Thursday, November 29, 2012

Dramatic decreases in hospital lengths of stay can occur. Here's how

I recently wrote about my plan to reduce hospital readmissions. Now I will discuss the problem of reducing length of stay.

The recent hurricane in New York City and the closures of some hospitals requiring the transfer of a large number of patients reminded me of something that happened on 9/11/2001.

I was working at a hospital near New York. You may recall that among the many problems that day was a breakdown in communications. Reliable information on the number of casualties and extent of injuries was hard to determine.

Late on the morning of 9/11, a meeting was held at my hospital. We canceled all elective surgery and decided to discharge as many patients as possible in preparation for the injured who, sadly, never arrived. Victims either got out of the World Trade Center and walked away or perished. Injured patients were few and were cared for by hospitals in New York.

Unaware of what was really happening in the city, we made rounds on every patient and discharged nearly 50 who otherwise would have stayed a day or two longer. As far as I know, there were no complications related to what seemed to be a premature departure from the hospital for many.

The next day someone wondered why, if we were able to discharge so many patients on the day of a disaster, could we not do so more often?

Granted, once a wholesale cleanout took place, there would probably not be 50 patients eligible for discharge every day. But it might be 10 or 15. Multiply that by a few thousand hospitals and you might see quite a savings in the cost of medical care.

Will it happen? I doubt it. For one thing, ours was not the only hospital to have that experience. If it was going to happen, it would have caught on by now.

Why not? On 9/11, the inpatients were motivated to leave. They were scared. They wanted to be with their families. They felt like they were helping others—the potential victims who never materialized. It would be hard to muster those feelings every day.

I have written before that hospital length of stay is not simply a matter of the physician deciding that a patient can go home. The patient may not want to leave. There may be no support at home. There may be no one to drive the patient home. The nursing home or rehab center may not have an available bed.

Still, it is interesting to contemplate what occurred on 9/11/2001 and why we can’t be more proactive in discharging patients.

Friday, November 23, 2012

How to operate on the wrong site

Here’s a story that illustrates how to operate on the wrong site. 

In a news article about some sanctions that the State of California imposed on certain hospitals for misdeeds, the following summary of one incident appeared. I have added some emphasis in bold.

A six-year-old boy had to undergo a second surgery to remove a growth after a surgeon performed the wrong surgery on his tongue.

"This failure resulted in [the patient] being exposed to the risks of bleeding and infection, and unnecessary exposure to the risks associated with anesthesia that was needed to perform the right procedure," state documents say.

The surgeon told investigators that he couldn't be sure whether a time-out [explanation: a pause in the preoperative routine to ask all members of the OR team if they all agree on who the patient is and what the operation will be], which was said to have transpired according to the hospital's policies, was ever done.

"Either time-out was not done or it was done, but I could not recall what procedure was said," the surgeon told state investigators. The surgeon then said that team members, who should have known the correct procedure, should have asked why there was no specimen of tissue from the removed growth.

Asked whether he examined the patient prior to the surgery, the surgeon replied, "Usually, I don't examine anybody. In this case, there was no time to do pre-operative visit. From now on, I need to see the patient prior to surgery."

The hospital was fined $50,000.

I can’t blame anyone who read that story for wondering just what the hell we are all doing in hospitals today. 

The wrong operation, a tongue-tie release, was performed. The surgeon couldn’t recall if a time-out was done. He blamed the staff for not mentioning that no specimen was obtained. He apparently had seen the patient in his office but did not re-examine him on the day of surgery and did not usually do so. It’s not all bad though. “From now on,” he will start seeing the patients before he operates. 

The official report cites the hospital for failing to follow its own procedures regarding verification of the type of operation to be performed. 

It is basic good practice and common sense to examine every patient again on the day of surgery and reconfirm the nature of the procedure, the correct side and answer any questions the patient or family might have. For example, I have seen lymph nodes that I was asked to biopsy shrink dramatically in the 10-14 days between my office examination and the planned surgery day.

Who obtained consent from the child’s mother? What did the consent form say? Didn’t the circulating nurse or anyone else look at the form to verify what operation was to be done? Don’t the nurses enforce the time out rule? What was the anesthesiologist doing?

Maybe the fine and the hospital’s “system error” type plan of correction, which entails monitoring 30 time outs per month for an unspecified period of time, will prevent this from happening again.

I doubt it. 

See how easy it is to operate on the wrong site? That’s why people can defeat any system correction plan.

Tuesday, November 20, 2012

Duh? Postoperative complications lead to readmissions

God knows I’ve written more than my share of papers that the Nobel Prize Committee has rightfully chosen to ignore. I understand that academicians need to publish in order to keep their jobs. Writing a paper is hard work and I don’t really want to demean it.

A paper reports that complications of surgery are linked to increased rates of readmission, and this seems rather obvious to me. It got a lot of media attention, and comment is needed.

The study, published in the Journal of the American College of Surgeons, looked at the records of over 1400 patients who had general surgical operations and found that 163 (11.3) were readmitted within 30 days of discharge.

The authors make some good points such as readmissions were not related to age, race, sex, or certain co-morbidities such as diabetes, smoking status, COPD, ascites, hypertension, steroid use, unintentional preoperative weight loss, history of bleeding disorders or renal disease. Readmissions were significantly more apt to occur if patients had preoperative dyspnea, open wounds or disseminated cancer.

But the main findings that readmissions were due to complications and the more complications a patient had, the more likely he was to have been readmitted, are not exactly earth-shattering.

The press release and articles accompanying the paper’s publication were a little over the top.

Here are some quotes from a few of the many articles about this research:

From the American College of Surgeons website: Findings published in the Journal of the American College of Surgeons lead researchers to devise a patient safety plan to decrease complications for the benefit of patients and hospitals.

From a site called Redorbit: [The surgeon-author] reported that the results of this investigation provided a framework for his research team to develop a simple complication-prevention plan that minimizes the risk of surgical patients developing complications.  

No such plan is mentioned in the paper.

From Infection Control Today: This patient safety approach includes engaging the postoperative care team to start transition-of-care planning early—especially for high risk patients—to encourage early discharge from the hospital. This too is not specifically stated in the paper nor is it supported by the data. In fact, early discharge might result in more readmissions. Who knows?

Incidentally, the press release, in most cases printed verbatim by the medical news websites, was wrong about the data forming the basis of the study. It says, “Researchers conducting this retrospective study analyzed patient records from hospitals that were enrolled in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), which is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of care in private sector hospitals. Data from Emory University Hospital was merged with ACS NSQIP data to identify unplanned readmissions.” Not so. The paper included patients who were operated on only at Emory University Hospital.

Slight digression: Even if readmission rates were not increased by complications, I would be in favor of a plan to reduce them.

One of the reasons I am skeptical about a lot of things is that when you look into the details, you often find that the “spin” produced by stories about a research paper is not always matched by its content.

I’m not the only one. A French study on the PLoS One website in September found that the spin generated by press releases and abstracts is highly likely to influence news reports about the research and overstate its beneficial effects.

I've written before about the need to read the whole paper and not just the abstract. You must be cautious about what is written in the press release too.

Thursday, November 15, 2012

Moderate maternal alcohol use lowers children’s IQ (not)

A new study shows that children of mothers who drank as little as 1 to 6 units of alcohol per week had children whose IQs at age 8 were statistically significantly lower than those of children who mothers abstained.

This finding was widely reported by news media yesterday. Google “IQ alcohol” and you will find many articles which uncritically describe the findings of the study. As is the case in many such articles, quotes from the press release accompanying the paper’s publication appear to have been liberally used.

The major problem with this study is one that I’ve written about before. Results that are statistically significant may not necessarily be clinically significant.

The difference in IQ between the two groups of children was 1.8 points. Do you really think that an IQ difference of 1.8 is going to be a life-altering finding for a child? I don’t.

IQ tests are often unreliable and if taken more than once can yield different results. A difference of 1.8 points is well within the margin of error of such tests. One source I found states that the margin of error of the IQ test used in this study is a minimum of 5 points. The children in this study were 8 years old when they took the test.

The study, done by a group in Bristol, England, was published on PLoS One and the full text is available here. Caution is advised if you plan to read it. There are many other problems to consider.

Data collected for this paper were pulled from another study which was done from 1992 to 2000 about the genetics of alcohol metabolism. The primary focus of the original study was not the hypothesis of the IQ study.

A unit of alcohol was defined as 8 grams by the authors. Since I was not familiar with what 8 grams of alcohol really meant, I looked it up. A “standard drink” was said to contain anywhere from 8 (in the UK) to 14 grams (in the US) of alcohol.

Here’s a quote from the paper’s “Methods” section, “At approximately 18 and 32 weeks of pregnancy women were also asked on how days during the past month they had drank [sic] 2 pints of beer (or the equivalent amount of alcohol), any women who reported doing this on at least one occasion was classified as a binge drinker in our analysis of the association between genotype and binge drinking.”

Really? Two pints of beer on one occasion makes a woman a binge drinker? Depending on the type of beer, a pint contains 2 to 3 units or 16 to 24 grams of alcohol.

To help you understand the paper better, here is a table:

I asked my wife what she thought of this study and she said, “I think the women who drank were probably more fun to be with.”

Wednesday, November 14, 2012

“Duty, Honor, Country” or “Generals Gone Wild”?

There are currently three high ranking military officers in trouble for alleged sexual misadventures. Unless you’ve just returned from the international space station, you’ve probably heard about former general David Petraeus’s schoolboy-like infatuation with his biographer, Paula Broadwell, and General John Allen’s voluminous email exchanges with Jill Kelley, described by some as a  “Tampa socialite” (an oxymoron?) and by others as a Real Housewife of Tampa.

But the third, General Jeffrey Sinclair, who really takes the cake. He is currently being court-martialed for the following charges: forcible sodomy, wrongful sexual conduct, attempted violation of an order, wrongfully engaging in inappropriate relationships, misuse of a government travel charge card, possessing alcohol and pornography while deployed, maltreatment of subordinates and fraud.

One of his apparent victims, an Army captain, testified last week that he threatened to kill her if she told anyone about an affair they had for some three years.

He was legendary for his mistreatment of women subordinates. When confronted about that, he allegedly said, “I’m a general; I’ll do whatever the [expletive] I want.”

Many of the allegations against the three generals involved their behavior while they were in positions of high responsibility in Afghanistan. Petraeus was the highest ranking general there. Allen replaced him. Sinclair was in command of the prestigious 82nd Airborne Division.

The conduct of these three men is deplorable and inexcusable on many levels, but here’s a point of view that I have not heard anyone yet express.

I have six children, who fortunately have not had to serve in the military. I can’t stop thinking about all of the families of soldiers who have died in Afghanistan. How would you feel if your son or daughter had been killed after being sent into harm’s way by one of these generals?

Your kids are dying. Meanwhile, General Petraeus is “All In”; General Allen is emailing his little Tampa socialite; General Sinclair is drinking, misusing credit cards and sodomizing women on the base.

When did these guys find the time to run the war?

“Duty, Honor, Country” is the motto of the US Military Academy (West Point)
Story of testimony that Sinclair threatened to kill a female captain
Story describing charges against Sinclair
Story containing Sinclair quote about being a general