Sunday, December 4, 2011

What is the Ashman's phenomenon

One of the core competencies of hospitalists is the appropriate and accurate interpretation of electrocardiograms (ECG). Of course, we are Internal Medicine or Pediatrics (or both) specialists and not Cardiologists.

The ECG interpretation requires skill, close observation, excellent knowledge of the vectorial conduction of electricity in the heart, and most importantly, lots of practice and seeing multiple ECG's. In addition having the mentorship of senior Cardiologists with experience is paramount.

I had a case in the pre-operative clinic (IMPACT - Internal Medicine Preoperative Assessment, Consult and Treatment) at the Cleveland Clinic, and as part of the routine evaluation an ECG was obtained. She did have Atrial fibrillation , however some unexpected presumed premature ventricular contractions.

Further investigation on this electrocardiographic phenomena let us reassure our surgeons team and have the patient undergo surgery safely.

Read here our report in the Cleveland Clinic Journal of Medicine December 1 issue.

Friday, November 18, 2011

What to believe?

This has been a rough week for all of us involved in Perioperative Medicine. As hospitalists in a large academic medical center we take care of a large perioperative clinic that sees 16,000 and more patients every year.

In order to ensure optimal care of the patients, we use evidence based guidelines to provide the safest medical decision making.

One of the most prolific authors in the field is Dr. Don Poldermans, a very well respected and renowned cardiologist who we had the fortune of knowing as he has visited our institution for the Perioperative Summit which is now hosted by the University of Miami.

In November 16, the University of Erasmus of Rotterdam asked Dr. Poldermans to leave. This on assumptions of misconduct in research. This is a very frail moment as for any institution to take such a decision is not easy and decisions like this are not taken lightly.

For us is very hard; I just gave a lecture in Mexico City last weekend on perioperative medication management and I cited the DECREASE studies findings supporting the current evidence to use betablockers, especially the ones recommending starting low dosing with gradual increase and preferentially within 1 to 4 weeks of surgery.

The media has been taken by assault and all of us feel like orphans. Can we trust the data? Is this a precipitated decision by Erasmus? Everybody should be cautious in times like this and careful in not destroying the prestige of somebody who has been an authority in the field and a good man.

I look forward to follow closely what happens and ensuring that the evidence we use is still valid or not. We should be careful in not labeling him until further clarification occurs either from him or Erasmus.

These are some links to these news:

Sigh!.......What to believe?

Tuesday, August 30, 2011

Perioperative management of morbid obese children

Obesity is the plague of our days. It takes years of life away in an instant. However, despite the knowledge and awareness of its terrible consequences, it seems that parents are blind to the devastating effects of it.

I presented a workshop on perioperative management of the pediatric patient in Kansas City, at the 2011 Pediatric Hospital Medicine meeting, sponsored by the American Academy of Pediatrics and the Society of Hospital Medicine.

A section I focused on, and brought special attention was the management of children with morbid obesity. You can read in further detail here.

Wednesday, August 3, 2011

Do hospitalists boost costs? - a reality or fiction?

The Hospitalists community is shocked. Or at least I am.

Yesterday Drs. Kuo and Goodwin published a very well written study in Annals of Internal Medicine. It is in fact, an impressive study despite all its limitations. They evaluated a 5% sample of Medicare patients in 454 hospitals, comparing 36,871 patients treated by their Primary care physicians (PCP) with 21,254 patients treated by Hospitalists during a period of 2001 through 2006.

They found that although the length of stay was lower (0.64 days less) among patients treated by hospitalists, and that the inpatient charges were S282.00 lower, the Medicare costs in the 30 days after patients were discharged were in fact $332.00 higher. This translates in an additional 1.1 billion in Medicare costs per year based on the approximate 25% Medicare admission managed by hospitalists. (This is very dramatic if we take into account that the government almost shut down yesterday).

In addition, the authors found that patients cared for by hospitalists may have a decreased lenght of stay hypothesizing that this may be at expense of increased rate of discharge to skilled nursing facilities or nursing homes by almost 20% compared with primary care physicians.

As well, they found that patients cared for by hospitalist had an 18% increase in subsequent emergency department visits and 8% increased risk of readmissions.

The findings were confirmed with an impressive statistical analysis in the entire cohort study of 205,190 admissions in 4657 hospitals.

However, this study had multiple limitations including: only included patients with an identified PCP; patients admitted with medical (non-surgical) diagnoses; did not include patients cared by subspecialists who may as well be hospitalists; only studied patients with fee-for-servide Medicare coverage; it included a period of 2001-2006 which may not be representative of the current practices; they extrapolated the costs, based on total Medicare charges, but did not actually directly assessed the costs.

Their last conclusion was very interesting - given that hospitalists may have incentives based on a fixed prospective payment based on the severity of the admission (medical diagnosis-related group or DRG) shifting costs to the outpatient in a post-discharge fee-for-service model, this drive overall to increased Medicare costs. The authors proposed the increase in bundling of payments based on the episode of care to minimize these incentives. The latter translates to the current proposed model of Patient-centered Medical home in which bundled payments will cover both inpatient and outpatient care.

I'm appalled. I am a strong believer that hospitalists in fact decrease overall costs of healthcare - why - because we provide evidence based quality care. We focus on quality improvement, increased patient safety, improved patient outcomes; we are very critical of our performance and advocates of increased accountability and transparency. We advocate the model of increased quality and decreased costs.

However this incredibly large national database is in fact, proving otherwise. In addition it proves some quality metrics to be in the red numbers area - for instance, shows an increased number of ED visits and readmissions.

If we take the heart failure model, it has been shown that early outpatient follow-up decreases readmission rates; but this requires a proactive behavior from all the healthcare system (including the patients). This is a current national priority and at least in this population we most likely will be seeing soon data of current practices.

I can argue that in the period of 2001 to 2006 a flawed system with limited access to outpatient medical care may have contributed to these results, and that this has been changing with time, and at least from my personal experience, we ensure that our patients receive a soon follow up with a PCP to facilitate transitions of care.

Now, it may be true that hospitalists may discharge patients more to skilled nursing facilities - but this may be due to the increased attention to detail to the patient's ability to perform activities of daily life and provide self-care; we may have increased Physical Therapy evaluations to ensure safer transitions of care. For instance, in this cohort of patients, they averaged 77.5 years old - any patient that age who is acutely admitted to the hospital may in fact suffer from substantial deconditioning that may not facilitate a safe discharge to home.

In addition, this analysis focus on economic impact and do not include all inpatient quality metrics, such as core measures, current national patient safety goals practices, use of VTE prophylaxis, documentation practices, etc.

An additional thing that is very important to take into account is the famous cost-to-charge ratios analysis in the Medicare population as well as differences in reimbursement in both inpatient and outpatient settings. In this study, the authors state that they calculated the Medicare spending 30 days after discharge based on total charges; as well they state that charges reflect price setting rather than resource consumption and therefore may overestimate costs.

So, this is a very statistically impressive study, but that focus on economic outcomes and may not be in fact evaluating the quality of care provided by hospitalists. In addition, Hospital Medicine has gone a long road since 2006 to 2011. We are very well embarked in the journey of patient safety and quality. We are advocates of the formula improved quality/decreased costs.

I believe further analysis based on newer populations, other payors systems (private insurances, Kaiser system, etc.), including more recent data, as well as more inpatient quality metrics, as well as adjusted severity and mortality should be done.

We need to be critical of our own practices and look in detail what can we do to improve. As the healthcare system in the United States moves toward the Patient-centered Medical home with bundled payments, most likely this presumable differences in healthcare expenditure between the PCP and the hospitalists model may in fact narrow to a non-significant level.

For the time being, the hospitalists will need to take this as an opportunity for reflection, and as a source of energy to fuel new research endeavors to improve patient outcomes and decrease healthcare costs.

For us as hospitalists our principle will always be....primum non nocere.

Sunday, April 3, 2011


In the previous ten years, a steadily progressive increased insight into patient safety and improved quality of healthcare delivery has been promoted by famous physicians-writers and has now become a focus of federal organizations such as the Joint Commission.

If I imagine myself in the hypothetical situation of being a patient in any random hospital in the USA, I really want to get the best of the medical standard of care and have medical errors as well as communication failures avoided at all. I want to receive safe, compassionate, cutting-edge medical care, where attention to detail on the type of medication and dosages are well thought, where medical knowledge is sufficient to provide my caregivers have a broad differential in the diagnostic work-up and avoid missing any diagnostic or therapeutic opportunity. Am I asking too much? I don’t think so.

We have read scary stories of medical errors which happen on a daily basis, as the human are not infallible. However, what is scary is that some of these errors happen to be entirely preventable, only based on taking a minute to think and review the situation. For instance, medication errors secondary to having a nurse administer the wrong dose or medication to a patient – in a busy environment, where the ratio nurse to patient can escalate a risky and ridiculous high number of patients per nurse (5 or more), in the setting where our patients are becoming sicker and more complex, and where expediting the medical care is paramount to minimize length of stay, etc. – can potentially be preventable if the nurse would have more time to verify the dose, the appropriate indication of the medication, and then double check the patient’s name, DOB and medical record number.

But sometimes the system is created in such a hierarchical fashion that nurses just obey doctors’ orders. For example - perhaps in a setting where a nurse detects that the patient’s platelets are low, and the nurse is about to administer a new medication ordered by the intern (the first year of a medical or surgical specialty), she could take a glimpse to medical causes of thrombocytopenia and whether the new medication may in fact worsen the problem.

Or the case of a patient with pancreatitis, who gets for dinner macaroni and cheese and the nurse, allows the patient to eat it as “the doctor ordered a soft diet”. A hard stop could have been put in place, but if the nurse ignores that the diet in a patient recovering from acute pancreatitis should be not only soft, but low in fat, then an unsafe medical practice could be avoided.

But this is not the nurse to blame – this is a result of a very complex system – the doctors input an order; the pharmacist prepares the medications (most of the time accurately, and pick up mistakes as well, but in a busy environment where they receive multiple medical orders at the same time, there is always place for mistakes); the kitchen receive the diet orders for the patient (they are not going to glimpse in the medical record to agree whether this should be a strict low sodium diet, or a diabetic diet, or a diet for a patient with renal disease on hemodialysis, etc.); the transport service receive orders to transfer a patient to a given study (which may be the wrong patient and the wrong study), etc. There are too many different steps involved in providing care to an inpatient patient. Having too many hard stops may in fact stop the process of patient care.

So, in a busy environment, where the time is precious, but the patient safety is even more precious, how can us, the healthcare professionals give the best and safest medical care? This is a question that has driven too many research endeavors targeting safety of patient care as well as quality of care.

I have been fascinated with the subject since I was in medical school. Physicians and nurses presumably always follow the primum non nocere philosophy; however there are multiple barriers to a perfectly safe medical care. The understanding and acknowledging process of what those barriers are is fundamental to be able to humbly attempt to minimize its occurrence. This requires not only a humble perspective to Medicine itself, but a very candid approach to Medicine and to acknowledge our own knowledge and abilities limitations. A large number of mistakes happen in the setting of ignoring subtle signs. For example, when I am on my Internal Medicine inpatient service, a rule of thumb I share with my residents and which a lot of my colleagues may not necessarily agree with me is: “a code blue in the floor is an avoidable mistake”. A code blue is when the emergency medical team is called to the bedside of a patient whose vital signs are critically compromised and his/her life is at danger or in the case of a patient with cardiopulmonary arrest.

Why do I consider a code blue an avoidable mistake? For starters, patients that undergo an abrupt deterioration may have had in fact subtle signs of worsening multi-organ failure which are “ringing alarms”. It is not just about maintaining a good blood pressure; the mental status changes, the worsening of the renal function, the increased oxygen requirements, the deterioration of the liver enzymes, etc. These things happen several hours or even days before the final event. However, in certain medical institutions, the acuity and severity of patients taken care of is so immensely high that the medical personnel can “lose the floor” and get used to them and sometimes take an increasingly common brave attitude of keeping those very ill patients in a regular nursing floor, when in fact appropriate triaging would demand an escalation of the acuity of care, meaning the Intensive Care Unit (ICU). However, those medical centers have in proportion a higher acuity level as well in comparison with other ICU’s. So in proportion everything is more complex in high volume academic institutions.

If I compare the acuity and complexity of medical care when I started my first residency 12 years ago in Mexico, with my second residency 8 years ago in Cleveland, and then when I started my work as a hospitalist 4 year ago, with my current patients, I can objectively state that the patients are now older and much sicker. Sometimes the average age of the patients in my Internal Medicine inpatient service is in the mid 80’s. Not only they have multiple co-morbidities (the number of active diseases and clinical conditions), but they have advance stage of some of these conditions, in addition to the advanced age. However, they have now achieved the opportunity of developing new diseases thanks to their increased survival, which has occurred thanks to the advance of medical science which skyrocketed in the second half of last century.

These patients develop a higher level of expectation from the medical science, sometimes unrealistic, which can put them at the danger of pursuing treatments and procedures which may not necessarily extend their life expectancy, or even worse, will not improve their quality of life. This is also a barrier for patient safety. How much is sufficient? This is a difficult question to answer and brings into the conversation serious bioethical issues and dilemmas which are not the objective of this blog post. The reason of framing this clinical scenario is that increasingly complex challenges are becoming the common picture in the current healthcare environment.

So, when facing an increasingly complex clinical practice, in a world with increased liability, in a steadily progressing complexity in the healthcare system, having hard stops and ensuring adequate patient safety is paramount. High patient volumes, in an environment that can seem a factory of healthcare, where multiple patient get admitted, other so many get discharged, in an endless cycle, there should be objective measures of accountability, transparency, ensuring each patient is appropriately identified and get the correct treatment; have hard stops in the pharmacy; have hard stops in the OR to run checklists, now fortunately so popular; have hard stops in the computerized personalized order entry (CPOE) obliging the healthcare givers to think twice and avoid reflex behaviors.

Creating a system where hospitals get graded accordingly to the level of the safety they provide, ensuring the minimum standards of quality are met, seems as a burdensome and difficult system to practice with. However, if we realize that we can be the patients subject to multiple levels of opportunity to have an error in our healthcare, then we can prove that these measures of standard of care are not unreasonable. The hospital safety get graded according to multiple levels, charting, medication reconciliation, knowledge of procedures in case of emergency, safety of the physical areas in the hospital (O.R., E.R., I.C.U, inpatient floor, etc.), level of hygiene (hand washing, garbage disposal, etc.), ensuring oxygen tanks are secured, etc., etc. All these different measures allow a minimum standard of safety to obtain an accreditation from the Joint Commission. And these ensure a more homogeneous safety across the whole hospital system nationwide.

In addition, other standards of care arise – the National Hospital Quality core measures and Surgical Care Improvement Project (SCIP), which are publically, reported measures of healthcare quality. In order to appeal for transparency, accountability and ownership of success, these measures are publically reported and everybody can know how well or poorly any hospital in the US performs. For instance, if you have a heart attack, which generally is due to the rupture of a plaque of fat inside your coronary arteries, with the subsequent activation of platelets that try to “heal” the plaque, causing a blood clot which occludes the artery, you want to get an anti-platelet medication as soon as possible in order to avoid your artery to get occluded and keep the blood flow to the heart going. Well, one of the so called “core measures” is that patients with a heart attack (myocardial infarction), receive an aspirin upon arrival to the hospital. Other core measure is in patients with pneumonia, which is an infection and inflammation of the lungs generally secondary to a virus or bacteria, a way to prevent them from having invasive infections that can put them back in the hospital is to immunize them against the Influenza virus and Pneumococcus (the most common bacteria causing invasive lung infection). Immunizations are part of the secret of the current society longevity, despite whatever the detractors to vaccines can say. If patients admitted to the hospital with a heart attack do not get an aspirin, or patients with pneumonia do not get immunizations, those are signs of a deficient medical practice which is detrimental to patients. Therefore, these core measures are safety hard stops that ensure hospitals provide a safe medical care to patients.

There are caveats against the core measures, like anything, nothing is perfect. In order to abstract the core measures, somebody needs to review the charts and identify when the standard of care is not met. However this depends on documentation practices. Therefore, patients can in fact get the standard of care, but if it is not documented appropriately, it did not happen. So, this brings a new window of opportunity to healthcare providers that imply a minimum of extra work – document what you do, or as well, the rationale for not doing an expected behavior. However, if you realize that providers are extremely busy, seeing a lot of patients, and taking complex medical decisions in an incredibly complex patient population, then you can ask yourself…do you want a doctor that spend more time thinking to provide sound medical decision making, sometimes at expense on the time for documentation, or a doctor that writes nice novels in the chart, but who is not precisely clinically skillful. The issue is that it is not up to physicians to decide. This is a reality and documentation is paramount. You wrote it, you did it. You didn’t write it, it never happened. That’s simple.

So, in the intrinsically fascinating world of Medicine, we have now, more than ever, new challenges in order to ensure that healthcare delivery is as safe as it can be. We have federal regulations, we have wonderful checklists, we have professionals who are passionate about quality in each institution whose role is to promote the active incorporation of safety behavior and practices in each hospital. This is a fascinating opportunity to ensure today that the healthcare we’ll give tomorrow is the safest ever in the history of humankind. We all need to be on board of the train of safety and quality, as this journey will be the most exciting ever, and as a hospitalist, we are passengers in the First class coach.

As always….primum non nocere.

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