Joint Commission Inspection and Data Entry Duty for the Doctors

I received an email from our hospital Accreditation Coordinator/Quality Coordinator in a manner that wasn’t clear if it was directed to me personally or if it was sent to the entire medical staff.  It said that she was reviewing the Joint Commission Accreditation of Hospitals recent survey which found that the charts did a poor job of reflecting the patient’s “Code Status”.  The institution only received a 40% rating.

Some patients were listed as “Do Not Resuscitate” (DNR) but did not have the yellow State of Florida DNR Form on the chart.  Some charts had the DNR form but the physician, in a progress note, had incorrectly indicated that if the patient’s heart stopped beating, or they stopped breathing, that the patient was in fact a “Full Code.”   Of the 25 charts reviewed only ten were in full compliance.

For some reason I took this email very personally.  In my practice I take the time to discuss end of life issues with all my patients who are at an age, or have issues, that make one believe they may face a catastrophic cardio- respiratory arrest in the future.  When I have the discussion with the patient and family, I present them with a large yellow State of Florida DNR form. The large top half and small detachable bottom half are identical. The patient is supposed to fill both out, with the physician signing both.  We photo copy the form and scan it into the patient chart while listing DNR Status on the electronic health record face sheet for all to see.  The patient is supposed to place the large yellow upper half on their refrigerator while carrying the smaller wallet sized version in their wallet or purse.

Most of my patients get to the hospital through the emergency department by self-referral. Sometimes they call us first but most times they call 911 or go themselves.  Most situations involve unexpected falls and trauma or pain from a chronic source.

When I am called by the ER staff the patient has been registered in, insurance has been checked, medications have been reviewed, as have allergies to medication, and the patient has been evaluated by nurses and physicians.  The patient’s record is a mix of paper documents and electronic health records.  The hospital recently instituted a new electronic health record system with inadequate staff training and support (in my opinion) with decisions for financial reasons.  The result is that most clinicians are constantly searching for information and not quite sure where all of it is.  There is still a loose leaf binder type shell for some daily paper information such as the EKG rhythm strips created on the telemetry monitors.  Where a State of Florida DNR form is kept is anyone’s guess.  I took the electronic health record training course on line and the two in person events. At no time did they discuss entering a code status or show us how to enter this data.

It seems to me that the question of a patients “Code status” is something that should be asked at registration in the ER and at elective pre admission. All patients should be considered a full and complete code unless they say otherwise and can produce the documentation needed. If they are not carrying the documents with them then the document should be re-executed and signed at the registration desk by the patient or their legal health care surrogate. When their physician shows up to admit them the document should be on the chart, filled out for us to see.  I can access my office patient files at the emergency department from my iPad but, due to lack of interoperability between electronic health records in the office and in the hospital, I have no way to print out the document from my office electronic health record while I am at the hospital.

If end of life issues have not been discussed with the patient prior to hospitalization, I have no problem beginning the conversation when the medical condition they are there with has been addressed and stabilized.

It turns out that the email was addressed to the entire medical staff and not directed at me alone.  None of the 25 charts reviewed by JCAHO were mine.  If administration wishes to fix the problem it needs to make sure its employed clerical staff are trained to ask the right questions and list the answers where the doctors and nurses can easily see them and interpret them and act on them if necessary. Don’t ask caregivers to be data entry clerks for JCAHO or anyone else.

Leave us free to provide health care.

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“They Paved Paradise, Put in a Parking Lot”

My local hospital has been petitioning the local city zoning board for permission to build an on-site parking garage for years now.  The city zoning board is very strict about the height of buildings and has turned the requests down repeatedly.

This past fall, the hospital administration announced that it needed a capital partner to expand and stay solvent.  Most of the members of the hospital medical staff have absolutely no idea if this is true and accurate or not.  We do know that several weeks after agreeing to a relationship with a well-respected health care system as a capital partner, they received permission to build that garage.

Construction is set to begin in March so it was no surprise to receive a three page email announcement that the physician hospital parking has been moved from adjacent to the hospital to an area that will make it significantly easier for me to get my daily 10,000 steps in. The construction will take a year. Florida’s sudden onset of torrential downpours will present a challenge but, that’s what umbrellas are for.

I bring this up after making rounds on my affluent patient, whose hospital identification information identifies him as a VIP Benefactor with a yellow star, upstairs in the spectacular VIP section known as the Rockwell Suites.  The operators have gotten used to us staff members calling in and asking the operator to connect us to the nursing station at the Rock and Roll Suites.

His room is the size of three to four rooms with dark wood paneled floors and walls. There are three big screen TVs in this room along with two computer screens. The floor has its own chef available to make a meal for a patient or family member anytime of the day or night.  There is a surcharge for this type of room not covered by insurance.

When I left this patient’s room, and had adjusted his medications at the nursing station, I went downstairs to the general medical telemetry floor.  My patient on that floor also is a benefactor but is in a semiprivate room being evaluated for a fainting episode.  I reached up behind his bed for a blood pressure cuff to check his blood pressure in various positions and there was none. I walked out to the nursing desk and asked the charge nurse for a blood pressure cuff and, after five minutes of going from room to room, she found one that didn’t hold the pressure load and was not working very well.   A digital one was finally located so I could measure the patient’s blood pressure myself.

My community hospital was built by neighbors and philanthropic donations after two young children died of a poison ingestion and there was no local hospital to bring them to. It was controlled by a lay community board, a community medical staff that represented the patient’s through the physician staff and a separate administration.  Addition of new doctors to the staff required the approval of a lay community council that first looked at the need for that specialty based on the population and the number of existing doctors already here practicing that specialty.  They were concerned that too many doctors would lead to many unnecessary tests because everyone needed to generate income.

That community hospital is now a “regional “hospital with a board filled by CEOs of Fortune 500 companies and doctors who are employed by the hospital. The pediatrics wing has been closed down because it lost money.  There is no geriatrics wing despite a plethora of senior citizens. There is little or no relationship with the student health programs at the two local universities.  There are no blood pressure cuffs in most rooms and no otoscopes or ophthalmoscopes in most rooms in the emergency department.  But, there are three big screen TVs in the Rock and Roll Suites and a parking garage in the works.

I wonder who now represents the health and medical needs of our community?

How to Deal With Pharmaceutical Product Recalls

In the last six months there have been numerous products voluntarily recalled because in the manufacturing process a possible human carcinogen was inadvertently produced as part of a new modernization of their production product. The important things to remember is that the product MAY have been produced and that the element produced MAY be a human carcinogen.

Mass media has used this information to inaccurately heighten the fear of consumers and sell more newspapers, magazines and air time. The risk, if there is a risk at all, is quite small.

The recalls all involve generic blood pressure medications manufactured outside the United States of America. Many of the factories have not been inspected in years because the US public’s thirst for “small government” has led to a decimation of funding for the federal agencies assigned to train inspectors and send them out to monitor manufacturing plants.

If you believe your medication has been recalled I suggest these steps:

  1. DO NOT ABRUBPTLY STOP TAKING YOUR MEDICATION.
  2. CALL YOUR PHARMACY THAT SOLD YOU THE PRODUCT AND ASK THEM IF THE PARTICULAR PRODUCT YOU HAVE HAS BEEN RECALLED. Most of these products come from multiple manufacturers and they may have a supply of non-recalled medication.
  3. If your supply has been recalled ask the pharmacy to replace it with non-tainted product. If they have a replacement product then call your prescribing doctor to seek a similar or alternative product.
  4. DO NOT STOP THE MEDICATION UNTIL YOU SPEAK TO YOUR PRESCRIBING PHYSICIAN. The risk of contracting cancer from taking these pills is minimal. The risk of getting ill from inappropriate worry and or concern is higher than the risk of cancer from these products.

Marijuana, Pain Relief and the Facts

On a daily basis patients of mine come in for office visits complaining of wear and tear injuries, as well as aches and pains, and their methods of dealing with chronic pain. As we all know, aging is a part of the normal life process.

For instance, as we approach 70 years old we typically lose three quarters of our functioning kidney cells (nephrons) but do well with our limited reserve as long as we do not constantly call on that reserve. When we take nonsteroidal anti-inflammatory drugs like ibuprofen and naproxen to relieve pain we are challenging that reserve leading seniors to look for alternatives. Opioids, even when appropriate, have become taboo so alternatives are being searched for.

Medical marijuana has become a very hot topic recently.  It is being heavily marketed as a pain relief alternative in several forms.  However, what little legitimate research has been conducted indicates it is not very good at relieving non cancer related chronic pain.

Not a day goes by when several patients reveal they are using cannabis products obtained out of state for pain relief with no consideration of how it interacts with the medications they are already taking. Recently, strong public relations campaigns for legalizing medical marijuana have led to its legalization in different forms, in various states, even if it doesn’t work. A select group of investors have positioned themselves to make vast sums of money from a product with little documented upside and potentially unknown downsides.

At the same time that medical marijuana enters mainstream medicine there is a similar legislative and marketing push to legalize marijuana for recreational use. Once again, a well-financed lobby of investors is trying to sell the concept of marijuana being less troublesome than legalized tobacco or alcohol. In the last few weeks there have been several articles appearing in reputable medical journals and periodicals such as the Wall Street Journal, New York Times and New Yorker magazine all examining the known results of liberalizing marijuana use in three states.

First of all, today’s marijuana is far stronger and potent than the “love generation’s” weed of the 1960’s with a higher percentage of the hallucinogen THC. To that point, states that have legalized marijuana have seen a tripling of visits to the emergency department for psychotic behavior. Also, violent crime and murders have tripled in many jurisdictions. A growing body of evidence indicates auto accidents have increased as a direct result of marijuana’s use.

Medically speaking, there is little research evaluating marijuana as a drug. Many questions remain.  What is the minimal dosage to create an effect? What is the dosage that can cause medical illness? How does the mechanism of delivery affect the final effects such as smoking versus vaping versus eating the product? Beyond the stoners’ credo of “start low and go slow” there is little data to evaluate the product as a pharmaceutical drug and or how it can interact with other drugs prescribed for you.

I am far from an anti-marijuana critic. I’d just like to know what I’d be getting in to before I consider hallucinating. It seems to me that before we liberalize marijuana use, the product needs to be put through the type of research and scrutiny the old Food and Drug Administration (FDA) put a product through before it was approved for public use.

Chocolate as a Cough Suppressant

Well before Valentine’s Day, and conspicuously in the middle of cold and flu season, Alyn Morice of the University of Hull in Yorkshire, England published a study showing that dark chocolate derivatives may be more effective than codeine in suppressing a cough. In a small study of 163 individuals, each with a cough due to an infection, her group randomly assigned them to a group receiving a codeine based cough syrup or a chocolate cocoa based syrup called Rococo. Their results showed that within two days the chocolate based recipients felt significant improvement in their cough compared to the codeine based group. A similar study had previously been performed at the imperial College in London showing that theobromine, a product in cocoa, is superior to suppressing coughs over codeine.

Professor Morice believes the properties in cocoa are demulcent and help relieve irritation and inflammation. “This simply means it is stickier and more viscous than standard cough medicines, so it forms a coating which protects nerve endings in the throat which trigger the urge to cough. This demulcent effect explains why honey and lemon and other sugary syrups help.” They believe chocolate has additional helpful ingredients so much so that they advise sucking on a piece of dark chocolate as a mechanism of relieving a cough. We now have some science to back mom’s hot chocolate and hot cocoa for a cold and a cough.

Winter is the Season for Upper Respiratory Tract Infections and Influenza

It’s the season for winter viral upper respiratory tract system infections. It is also influenza and influenza- like illness season.

Winter brings crowds of people indoors together and holiday travel places crowds together in indoor areas as well. These viral illnesses are transmissible by hand to mouth transmission and airborne particle transmission with coughing. The viral particles can live with minimal water on surfaces for long enough periods of time to infect patients who unknowingly touch a foreign surface and bring their hands up to their mouths. Hand washing frequently is an essential part of preventing the transmission of these diseases. Common courtesy such as covering your mouth when you sneeze or cough and not coming in close contact with others when ill is essential.

Research has shown that consuming an extra 500 mg a day of Vitamin C can prevent colds and reduce the intensity of a cold if you catch one. You must take the Vitamin C all the time and in advance of exposure. Waiting until you have symptoms has no positive effect. Viral upper respiratory tract infections usually include fatigue, runny nose (coryza), sore throat (less than 90 % of adult sore throats are not a strep throat).

If you have been around a sick child age 2-7 who has a fever, swollen neck glands and an exudative sore throat your chances of having a strep throat are increased. Fever is usually low grade, less than 101, and short lived. Very often patients develop viral inflammation of the conjunctiva or conjunctivitis. While this is very contagious to others, it is self-limited and rarely requires intervention or treatment.

Caring for a cold involves listening to your body and practicing common sense solutions. Rest if tired. Don’t go to the gym and workout if you feel ill. If you insist on going, warm up slowly and thoroughly and, if you do not feel well, stop the workout.

Sore throat can be treated with lozenges. Warm fluids including tea and honey (honey is antimicrobial and anti-viral), chicken soup, saline nasal spray for congestion and acetaminophen for aches and pains or fever are mainstays of treatment. Over the counter cough medications like guaifenisin help.

Some of the viruses affect your gastrointestinal tract causing cramps and diarrhea. Nausea and vomiting are sometimes present as well. The key is to put your bowel to rest, stay hydrated and avoid contaminating or infecting others. Clear liquids, ice chips, shaved ices, Italian ices or juice pops will keep you hydrated. A whiff of an alcohol swab will relieve the nausea as well. If you are having trouble keeping food or fluids down call your doctor. If you are taking prescription medications, call your doctor and see which ones, if any, you can take a drug holiday from until you are better.

Influenza is more severe. It is almost always accompanied by fever and aches and pains. Prevention involves taking a seasonal flu shot. Flu shots are effective in keeping individuals out of the hospital from complications of influenza. They are not perfect but far better than no prevention. If you run a fever of 100.8 or higher, and ache all over, call your physician. An influenza nasal swab can confirm influenza A and B 70 % of the time.

The new molecular test which can provide results in under an hour is far more accurate but not available at most urgent care or walk in centers or physician offices. Immediate treatment with Osetamivir (Tamiflu) and the newer Peramivir are effective at reducing the duration and intensity of the infection if started early. Hydration with clear fluids, rest, acetaminophen or anti-inflammatories for fever in adults 101 or greater and rest is the mainstay of treatment. Prolonged fever or respiratory distress requires immediate medical attention. Call your doctor immediately.

I get asked frequently for a way to speed up the healing. “My children are coming down to visit. We have a cruise planned. I am flying in 48 hours on business.”  I am certainly sympathetic but these illnesses need to run their course. They are not interested in our personal or professional schedule and everyone you come in contact with is a potential new victim. If you are congested in the nose or throat, and or sinuses, then travelling by plane is putting you at risk of severe pain and damage to your ear drum. See your doctor first. Patients and pilots with nasal congestion are advised not to fly for seven to ten days for just this reason.

If you have multiple chronic illnesses including heart disease, lung disease, kidney disease and you run a fever or feel miserable then call your doctor and make arrangements to be seen. It will not necessarily speed up the healing but it will identify who actually requires antibiotics and additional follow up and tests and who can let nature take its course.

Artificial Sweeteners and Your Health

An article published in the online version of Primary Care brings up the issue of whether artificial sweeteners are a positive, helping people lose weight, or is there more to the story. Editor David Rakel MD, FAAFP discusses a recent article in the neurologic journal STROKE showing an association between the number of artificially sweetened beverages consumed per day and the onset of a stroke. This relationship was seen only with artificially sweetened beverages not with sugar sweetened beverages.

Dr Rakel goes on to discuss the ongoing public health concern of consuming nonnutritive sweeteners and its effects on weight gain and insulin resistance. Recent studies known as observational studies have linked high consumption of beverages with nonnutritive sweeteners with weight gain, increased visceral adiposity and a 22 % higher incidence of diabetes despite consuming less energy.

The reasons for consuming fewer calories but gaining weight are considered to be many. Sweet tasting compounds including NNS activate sweet “taste receptors” that were once thought to be only located in the mouth but are now known to be throughout the body. This activation results in release of insulin. The continued release of insulin by the pancreas, without energy producing calories present to be metabolized, may lead to insulin resistance. Insulin resistance involves insulin being released in response to food being consumed but is becoming ineffective in moving sugar into the cell where it can be metabolized into energy.

There is additional belief that supplying sweetness without calories may result in disturbances to appetite regulation and communication within the body about when we are full. Products such as aspartame, saccharin and sucralose have been found to have negative effect on the intestinal bacteria or microbiome potentially having an effect on glucose tolerance and metabolism.

We see artificial sweeteners on tables in every setting. Aspartame produces a sweetening effect 200x sugar. Saccharin produces a sweetening effect 500x sugar. Sucralose is 600x sugar sweetening and Advantame 20,000x sweeter.

A teaspoon of sugar only contains 16 calories. Portion control of products made with real sugar may be the safest and healthiest way to eat sweets as the holiday season approaches. A level teaspoon of sugar in your coffee or tea may be far healthier for you than that packet of artificial sweetener.