Operating Room

A Safe Operating Room Is A Cold Operating Room

On Monday, I got a text message from our hospital’s Chief of General Surgery at 6:40 AM that the operating rooms were in excess of 100° F. When the air temperature in the OR is too high, it is not only uncomfortable for the surgeons and OR staff who are all wearing surgical gowns, it is unsafe for the patients because of the risk of infection. When temperatures are too high, microorganisms grow. When the humidity is too high, condensation can develop on the ceilings and equipment resulting in non-sterile indoor “rain” on patients or instruments. If either the temperature or the humidity is too high, then the surgeons start sweating which is not only a distraction but no one wants drops of sweat falling into a patient’s open incision. Too cold is also bad, hypothermic patients are more likely to get wound infections. Because both too hot and too cold is dangerous, the CDC adopts the American Institute of Architects parameters for operating room ventilation:

Temperature: 68-73° F

Humidity: 30-60%

Air changes: 15 total air changes per hour and minimum 3 air changes of outdoor air per hour

Keeping a relatively narrow temperature and humidity range turns out to be more difficult than it might seem because of the relationship between temperature and humidity. For example, if a room is 68° F with 60% relative humidity (within parameter range) and you drop the temperature to 64° F, the relative humidity will rise to 68% (out of parameter range).

Operating rooms have visual alerts in a central location when the OR air temperature or humidity is out of the parameter range but these alerts are on monitors and if no one happens to be looking at the monitors, then the alerts go unnoticed.

When a hospital goes through a JCAHO (Joint Commission) site survey, the surveyors will make a bee-line for refrigerators and freezers to be sure that there are temperature logs being kept and alarms when there is a loss of power or refrigeration. However, no one ever thinks to have logs or alarms for the air temperature in an operating room.

So, on Monday morning, we moved as many procedures from the overheated primary OR area to an unaffected secondary OR area. However, when temperatures get to 110° F, many disposable supplies can be damaged and have to be thrown out and sterilized instrument sets need to be re-processed. Therefore, a number of surgeries had to be canceled at the last minute. Fortunately, although there was inconvenience, no patients were placed in jeopardy.

The best way to avoid excessive heat in the OR is to have multiple, redundant alerts. So, make sure that you have both audible alerts as well as visual alerts on the temperature monitors.  Also, arrange that the alerts trigger auto-pages to hospital administrative staff when OR temperature or humidity parameters are out of range.

I must have missed the class on HVAC systems in medical school.

December 21, 2016

Emergency Department

Diversion Is Deadly

Every day, I get an email with all of the statistics from the previous day’s emergency department activity. The one statistic that can drive me crazy is the emergency department diversion hours. These occur when the ER goes on “divert” status which means that emergency squads are told to bypass our emergency department and take patients to some other hospital’s emergency department. We never close the emergency department and patients can still walk-in to the ER normally.

There are several reasons that the ER can go on divert:

  1. The ER itself is overwhelmed (for example, multiple critically ill patients arrive at the same time)
  2. We don’t have any empty beds on the nursing units to admit patients to from the ER
  3. We don’t have any ICU beds to admit patients to from the ER
  4. We don’t have enough inpatient nurses to take care of more admissions

Diversion is bad news for several reasons. First, and most importantly, it means that our hospital does not have the resources to care for the patients in our community at that particular time. A patient who lives 5 blocks away should not have to be taken to another hospital 15 miles away where their family and friends cannot easily visit. Second, it disrupts continuity of care. Patients who always get their care in one hospital and whose physicians practice at that hospital are best served by being taken care of by the doctors who know them the best. Third, it is bad business. Hospital admissions are the fuel that keeps the hospital running and patients arriving by squad are far more likely to be admitted to the hospital than those who walk in through the front door who are more likely to be treated and released.

Last year, our ER diversion hours reached record highs. Rather than being a rarity as it had been for more than a decade, it was becoming a regular occurrence, at least once a week. Our initial solution was to open up 4 new ER beds and 5 new inpatient beds to avoid the “no room at the inn” phenomenon. That helped but didn’t solve the entire problem entirely. So next, we asked the 5 whys.

The 5 whys was a concept developed by the founder of the Toyota Corporation, Sakichi Toyoda. His idea was that if you identify a problem, then you keep asking why it occurred through 5 layers of inquiry in order to get to the root of the problem and solve it. So, for example, you identify a problem that your medical students are passing out when holding retractors during pancreatic surgeries.

  1. Why are the medical students passing out? Because they are hypoglycemic.
  2. Why are they hypoglycemic? Because pancreas surgeries go on for 5 hours and the medical students haven’t had anything to eat.
  3. Why don’t they get something to eat before the start of surgeries? Because they are pre-rounding on their patients until 8:00 AM and all of the donuts in the physician lounge are gone by 7:00 AM.
  4. Why are all of the donuts gone by 7:00 AM? Because the donut company only brings 3 boxes of donuts even though the administrator in charge of donuts always orders 8 boxes of donuts.
  5. Why do they only bring 3 boxes rather than 8 boxes of donuts? Because the donut administrator always fills the donut order out in blue ink and faxes the order to the donut company and since the blue ink doesn’t fax well, the “8’s” look like “3’s”.

So, what is the solution to the syncopal medical students? Buy the donut administrator a pen with black ink.

We applied this principle to our emergency squad diversion problem. First, we looked at the what days of the week we were going on divert and found that over the course of a year, diversion hours peaked on Wednesdays, pretty regularly and pretty dramatically on Wednesdays. In contrast, diversion was very rare on Fridays, Saturdays, or Sundays. Next, we looked at when our emergency department admissions peaked and it was on Mondays, again, pretty regularly and dramatically peaked on Mondays. Next we looked at when our elective surgery admissions peaked and it was on Tuesdays, very consistently on Tuesdays.

So the solution wasn’t to bring in extra ER physicians on Wednesdays or open additional inpatient beds on Wednesdays. The solution was to move one of our busiest orthopedic surgeons from operating on Tuesdays to operating on Thursdays. What had been happening was that we would get a bolus of emergency department visits on Mondays followed by a bolus of joint replacement surgery admissions  on Tuesdays and then by Wednesdays, we’d be out of inpatient beds. By Fridays, the Monday and Tuesday admissions would be ready for discharge and then we’d have excess inpatient capacity through the weekend. By moving the orthopedic surgeon to Thursdays, we evened out the admissions over the course of the week and presto, the ER diversion hours plummeted.

The 5 whys can keep you from making stupid decisions. Getting back to our medical students who were passing out in the OR, if we had stopped with the first why, we may have banned medical students from holding retractors. If we had stopped with the second why, we may have told the surgeon that he needs to finish his pancreas surgeries in 4 hours. If we had stopped with the third why, we may have required the medical students to come in an hour earlier to do their rounding. If we had stopped with the fourth why, we may have fired the donut company. It was only after the fifth why that the solution of buying a 99¢ black ballpoint pen to fix the problem became apparent.

December 17, 2016


Inpatient Practice Outpatient Practice

I Can’t Get No (patient) Satisfaction

Last week, I attended a breakfast that our medical center put on for physicians ranking in the top 10% nationwide for patient satisfaction. The remarkable thing is that last year, no one invited me to breakfast. Not even close. In fact last year, my patient satisfaction scores were abysmal. Did I change my doctor-patient interactions? No… I’m 58 years old and I don’t change anything very easily. So what happened?

Outpatient satisfaction scores are derived from a series of questions on the CG-CAHPS survey (Clinician and Group – Consumer Assessment of Healthcare Providers and Systems). This is a questionnaire is a cousin of the HCAHPS questionnaire used for hospital satisfaction and it is based on a 1-10 rating scale; only 9’s and 10’s really count so in other words, you have to get an “A+” grade every time. One of the questions is: “In the last 12 months, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results?” The questionnaire is sent to patients one week after they are seen in the office.

In our clinic site, we found that we were not always getting results to patients before they got their CG-CAHPS questionnaire. It is pretty easy when patients are computer-savey and sign up for the “MyChart” account on our electronic medical record, because with a mouse click, I can release blood test results to the patient’s account and they get an email telling them that there are test results available so they should log-in and check their MyChart account. There were three problems:

  1. A lot of the blood tests that I order have to be sent out to reference labs and they can take 2-3 weeks to come back. These results aren’t available when the patients get their CG-CAHPS questionnaire in the mail 7 days after their office visit and so they haven’t been contacted by anyone in my office with lab results.
  2. For some of my patients, our hospital is not in their insurance network so when I order labs, those tests have to be done at another hospital and it can often take many days for me to get results by mail. So, if I see a patient on December 1st and order labs, the patient gets their labs drawn at another hospital on December 5th, and then I get the results in the mail on December 9th, then no one from my office will have called the patient with results on December 7th, when the patient gets the CG-CAHPS survey in the mail because I don’t have the results yet.
  3. Because of the nature of my practice, a lot of my patients are taking immunosuppressive medications that requires monitoring lab tests every 1 or 2 months. Because many of my patients are from out of town, they get their labs drawn at their local doctor’s office or lab and then the results are mailed to me for review. The results are then scanned into our electronic medical record system and my office staff call the patient to tell them that the labs are OK. Many of these patients are used to being able to see all of their test results on their MyChart account when those tests are done at our hospital’s lab. However, scanned PDF files (of outside hospital labs) are not visible on MyChart. These patients were frustrated because they expected that the labs drawn at their primarily care physician’s office, often in a different state than Ohio, would show up on their MyChart account just like those labs from our hospital.

So, what was the solution? Well, all we did was to add a phrase onto the patients printed after-visit-summary (AVS). The AVS is a printed document that we give the patients after their office visit that goes over their medications, future appointments, etc. We added to the AVS:

“If you had blood tests today, many of those blood tests can take up to 3 weeks to complete; our office will contact you when those results are available. If you have an OSU MyChart account, we will release results to your account within 24 of when we receive those results; if you do not have an OSU MyChart account, we will mail you the results and it may take several extra days for you to receive them by mail. If you have blood tests done at non-Ohio State laboratories, these results will not be available on your OSU MyChart account and the results of these tests may take an extra 1-2 weeks to get back, depending on the mail.

With this simple change to the AVS, I went from having 91.4% of patients rate me with either a 9 or 10, to having 98.1% of patients rate me with either a 9 or a 10. Because there is a tremendous amount of grade inflation with the CG-CAHPS survey, the difference between a 91.4% and a 98.1% is the difference between significantly below average and being in the nationwide top 10th percentile.

The lesson is that patient satisfaction is all about expectations and if we set the expectations, in this case, of when lab tests become available, then we can impact patient satisfaction. My patients didn’t know that when they had an anti-strongyloides antibody, that it takes 3 weeks to get the results back. To the patient, the anti-strongyloides antibody wasn’t any different that a CBC (that results come back in a few hours).

Ultimately, however, medicine is a team effort and even though I’d like to think that my patient satisfaction is high because I’m a good doctor, the reality is that the physician’s patient satisfaction is a reflection of the entire team. So, if you as a physician want to have a high patient satisfaction score, get good nurses, friendly registration staff, responsive housekeeping staff, and plenty of convenient parking at your office. Because the doctor’s patient satisfaction scores really aren’t just about the doctor.

December 11, 2016

Hospital Finances Operating Room

Thou Shalt Not Covet Thy Neighbor’s Surgeon

penguin-rockIf you are addicted to the National Geographic Channel, like I am, then you’ve probably seen videos of Adelie penguins. The males build nests out of stones in frozen Antartica in order to attract female penguins. Instead of going out and collecting their own stones, some criminal male penguins will steal stones from one his neighbor’s nests when his neighbor is out stone-hunting. Hospitals do the same thing – except instead of stones, they steal surgeons.

Surgical admissions to the hospitals are more lucrative than medical admissions. Surgical admissions account for 29% of all hospital admissions but account for 48% of hospital costs. If you are paying out of pocket, the hospital expense of a heart valve surgery is about $117,000 and a hip replacement is $39,000. For most hospitals, surgeries are their lifeblood. And inpatient surgeries are far more valuable than outpatient surgeries. Consequently, hospitals are constantly on the prowl for surgeons, especially those surgeons who do big-ticket surgeries that bring patients into the hospital and who can do a large volume of surgeries with low complication rates.

There are two ways that you can get acquire a high-volume, low-complication surgeon. You can hire him or her straight out of residency and then develop him/her by careful mentoring. Or, you can recruit them from another hospital. Recruiting from an out-of-state hospital is usually seen as fair game. A hospital in Columbus, Ohio doesn’t really compete with a hospital in Tampa, Florida when it comes to doing hip replacement surgeries so leaving a hospital in Columbus for a hospital in Tampa is not seen as taking surgical market share to Tampa.

moses-10-commandmentsBut recruiting a surgeon from one hospital to a different hospital in the same city is typically seen as playing dirty. First, that surgeon likely has a large referral base of primary care physicians and those physicians will continue to refer their patients to the surgeon regardless of which hospital he/she is operating at. Second, the first hospital has invested several years developing that surgeon to get him or her to a point of efficiency and notoriety.

A great surgeon wasn’t a great surgeon the day he/she finished residency. It takes time after training to become really great. In his book Outliers: The Story of Success, Malcolm Gladwell proposed that to be really great at something, you need to spend 10,000 hours in meaningful practice of it. For example, Bill Gates spent about 10,000 hours programming before he came up with the foundations of Microsoft’s operating system. The Beatles practiced and played concerts together in Germany for 10,000 hours between 1960-1964 before they made music history. A surgeon can’t get 10,000 hours of operating room time during a 5-7 year residency. Most of their operating time during training is spent as an assistant rather than being the primary surgeon and even so, they’d have to spend 40 hours a week operating for 5 years to get to 10,000 operating hours. So it takes some time after residency to make a good surgeon a great surgeon – I think it is typically about 7 years. Those 7 years are kind of like the time the Beatles spent in Germany before they became famous.

Not only does it take time for a surgeon to hit peak surgical skill, but it also takes time for that surgeon to cultivate a referral base and to become efficient. That part typically takes about 5 years. Therefore, the hospital has to subsidize the surgeon for about 5 years during the surgeon’s start-up period. So, a typical start up funding package from the hospital for a newly trained surgeon might be $250,000 for year 1, $150,000 for year 2, $125,000 for year 3, $100,000 for year 4, and $50,000 for year 5. That’s a total of $675,000 that the hospital invested in that surgeon to get them to a level of self-sustaining practice.

Now, if you are a competing hospital in the same city, you can either spend $675,000 cultivating your own surgeon right out of residency or you can spend $675,000 recruiting another hospital’s surgeon who is at the end of their 5-year start up. And if you really want to come out ahead financially, you can give that surgeon an extra $150,000 per year for 4 years (total $600,000) and save yourself $75,000 that you would have spent cultivating a newly trained surgeon.

pattonWhen leaving Africa in 1943, General George S. Patton famously said “No dumb bastard ever won a war by going out and dying for his country. He won it by making some other dumb bastard die for his country.” Similarly, a hospital wins the surgery volume war not by paying to develop its own surgeons but by making some other hospital pay to develop the surgeon… and then stealing them.

Not all types of surgeons are equal in this regard. For example, a surgeon who is really good at something unique and cutting edge that brings in lots of new lucrative elective surgeries to the hospital, like robotic prostatectomy, makes for great stealing. On the other hand, a general surgeon in a city with 50 general surgeons may not be worth spending as much to steal.

Additionally, optimal efficiency is not just a function of the surgeon but it is the entire operating room team, including the physician assistant, nurses, and operating room technician. It is much harder to steal an entire team from a hospital so there is inevitably some lost efficiency from a newly stolen surgeon.

Hospitals create barriers to other hospitals absconding with their surgeons by implementing “non-compete” clauses in the surgeon’s contract. A typical non-compete clause will say that the surgeon cannot work at a hospital within 10 miles for a year after resigning. There are ways around the non-compete clauses, however. They can be contested in court and the surgeon may or may not win. Or the hospital stealing the surgeon can locate the surgeon in a branch hospital or surgical center just outside of the non-compete radius. This happened to us a couple of years ago when 2 plastic surgeons a few years out of residency were recruited by a competing hospital system in Columbus that then located them at one of their branch hospitals that is 10.5 miles away from the OSU Medical Center, a half mile beyond the non-compete radius.

So in deciding whether to grow your own surgeon or steal someone else’s, it all comes down to financial strategy. Either approach can be cost effective and it is ultimately finances and not morality that guides behavior.

December 6, 2016

Hospital Finances Medical Economics

How Many Researchers Can You Really Afford?

Academic medical centers’ reputations are rarely built on the quality of clinical care or the quality of education. Reputations are built on the volume of research grants and publications. The academic medical center becomes famous by doing research about clinical care and publishing about education. Similarly, to be promoted as a faculty member at most colleges of medicine in the U.S., it is not enough to be a great clinician or great teacher, you have to do research and publish about medicine and teaching. In theory, devoting a lot of time to research and publication about clinical care and education will also make the institution a better place to provide clinical care and medical education. But in reality, the best researchers and journal article writers are not necessarily the best clinicians or teachers.

To be successful obtaining and implementing research grants, physicians have to have “protected time”. This is time that they are not assigned clinical duties and can devote to scientific investigation and writing in order to be competitive for research grants. The most prestigious grants for physicians are those from the National Institutes of Health and these grants provide money to conduct research projects and also provide money to pay for the physician’s “protected time”.

But we have a problem in American research. Grants from the National Institutes of Health don’t really cover the physician’s protected time. It all comes down to something called the NIH salary cap. This is the maximum salary that can be paid from an NIH grant. Currently, the salary cap is $185,100. To any normal human being, this seems like a lot of money, a whole lot of money. The problem is, that physicians doing clinical practice usually make more than this. In fact, according to the MGMA salary survey, the average salary for most specialties is higher than $185,100. This means that to be a researcher, you either have to accept a lower salary than a clinician in the same specialty or someone else needs to subsidize your salary.

Lets take an example of a group of physicians who have 50% protected time, meaning that they see patients half of the work week and do research funded by the NIH for the other half of the work week. In the table below, the salary is taken from the MGMA survey. The the cost of 50% protected time is listed as 50% salary. The NIH salary cap is for a 100% full-time researcher is $185,100, so half of that (to cover the 50% protected time) is listed as 50% NIH cap. For most specialties, the NIH salary cap will not fully cover the salary that the physician would receive if her or she was a full-time clinician; this difference is listed in the last column.


From this analysis, you can see that a hospital can afford to have 4 specialties do research without having to subsidize them: infectious disease, general internal medicine, nephrology, and general pediatrics. For any other specialty, the hospital has to come up with additional funds to make up the difference between the NIH salary cap and what that physician could make doing pure clinical practice. Neurosurgeons are the most financially challenging since they have the highest salaries: you can fund 19 endocrinologists to do research for the price of funding one neurosurgeon.

In reality, most researchers accept a lower income than full-time clinicians. Researchers don’t have to round on weekends, don’t get called in at night for emergencies, and don’t have malpractice suits filed against them. But there are limits and even the most scientifically curious physicians will find the allure of an extra $50,000 or $100,000 too much to keep them in research.

As a consequence of this, an academic medical center that wants to get the greatest return on research investment will seek a lot of researchers from endocrinology, physical medicine, infectious disease, and nephrology. Researchers who are neurosurgeons, orthopedic surgeons, and cardiologists are too expensive to have more than a small number of researchers.

One of my colleagues who is a cardiologist on his division’s finance committee once told me that that the worst news he can get is a mass congratulatory email from the division director telling all of the cardiologists that one of their peers just got an NIH grant. The unwritten implication of that grant was that the rest of the cardiologists were going to have to pony up to help subsidize the portion of the grant awardee’s salary not covered by the NIH salary cap. Now days, the clinical physicians usually can’t afford to pay this difference because it means that they have to take a pay cut in order to support their research colleagues. Therefore it comes down to the hospital to provide the salary difference subsidy.

So as a hospital medical director, how should we view this? We only have a limited amount of money to invest in researchers so we have to be prudent in how we spend it and who we spend it on. It is like investing. For high salary specialties, the hospital can only afford a small number of researchers and they have to have a high probability of research success – think of this as buying 1 expensive stock share in Apple. For lower salary specialities, the hospital can afford a larger number of researchers and can afford to take a chance on researchers with a less certain probability of research success – think of this as buying 1 inexpensive stock share in each of 10 start-up companies.

The holy grail of research funding is the endowed chair where the academic medical center can use money from donors to off-set the NIH salary cap difference. This is pretty easy at a well-endowed college of medicine like, for example, Harvard. But it is not so practical at a state-supported college of medicine (like Ohio State) with relatively meager endowment funds. For institutions with less endowments, you have to decide what the right ratio of clinicians:researchers is. That ratio will vary depending on the specialty and the percent protected (research) time that the researchers have. The goal is to have the right balance so that you have enough research to make the institution famous but not so much research that institution goes into debt.

December 3, 2016

Intensive Care Unit

BRAVE New World In the ICU

Glucometers are one of the most common medical devices in use today. They cost about $20 or $30 to buy at the drugstore and every nursing station and doctor’s office has one. Most of the time, they work great and are very accurate to measure the blood glucose level by pricking the skin to obtain a drop of capillary blood to put into the glucometer.

In 2001, a study published in New England Journal of Medicine showed that tight glucose control in critically ill patients resulted in improved ICU outcomes. In this study, blood was drawn every 1-4 hours and glucose levels were checked on a laboratory chemistry analyzer. In response, ICUs across the country started practicing “tight glucose control” in critically ill patients and this often meant an insulin drip with glucose checks every hour.

But over the next 10 years, outcomes in most ICUs did not improve with tight glucose control and a lot of patients actually did worse. As a consequence, critical care physicians backed off on the tight glucose control strategy. One of the reasons patients did worse may be that in the original study, blood was drawn up in regular blood tubes and sent to the hospital lab but in normal clinical practice, most of the time, the blood to be tested is not in tubes sent to the hospital lab but instead is from a drop of capillary blood tested with a point-of-care glucometer after pricking the skin on a finger.

It turns out that in our sickest patients, glucometers using capillary blood often don’t work. Because of this, the FDA has not approved glucometers for use in critically ill patients with capillary stick specimens and in 2013, the FDA advised against using glucometers in these patients. The problem is that patients with edema, low blood pressure, and poor capillary filling can have inaccurate results from that drop of capillary blood and it may not truly reflect the real blood glucose level. These patients must have regular arterial or venous blood specimens drawn rather than a skin prick capillary blood specimen.

This means that blood must be obtained from a intravenous line, arterial line, or venipuncture. This is a problem for patients who are on insulin drips because they need glucose measurements as frequently as every hour. Since the FDA does not approve glucometers to be used on capillary blood specimens in critically ill patients, their use in these patients is considered “off label” which poses medical-legal risk for using them. The FDA and CMS did not define what “critically ill” means and left this up to individual hospitals to define; at our medical center, we developed the BRAVE criteria to identify those critically ill patients in whom the capillary blood specimens are inaccurate and should not be used:

Blood Pressure: systolic blood pressure < 80 mm Hg or mean arterial pressure < 55 mm Hg.

Reduced capillary refill rate at collection site: capillary refill > 3 seconds

Acidosis from diabetic ketoacidosis or non-ketotic hyperosmolar acidosis

Vasopressors: norepinephrine, phenylephrine, vasopressin, or dopamine (> 5 mcg/kg/min)

Edema: pitting edema at the capillary stick site

For these patients, you need to get regular blood, commonly from a central venous line or an arterial line. In the past, nurses would need to draw a 5-10 ml blood discard to clear the central line or arterial line of saline or other fluids and this would result in a lot of discarded blood (you could waste an entire unit of blood in 3-4 days in patients needing hourly glucose checks). We now use the VAMP system manufactured by Edwards Lifesciences that allows the “discard” blood to be re-infused into the patient.

For documentation purposes in our electronic medical record, our nurses now have to select whether BRAVE criteria are met when documenting glucometer use and then they have to documents what type of blood specimen they are using. If there is a mismatch in the two selections, then the result is flagged by our point-of-care software. Weekly, our point-of-care staff notify the nurses and nurse managers that have mismatches to provide regular feedback to the nurses. We now have data showing a nice weekly improvement in the number of events since inception of the BRAVE program.

nova-stripIf blood was sent to the lab for a regular glucose check, this would require a full blood tube (another 5 ml). In 2014, the FDA approved one brand of glucometer, the Nova StatStrip Glucose Hospital Meter System, to be used on venous or arterial blood in critically ill patients. This is now the glucometer that we use in our ICU. It permits nurses to just draw up less than 1 ml of blood to put in the point-of-care glucometer (rather than filling up a blood tube to go to the lab) and this has greatly cut down on wasted blood.

In medicine, as with many other disciplines, bad data is often worse than no data. By using BRAVE, we can improve the data on glucose measurement in critically ill patients. Going forward, this may allow us to re-think the advisability of tight glucose control in the ICU for critically ill patients by ensuring that we are accurately measuring glucose levels.

December 1, 2016

Inpatient Practice

“The Patient Suddenly Worsened”

Patients who get transferred to the ICU often have transfers notes saying to the effect “The patient’s condition suddenly worsened.” In reality, the patient’s condition didn’t suddenly worsen, it is just that we suddenly noticed. In its extreme, that worsening results in a cardiopulmonary arrest. It goes by different names in different hospitals. Sometimes it is called a “Condition A”, sometimes a “Code-2” or an overhead page to “Dr. Quick” but most often it is a “Code Blue”.

Here are some numbers about in-hospital cardiopulmonary arrests. According to the American Heart Association, there are about 209,000 in-hospital arrests per year. In comparison, there are about 350,000 out-of-hospital arrests per year. Most in-hospital arrests (61%) occur in intensive care units. According to a 2012 study, the reasons for the arrest is most commonly systole or pulseless electrical activity (PEA) which together account for 82% of cardiac arrests with ventricular fibrillation or ventricular tachycardia accounting for 18%. For hospitalized patients, the most common underlying cause of a cardiopulmonary arrest is pulmonary rather than cardiac. For those that are cardiac in origin, a critical determinant of survival is the time to first defibrillation shock if the patient has ventricular fibrillation – the goal is < 2 minutes, after 2 minutes, the chance of survival falls. We are getting better at in-hospital cardiopulmonary arrest management: in 2000, the survival was 15% but in 2015, survival was 30%. Interestingly, the survival is lower if the patient is tracheally intubated during the arrest – presumably because chest compressions are held during intubation and holding those chest compressions, even briefly, has a negative impact on survival.

All too often, there are unrecognized warning signs prior to a patient having a cardiopulmonary arrest, particularly when those arrests occur out of the intensive care unit. Our challenge is to identify those patients before they have an arrest so that medical interventions may prevent the arrest from happening. One way of detecting at-risk patients is the “MEWS” score, or Modified Early Warning System score. This score is derived from 5 variables:

  1. Respiratory rate
  2. Heart rate
  3. Systolic blood pressure
  4. Conscious level (RASS score)
  5. Temperature

For each of these variables, there are points assigned for if the variable is either too high or too low.


If the total MEWS score is 5 or greater, then there is a 5-fold risk of death and a 10-fold risk of being transferred to and intensive care unit. So, in our hospital, our electronic medical record can calculate the MEWS score, allowing doctors and nurses to identify those patients who are clinically deteriorating before they deteriorate to the point of a cardiopulmonary arrest. If they get to a MEWS of 4, the nurses will contact the covering physician and increase the frequency of clinical monitoring. If they get to a MEWS of 5, the nurses are asked to consider calling an ERT (Emergency Response Team) that results in an ICU nurse plus a respiratory therapist coming to the bedside to do an emergency assessment of that patient and report to the physician covering the ICU to decide if the patient requires transfer to the ICU or some other intervention.

After a cardiopulmonary arrest occurs, one of the key events is the debriefing, when the code team members stop and review what happened, what went right, and what went wrong. Debriefing has been shown to improve a hospital’s cardiopulmonary arrest survival rate.

So, what can we do to better position our hospitals to have improved outcomes of cardiopulmonary  arrests?

  1. Institute processes, such as MEWS scores, to identify patients early in their deterioration
  2. Remove barriers to early transfer to the intensive care unit (such as ICU bed availability and hospitalists’ unwillingness to transfer care)
  3. Incorporate “mock codes” into the emergency preparedness of your hospital with attention to time to defibrillation, chest compressions per minute, avoidance of holding CPR to intubate, etc.
  4.  Hard wire code team debriefing
  5. Regularly review cardiopulmonary arrest outcomes and statistics at the quality committee

In the future, one measure of a hospital’s success at early identification of patients who are deteriorating is the percentage of cardiopulmonary arrests that occur in the ICU versus in a regular nursing unit. Ideally, most arrests (particularly non-ventricular tachycardia/fibrillation) should occur in the ICU.

November 22, 2016

Life In The Hospital

The 6 Words

As the medical director of a hospital, my job is not to cure disease and save lives. My job is to create an environment where other doctors can cure disease and save lives.  And that’s where the 6 most important words for a medical director comes in.

Being a hospital medical director is a lot like being a hotel manager. When I first get up in the morning, I check the hospital census to see how many open beds we are starting the day with. I usually start my day by rounding in the hospital. First, the physician lounge to catch any doctors who are pre-rounding on their patients on the computer over a cup of coffee. Then through one or two of the nursing stations to get the pulse of inpatient care for the day. Next, the cardiovascular cath lab to see what what the morning’s invasive procedure schedule is looking like and how any emergency STEMI catheterization cases from the night before went (STEMI = ST-Elevation Myocardial Infarction). Then down to the OR to see which surgeons are operating that day and how many post-op patients are anticipated to need to be admitted (and thus require an inpatient bed). The ICU comes next and I’ll check in with the ICU hospitalist to see how many ICU beds we have and whether there were any patient care issues overnight. I have my cell phone set to get a text page with every STEMI and Code Blue (cardiopulmonary arrest) 24 hours a day so in the ICU, I’ll check in to find out how any STEMI patients or Code patients did overnight. After the ICU, I go to the ER to see how many open ER beds we have, how many are being occupied by patients that need to be admitted or that are being held for psychiatric care. Next is the endoscopy suite to see how many cases are on the schedule and which gastroenterologists or surgeons are doing procedures that day. Last, it is upstairs to the Education Suite to check in with the residents to be sure that their service census is reasonably full and that they are getting a good educational experience in our hospital.

At each stop, I use the 6 words.

Some leaders think that a leadership position is all about them. Its not – its all about the people that you are leading. As an example, a few years ago we were interviewing candidates for the Division Director for my division, Pulmonary and Critical Care Medicine. One of the candidates who came through for an interview visit asked whether as Division Director, he would be able to add his name to all of the manuscripts submitted for publication from the other members of the division. You see, he thought that being the Division Director was a way to make him more famous. He didn’t realize that being a Division Director is all about making everyone else in the division famous (and he didn’t get the job).

He didn’t know the 6 words.

Being a leader for a group of 50 physicians is a lot different than being a CEO of a company. That’s because leading 50 physicians is like leading 50 CEOs. They are fiercely independent and have to be when they are the one ultimately responsible for a patient’s life or health during a surgical procedure, in the ER, in the ICU, or during an emergent cardiac catheterization. What those physicians want during their work day is know that someone has their back, that their efforts to take care of patients is recognized and valued, that their needs are being heard.

They want to hear the 6 words.

As a medical director, the doctors don’t work for me, I’m supposed to work for them. My success is defined not by my personal successes but by their personal successes. So what are the 6 words?

“Anything I Can Do For You?”

November 19, 2016

Outpatient Practice

The Obesification of America

prevalence-of-obesity-in-the-usAmericans are obese. We’re more obese than any other country and we’re getting more obese each year. The most recent results of the 2015 National Health Interview Survey were recent released and they paint a picture of the reality of Americans’ health. In 2015, 30.4% of American adults were obese. For those of you unfamiliar with the definitions, overweight is a body mass index (BMI) between 25-30. Obese is a BMI > 30. Obesity can be further stratified into different grades: a BMI 30-35 is grade 1 obesity; a BMI of 35-40 is grade 2 obesity; and a BMI > 40 is grade 3 obesity (also called morbidly obese). It used to be that morbid obesity sufficed as the term for people who were really, really obese. However, because so many people have moved into the morbid obesity range, a new class of obesity had to be added, the super obese, who have a BMI > 50. But if you drill down, there are some interesting findings. For example, Americans in the age range of yours truly, between 40-59 years old, are the most obese people in the U.S. Also, obesity is not a equal opportunity condition: African Americans are more obese than other racial groups.

age-and-race-and-obesitycountry-overweight-caloriesHow does the U.S. stack up compared to other countries? The best information comes from the “Organisation for Economic Cooperation and Development” or OECD. The OECD 2015 health data indicates that the United States is the most overweight of all countries on the planet. 70% of Americans have a BMI in either the overweight category or the obese category. I’ve just selected a few countries in this table but even when you look at all OECD countries, the United States has the highest percentage of its population being overweight. The other way of looking at this is that less than a third of Americans have a normal BMI. This is not something that we should be particularly proud of. One of the reasons that we are so overweight is that we take in too many calories. Here again, Americans lead the world. We consume an average of 3,750 calories per day. The only country whose citizens eat more than the United States is Austria at 3,800; however only 40% of Austrians report being either overweight or obese, presumably because they are more physically active than Americans. The recommended caloric intake for a middle-aged, moderately active adult is 2,000 per day for women and 2,600 per day for men (drop that number by 200 calories if that middle-aged person is sedentary). So we eat too much. Another way of looking at this is that Americans need to drop about 1,500 calories per day. Obesity is due to the confluence of two variables: calories in and calories out. If you want to become obese, you either have to have too many calories going in or you have to have too few calories being burned up. We are taking too many calories in, so what about calories being burned up?


physical-activityNot surprisingly, we don’t exercise enough. Although the percentage of Americans who do meet the 2008 Federal guidelines for aerobic and muscle-strengthening exercises during leisure time has been slowly increasing over the past 20 years, only 21% of Americans got enough exercise in 2015 according to the 2015 National Health Interview Survey. This is especially true for older Americans: the older we get, the less we exercise.

diabetes-in-the-usSome people argue that we have placed too much emphasis on obesity and physical exercise. I disagree. Obesity is at the root of so many medical problems that result in healthcare costs, disability, and death: sleep apnea, hypertension, hypercholesterolemia, arthritis, heart disease, stroke, breast cancer, colon cancer, and diabetes. In fact, the prevalence of diabetes over the past 20 years tracks almost perfectly with the prevalence of obesity. Along with diabetes comes foot ulcers, leg amputations, coronary disease, stroke, peripheral neuropathy, renal failure, retinopathy, not to mention the cost of medications like insulin.


If you add up all of the bad things that happen when you are obese, the result is that the higher the BMI, the more likely a person is to die. In a study from BMJ (the British Medical Journal) this year, researchers from the United Kingdom reviewed the world’s published literature on the relation of obesity and death and confirmed what has been generally accepted for many years. risk-of-death-by-bmiIf a person is excessively underweight or overweight, their risk of dying goes up. The graph to the right is for all persons but when the researchers broke down the results into smokers and non-smokers as well as persons followed for 5, 10, 15, 20, or 25 years, the curves look the same. The best BMI to have is 22-24. If your BMI is less than 22 (underweight), your risk of death starts to go up. Similarly, if your BMI is above 24 (overweight), your risk of death starts to go up. And if you are morbidly obese, then you are 3 times more likely to die in 25 years compared to a normal weight person.

So what can we as physicians do? First, we need to educate our patients about where their calories are coming from. That half-liter bottle of soda has about 200 calories. A Snickers bar, 215 calories. The large fries at your local fast food restaurant, 500 calories. And if you top those fries off with a medium milk shake, add 670 calories. Then if you finish off your day by splitting a medium pepperoni pizza with someone, that half of a 12-inch pizza cost you 900 calories. Total calorie cost = 2,485. If that same person instead had a diet soda, a couple of fun-sized Snickers bars, small fries, skipped the milk shake, and split a small pepperoni pizza, they would have cut 1,500 calories off of their day.

The other thing that we as physicians can do is to promote aerobic exercise in our patients. It doesn’t really matter whether that is running, swimming, treadmill, elliptical machine, or stationary bike. The best exercise is the one that the person will actually do. You can figure about 300-400 calories burned with 30 minutes doing any of these. Even regular walking for a half-hour burns up about 150 calories.

The irony is that obesity is what keeps me in business. Overweight and obese patient need to see the physician more often, they get sick and use our hospital more often and all of that translates into more medical bills that we get to submit to insurance companies and Medicare. But we as a society can no longer afford obesity. If we really want to keep health care costs down, the best way to do it is to keep our BMI down.

November 16, 2016

Medical Economics

Dismantling Obamacare

chopping-blockAfter the elections of 2016, the Affordable Care Act (aka, Obamacare), will no longer exist as it is today. Many politicians have vowed to repeal it immediately. Repeal would be pretty complicated but dismantling would be considerably easier. So what’s on the chopping block?

First, the ability to keep children on their parent’s health insurance until age 26. When the Affordable Care Act was passed in 2010, the country was still in the depths of a recession and children straight out of high school or college had a difficult time finding jobs and if they did find one, those jobs had relatively meager benefits such as health insurance. So 6 years ago, this feature of the Affordable Care Act was widely praised. But in 2016, the economy is much better (despite what aspiring politicians running for office in the past 6 months have told us). unemployment-rateThe U.S. unemployment rate hit 10% in 2010, the highest it had been in more than 25 years and young adults between the age of 18 and 26 were the hardest affected so it made sense to create access to health insurance for them at that time. Last month, the unemployment rate was only 4.7% which is nearly the lowest that it has been for the past 45 years. Young adults are no longer living at home with their parents, they are living on their own with jobs that have richer benefits, including health insurance. So now, it is not as necessary to keep young adults on their parents health insurance plans. health-care-costs-per-capitaOn the other hand, this is a pretty low-cost part of the Affordable Care Act. Adults in this age range have relatively few health care costs on average – they don’t require much health screening, they haven’t lived long enough to get too many diseases, and they don’t take many medications.

Second, the pre-existing condition clause. This was also very popular and prevented insurance companies from denying a person health insurance if they had a pre-existing condition. On the surface, this sounds like a great idea but you can only have it if you also have an individual mandate.

Third, the individual mandate. This is one of the most contentious parts of the Affordable Care Act, namely, that all persons had to buy health insurance, whether they wanted to or not. This went against the core of Americans’ sense of self-determination and freedom from government interference with their choices. The problem is, that you can’t have the pre-existing condition clause without the individual mandate. So if you get rid of the individual mandate, then you have to get rid of the pre-existing condition clause. Otherwise, no one in their right mind would buy health insurance until they got sick – why buy it if you’re healthy and just throwing your money away? It would be like waiting to buy life insurance on your spouse until after he or she was dead. The problem is that if everyone waits to buy health insurance until they have an illness or an accident, then the cost of that health insurance would skyrocket and likely exceed the overall health care costs of people over 85 of $32,000 per year (in the graph above).

Fourth, Medicaid expansion. This part of the Affordable Care Act is almost as disliked as the individual mandate. Many states opted out of Medicaid expansion because of their state legislatures hatred of what was perceived as an expansion of entitlements. The good news is that with the economy improving so much since 2010 and the unemployment rate falling by more than 50%, there presumably won’t be as many people on Medicaid as there were in 2010. But the bad news is that in any society, there will always be people who are poor and like it or not, those people get sick. Before the Affordable Care Act, about 12% of patients in our hospital were uninsured, which basically meant that they couldn’t pay anything. But we as hospitals and physicians are required by law to take care of those patients which means the doctors’  time, the nurses’ time, the lab tests, the hospital food, the x-ray tests, the operating room time, and the medications all had to be provided for free. Can you imagine running a restaurant where you were required by law to feed 12% of your customers for free? Or maybe a car shop where you were required to provide free car parts and service for 1 out of every 8 people who come to your shop? You’d go out of business in 3 weeks. The reason that hospitals didn’t go out of business before the Affordable Care Act was the DSH (disproportionate share hospital) funds that provided hospitals Federal funds if they provided a lot of free care to the uninsured poor. The problem is that the DSH funds were reduced as Medicaid expansion took place as part of the Affordable Care Act and unless those funds are re-instated, then hospitals with a lot of uninsured/poor patients stand to go out of business (and then the uninsured poor will just go to another hospital that hasn’t gone out of business yet).

Fifth, the contraceptive mandate. Oh boy, did this one fuel anger. Religious organizations, that are historically on the side of more liberal social justice issues, were burning at the thought of having to pay for birth control pills when church doctrine opposes birth control. But here’s the thing: birth control pills are not terribly expensive, about $15 per month or $180 per year. On the other hand, the cost of a pregnancy (including pre-natal care, delivery, and post-natal care) is about $8,800, that is fifty times more expensive than a year’s worth of birth control (and that doesn’t even include the cost of maternity leave). Many of the same groups who don’t want to pay for their employees’ birth control pills also want to make abortion illegal. My own opinion is that, with the exception of rape, mother’s health, and minors, most abortions are a symptom of inadequate access to birth control and inadequate education about birth control. So if you really want to reduce abortions, then increase access to birth control. And if you really want to save money and reduce abortions, then make IUDs accessible – they cost about $800 all told and last for 12 years plus they are more effective than birth control pills. If you depreciate the cost over 12 years, it works out to about $65 a year. So, the reason to get rid of the contraceptive mandate would have to be a moral one because from an economic standpoint, it would make absolutely no sense. chance-of-pregnancy

Sixth, accountable care organizations. These were created as a part of the Affordable Care Act as a mechanism for hospitals and physicians to find low-cost ways to care for a large group of patients by promoting disease prevention, reducing unnecessary testing, and reducing unnecessary surgery. A lot of hospitals and physicians have been wary of ACOs and our health system, like many health systems, did not jump straight in head first to form an ACO. In the past 2 years, many ACOs failed to save money and as such the hospitals and physicians had reduced Medicare payments and basically lost money.

I have absolutely no idea about what is going to happen with heath care legislation over the next 4 years but we can be sure that something is going to happen. Currently, even with the Affordable Care Act, the United States has more uninsured citizens than just about every other industrialized country, we pay more for health care per person than any other country, and by most metrics, we have lower quality of health care than the majority of industrialized countries. Whatever we do in the next 4 years, I hope it is done with the goal to reduce our health costs and improve our health quality and not just to seek revenge on those that created and passed the Affordable Care Act.

November 13, 2016