Haste Makes Waste in Meeting Core Measures

Affordable Care ActOnce again government regulators have put in place well-meaning rules without anticipating the consequences. We all hate sitting around in the Emergency Department waiting to be seen and to be treated. On October 15, 2014 as part of the new Affordable Health Care Act and the patient satisfaction portion, hospital ER’s will have about 180 minutes from the time you arrive and sign in to evaluate you , treat you and make a disposition or decision. The game starts on Oct. 15 but already hospital administrators have their systems operating to prepare to comply. If you fail to comply the hospital will be punished financially with fines and reductions in payments. Take the case of LH who is 88 years old, demented and lives with her loving and nurturing son in South Florida. She went to the beach with her son on a hot humid day in August with temperatures in the 90 degree range and humidity of almost 80 percent for a feels like temperature of 110. While she sat under an umbrella for several hours, the beers she drank to celebrate her birthday did not react well with her medications for dementia. She stood up and swooned to the ground and ended up in the ER. Labs, EKGs and Chest X Rays were done and it was decided that she was dehydrated. She was given some fluids and sent home. Two days later a urine culture obtained at that visit became positive indicating an excessive number of bacteria and she was placed on an oral antibiotic for ten days.

Six days later she was still feeling weak and shaking when she stood up and moved about. Her son took her back to the ER concerned that she was having seizures. She was evaluated by the ER staff and noted to be running a fever. A Chest X Ray was taken and was read as left lower lobe pneumonia by the radiologist without comparing it to her film six days prior. As I was finishing up with my last morning patient I received a phone call from the ER physician advising me that my patient was there with pneumonia and fever and required admission. He told me he had obtained blood and urine cultures and started her on Rocephin. I reminded him she was already on an antibiotic trimethoprim/sulfamethoxazole for a urinary tract infection. I told him I could be there in about 30 minutes and asked him to keep her in the ER until I got there. He said that was fine. To meet the Core Measures need for a quick disposition I suggested that the patient be admitted to a medical floor on my service, be given a clear liquid diet and I would take care of the rest. He said that was fine.

In August, Boca Raton, Florida is a sleepy seasonal vacation town enjoying the offseason quiet with its two colleges and seasonal visitors off on holiday. Restaurants are never full. There are no lines at the movies. There are few if any traffic jams and beds are readily available in the hospital. The hospital is usually 1/3 to ½ full at best. Our brand new emergency room is bright, wonderfully equipped with digital and manual blood pressure cuffs, otoscopes and opthalmoscopes at each bedside in marked contrast to the paucity of them on the hospital inpatient floors. It is always easier to be thorough and complete in your exam in the emergency department where you are not wasting time looking for equipment to examine the patient. I arrived at the ER in 40 minutes and was met by the icy stare of the staff nurse who said, “She has a bed upstairs can I send her?” My response was, “Not until I have a chance to take a history from her and her son and examine her.” While I was taking the history and doing the exam my cell phone went off. It was another physician in the ER department calling to talk to me about another patient who was in the department having been sent there by his surgical specialty physician who had just examined him in his office for a problem. I excused myself and walked toward another section of the ER when my patients nurse asked, “are you finished can I send her up?” I again declined and informed her that Dr L in the urgent care session wished to talk to me about a patient now and I would be back. My patient was not critically ill. Antibiotics, food and fluids had been ordered. Taking a short break to speak to the other ER doctor would not jeopardize her care or safety.

I returned 10 minutes later to learn that the nurse had called the Nurse Practitioner working with the hospitalist service and she had written admitting orders in my absence to speed the process along the way. In the hospital’s view the most important issues were to move the patients along, get the medication reconciliation form filled out and get the form on preventing phlebitis and use of anticoagulants filled out so they can meet their Core Measures goals. I went into the patient and son , completed my exam, explained my findings and disappeared into the physician computer room to enter orders, dictate the admission summary after I had reviewed the nurse practitioner’s orders, reviewed the chest x ray and all the lab data. The computerized orders revealed the patient had been admitted to a medical floor, on antibiotics, on heparin for phlebitis and pulmonary embolus protection. They had missed the fact that the patient had executed a “Do Not Resuscitate “form and her son had brought it with him. This was not recorded in the orders. They had also missed the fact that the pneumonia or left lower lobe consolidation they diagnosed was the same on the x ray from 6 days prior and another from one year prior. I walked over to the radiology reading room and pointed this out to the radiologist who said what was being called a pneumonia was actually an innocent long standing hiatal hernia appearing behind the heart on x ray. Despite not having pneumonia, the patient was sick, weak, and febrile and needed admission to sort it out. I sat down at the computer and spent thirty minutes on the orders and admission notes and then spoke to the patient and family. At that point I allowed the ER nurse to call the transporter and bring the patient up to the floor. The nurse literally scowled at me and told me I was violating their Core Measures policy and their director would not be happy and would want to talk to me. I told her I had another patient to see and that if her director wanted to talk to me they knew where to find me since I have been on staff for 35 years. I reminded her Core Measures criteria did not officially start for three more months and that with an empty ER she needed to take a deep breath, count to ten slowly and relax. My comments were not appreciated.

The next morning I arrived at the hospital and looked up the patient’s location. To my surprise despite requesting a medical bed for a “DNR” patient she had been located on the cardiology telemetry floor and was hooked up to a monitor measuring her heart rhythm. Why would I put a patient who asked not to be resuscitated, who was not having irregular beats, who did not have blood chemistries favoring the development of an arrhythmia on a cardiac monitor? The hospital gets paid a flat fee for her admission practically independent of how much service we deliver. I had no idea how this happened but realized that on the computerized order sheet even though it listed the bed as “medical” the nurse practitioner had ordered a cardiac monitoring bed. This flaw in our computer entry ordering system does not allow visitors to see the type of medical bed requested unless you know to click on it. The extra cost of the monitor approaches a $1000 per day. Her antibiotics for the pneumonia she doesn’t have also were quite costly. Yes the hospital expedited her trip to the floor to meet Core Measures but did so at the expense of making the wrong diagnosis, applying the wrong treatment and providing an expensive service the patient did not need. Haste makes waste. This is just the tip of the iceberg. On October 15th the best is yet to come. Pity the poor patients.

End of Life Issues

Sun and Wispy Clouds Over MountainsIt is the right of every individual to choose and define how they wish to be treated if they are faced with a terminal or life threatening illness and are incapacitated and unable to make the decisions needed to provide care and relief of discomfort. It is best to make these decisions while alive, healthy and mentally competent. The State of Florida has created the Florida Living Will which directs how you wish to be cared for if you develop a terminal illness and end stage condition or enter into a vegetative state and are unable to convey the answers about your care yourself. It is a nonspecific document requiring your signature and the signature of two witnesses. I address these issues with my patients frequently. The living will should be reviewed and signed and given to your physicians, lawyers and a copy kept at home. I usually advise patients to be more specific than the document requires. Do you wish to have a feeding tube placed and be fed artificially if you stop orally taking food and liquids due to a life ending illness? Do you wish to be resuscitated if your heart stops or you spontaneously stop breathing. There is a particular form called a Do Not Resuscitate or DNR form that should be signed and prominently displayed on your refrigerator if you do not want caregivers or first responders to perform CPR on you. A copy can be kept in your wallet and your physician and attorney should have a copy.

You should appoint a health care surrogate to make decisions about your care if you are unable to. This should be someone who knows you and has discussed with you how you wish to be treated in these situations. There is a form to designate a surrogate and it too must be signed and witnessed by two people. It is best to have one surrogate and one alternate. Appointing all your children surrogates just leads to confusion and conflict by committee when a decision that you have already made needs to be instituted.

As a patient you have the right to change your mind at any time either verbally or in writing. It is not unusual for patients to change their mind when they develop an acute medical illness which complicates their chronic life threatening issues which led to executing these documents. Make your choices for yourself. Your doctor and attorney should be able to direct you to the appropriate documents and discuss these issues in greater detail with you.