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.

A Clinician’s View of the Opioid Crisis

“Do Not Get Caught.” seems to be the real rule of the law in S. Florida, where I live.

I was trained to limit the use of controlled substances, narcotics, hypnotics and sedatives. Their use can affect consciousness, ability to drive a car and work.  More severe consequences include respiratory depression and overdose from too high of a dosage or mixing too many medications and over the counter items.

The Joint Commission on Accreditation, medicine’s good housekeeping seal of approval authority, along with major medical organizations have accused clinicians of under treating pain. “Pain” is the fifth vital sign, they said.

This was accompanied by professional society leadership and academic researchers receiving grants from pharmaceutical companies touting the newer longer acting pain medications which “have very little addictive potential”. We were then informed we would be receiving evaluations and scores of our treatments of pain which would influence our reimbursement if we under treated pain.

In my current concierge medical practice I see 10 or fewer patients per day. In my previous general practice I saw 2- – 30 patients per day. I could go days without prescribing a narcotic pain medication. In most cases when I wrote out a script for a narcotic pain medication it was for a patient with a severe chronic pain problem, seeing a specialist for that problem, and requiring a pain pill because there were few effective alternatives. The patient visits to doctors and physical therapists and massage specialists and other alternative pain therapies were well documented in the medical record and mostly unsuccessful in attempts to relieve the pain.

This contrasts markedly with the opening of pain clinics in nearby counties with their own in-house prescribing pharmacies. One or two physicians wrote thousands of pain pill prescriptions per day. Patients lined up around the block to see these employed physicians of the pain clinic with many arriving in cars from other states. The cash flow generated was so vast that the clinics needed private security to protect the profits. Many of the security hired were off duty city and county police officers trying to supplement their income.

It’s hard to imagine that law enforcement and the DEA, were unable to recognize the difference between pill distributing centers and legitimate practices prescribing medications on a limited basis to individuals with documented needs. City, County and State governments gladly accepted the tax benefits, occupational license fees and pharmaceutical license fees from these sham clinics while drug dealers drove in and out of our state to obtain prescription pain medications for sale in their home towns. Of course the blame for this was placed on the doctors and dentists.

The State of Florida tightened up its laws and somehow law enforcement was given the tools to see and eradicate what was occurring right under their very noses. As prescription drugs dried up, the Mexican drug cartels got smart and flooded the market with cheap strong heroin. It was obviously the fault of the physicians and legitimate pharmacies that white working class people were buying plastic bags full of dope and inserting needles into their veins to avoid the pain of life.

As drug addiction soared, City and County Governments found it in their hearts to sit as zoning boards allowed drug rehabilitation centers to open up in the heart of their communities. There was little or no effective investigation of who was running these clinics and or their previous experience, methods and or success rates. If you want to read about where the soaring number of narcotic overdoses occur in our community – follow the zoning board’s placement of rehab centers and sobriety houses. What better way to increase your drug overdoses than to encourage unsuccessful addicts to come to your community and leave their money and their family’s money to improve the tax base and create new headaches for EMS and police officers?

Somewhere there should have been a higher level of thought by our elected and appointed officials about the consequences of bringing hundreds of drug dependent individuals into our area before they permitted these facilities to open.

Last week my advanced pancreatic cancer patient with severe back pain tried to purchase a controlled substance prescribed by his oncologist to relieve his suffering. Six pharmacies no longer stocked the product due to their fear of liability. It took hours to find a pharmacy that would order the medication for the patient. Physicians, pharmacists and law enforcement accessing our state narcotic registration website clearly can see that this patient only uses his medications as prescribed by one physician. This patient, and others like him, are victims of the government legitimizing of pain pill mills and drug rehabilitation centers in their communities.

As a physician we all have our failures in this area as well. I painfully recall the doctor’s wife I sent to a disciplined pain doctor to wean her off narcotics prescribed by a rheumatologist, urologist and gastroenterologist for legitimate reasons documented by tests and biopsies. I refilled the prescriptions for her convenience and ease never dreaming I was contributing to her problems.

I feel for my colleagues in the Emergency Department and in orthopedic offices having to daily differentiate acute pain requiring intervention with controlled substances as opposed to individuals with drug seeking personalities. This being said, the opioid crisis was caused by the most trusted members of the academic medical community in cooperation with the medical inspection and certifying agencies in concert with public officials and law enforcement looking the other way. They all made a great deal of money at the expense of the public. Now as they struggle to clean it up they give us medical and recreational marijuana.

Deep Vein Thrombosis Prophylaxis, Safety and the Joint Commission on Accreditation of Hospitals

Over the last few years, great emphasis has been placed on preventing blood clots from forming in the legs and pelvis of all hospitalized patients. These blood clots can break off and travel to the lungs causing life-threatening breathing problems and fatal heart arrhythmias and sudden death. Preventing these “venous thromboembolic events” has been a priority of quality organizations like the Joint Commission on Accreditation of Hospitals which inspect hospitals and offer certification if the hospital meets their criteria.

The movement to prevent these clots and sudden death has become so strong that you cannot admit a patient to the hospital without addressing these issues. Physicians must either choose to give injections below the skin with the blood thinner heparin three times a day or the low molecular weight heparin twice a day. You are additionally asked to prescribe mechanical compression stockings to the legs to further reduce the risk.

If you choose not to institute these orders you must clearly write out and outline your objections and reasons for not taking these measures. Even if you document your reasons for not instituting these measures you’re assured of receiving a call from your hospital’s quality care organization.

This all becomes newsworthy because two recent studies called into question the practices. One study concluded that mechanical compression stockings added nothing to the use of blood thinners in preventing deep vein clots. The other study cited that for every 1000 patients treated with blood thinners to prevent pulmonary emboli; you prevented three non-fatal pulmonary emboli at the expense of causing nine bleeding events – four of which are major.  I suspect this data will be discussed in our medical journals and at scholarly meetings and a consensus opinion will be reached on how to proceed. Letters will be written to journals criticizing the methods of these studies and other letters will be written defending them and, ultimately, a common sense approach will be reached.

In the meantime, it would be far more interesting to look at the Joint Commission on Accreditation of Hospitals and determine how they got so powerful that they can mandate procedures which may not have any value and may do harm?  Who are they?  How do they generate income and how much goes to who and why?

It is a fact that in the state of Florida, private insurers like Blue Cross Blue Shield, Aetna, Humana, will not contract with a hospital or institution unless it receives certification from this organization.  A study should be done to see if these JCAHO inspections costing $7-8 million dollars every other year resulted in any reduction of in-hospital errors, iatrogenic illnesses, death rates and serious illness?

Insurers and employers who pick up the “lion’s share” of our health care costs are always asking for accountability and efficiency and want to pay for what works. It would be nice to know if their relationship with JCAHO has made the patient safer or healthier over the last 15 years.