respectfully
Danny

Skeptical Scalpel said...

Danny, I think you have misinterpreted this information. It's not that 10% of all surgery patients die from complications. Rather it's that 10% of surgery patients with serious complications die. As I have pointed out in several posts, every complication is not necessarily due to a mistake by someone. Sick people get complications and sometimes die. It's not always anyone's fault.

Danny Long said...

Skeptical Scalpel,
Of course all of the 10% don't die because of someones fault.. No one is saying that..no one is saying surgery is the cause, yes sick people do die..

Remember to the starting point?
1. Nationally 10% do die post-op,
2. Adherence to basic safe surgery protocols is spotty at best even with 2004 Joint Commission mandates..
3. Mandating without enforcement has never been successful in any venue.
4. The toxic environment of many operating rooms is unsustainable..

Danny

Danny Long said...

Skeptical Scalpel, again, thanks for the insight, I think I got the bogus universities off the list..
You said..
"I think you have misinterpreted this information. It's not that 10% of all surgery patients die from complications. "Rather it's that 10% of surgery patients with serious complications die."
.... personally, I'm not sure if that is good or bad..

EXAMPLE:
2014 Surgical Procedures, including Endoscopy:

Duke University Hospital: 50,582
Duke Raleigh Hospital: 15,809
Duke Regional Hospital & Davis Ambulatory Surgical Center: 18,857

Let's just round it down to 50,000 for easy math and just ball-parking just 10% develop serious complications..
That is 5,000 X %10 = 500 preventable deaths in 2014?
(now we are only talking about deaths here, not even mentioning the much larger number of walking wounded/survivors.... but Im fine with that..for now)

Sounds like to be accurate, we need the complication percent of total surgeries..

http://corporate.dukemedicine.org/AboutUs/Facts_and_Statistics/

Thanks again
Danny

Skeptical Scalpel said...

Danny, you are making the same mistake that many other critics of medicine make. You are assuming that every complication is preventable. That is just not so. Some are and some are not. I am sorry to tell you that some deaths are not preventable either. What percentage of complications and deaths are preventable is anyone's guess.

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