Inpatient Practice

Not On My Watch: Avoiding Deaths In The Hospital

Hospitals don’t want patients to die in the hospital. On the surface, this seems like a good thing. However, patients do get ill and eventually, every patient (and everybody else) will die somewhere. Hospitals are incentivized to have patients die anywhere except in the hospital, even if the hospital is the best place for them to die.

Hospitals are judged by their mortality index – that is the number of deaths adjusted for the severity of the patients’ illnesses. You can see your local hospital’s mortality data for 5 different medical conditions on the Medicare Hospital Compare website. Overall, the mortality rate for these conditions nationwide is:

  • COPD: 8.0%
  • Heart attack: 14.1%
  • Heart failure: 12.1%
  • Pneumonia: 16.3%
  • Stroke 14.9%

In my experience about 80% of the patients of patients who die in the hospital are DNR-CC (Do Not Resuscitate Comfort Care) or DNR -CCA (Do Not Resuscitate Comfort Care Arrest). Whenever possible, hospitals try to move patients who have impending death to an inpatient hospice location. The rules that Medicare uses in mortality rate calculation require hospitals to count deaths of DNR-CC/DNR-CCA patients in the hospital’s mortality rate if they die in the hospital but if they get transferred to a hospice facility, the death does not count against the hospital’s mortality rate. The catch is that the hospice facility has to be separate from the hospital, it cannot simply be a hospice wing of the hospital. Here are the ways that hospitals try to keep their mortality rates down:

The Inpatient Hospice

One strategy that our medical center has used in the past, and that many hospitals use, is to lease a few rooms in the hospital to a separate hospice organization. In this situation, the patient is discharged from the hospital and moved down the hall to the hospice room where they are admitted to the separate hospice organization. The nurses and staff are employed by the hospice and not by the host hospital. The advantage to the patient is that these patients can be cared for by hospice professionals without having to leave the building. The advantage to the hospital is that when the patients die, it doesn’t count against the hospital’s mortality rate. The disadvantage is that the hospice needs to have a minimum number of beds to be financially viable – usually 4 beds is the minimum number. Many hospitals are not able to provide enough patients to continuously fill 4 beds.

Transfer To Free-standing Hospices

Once a patient is identified as having impending death and are in a DNR-CC status, they are frequently transferred to a hospice facility. We are fortunate in Columbus to have great options for this and they really do a good job. However, patients need to be able to make the trip in an ambulance from the hospital to the hospice several miles away and sometimes that ambulance ride can be an uncomfortable part of that patient’s last few days of life. In the past, I have had patients die in the ambulance when getting transported to hospice units in other cities and this is something we all want to avoid. This is also a particular challenge for those patients in the ICU who are on mechanical ventilators who will be having life support withdrawn – often they don’t survive long enough after being extubated to get to a free-standing hospice. Occasionally, free-standing hospice facilities will accept patient who are on a ventilator with the intention of terminally extubating them shortly after arrival.

Keep The Patient In Observation Status

I discussed this in more detail a previous post. When the admitting doctor anticipates that a patient will be in the hospital for “less than 2 midnights”, Medicare requires us to put the patient in observation status rather than admit them to the hospital. When a patient is in observation status, the patient is considered to be an outpatient rather than an inpatient. Therefore, if the patient dies, they die as an outpatient rather than as an inpatient and the death does not count against the hospital’s mortality rate. This comes up a lot in patients who are admitted after having a cardiac arrest or a drug overdose and we anticipate that they will be pronounced dead within the next 1-2 days. The downside of this strategy is that, as an outpatient, patients in observation status are responsible for a sizable co-pay for their hospital charges and they are responsible for all of their medication charges. These charges can be very high, particularly for a patient who spends a day or two in the high-cost ICU with very expensive intravenous medications.

Transfer The Patient To Another Hospital

Although we do not use this strategy at our hospital, we are on the receiving end of a lot of these patients. Often it is because a smaller hospital may lack anyone credentialed to do a brain death exam or they do not have a full-service ICU. However, we do get patients transferred to our hospital from the emergency departments of other hospitals because the physician at that hospital doesn’t think there is anything they can do for that patient and doesn’t want his/her mortality rate affected by someone who inevitably is going to die. We always accept these patients because you just can’t be sure of the patient’s condition until you can actually see and examine the patient. However, it can be frustrating when we get a patient in transfer and the first thing the family says is that “grandma has a living will and said she never wanted to be on life support in the first place” and we end up doing a terminal extubation in the first hour of admission.

TPS (Trach, PEG, Select)

Select Specialty Hospital is a long-term acute care hospital organization that leases a floor of our hospital. They specialize in patient requiring long-term hospitalization, for example, those on a mechanical ventilator needing a few weeks to wean from the ventilator. Often times, we have patients in the ICU who have catastrophic illnesses: massive stroke, permanent coma, end-stage dementia. These patients can’t breath on their own and can’t feed themselves. Sometimes, they will have an advance directive stating that they do not want to be kept alive on life support and sometimes their family will make that decision – in which case, we do terminal extubation and provide comfort care. However, sometimes they don’t have a living will and the family wants “everything done” or there is no family to make end-of-life decisions. In that situation, we place a tracheostomy tube, a percutaneous endoscopic gastrostomy tube (PEG or “feeding tube”), and transfer the patient to a long-term acute care hospital, like Select. In some situations, patients get the trach and PEG because the doctors are unwilling to acknowledge that the patient has no realistic hope of meaningful recovery – this is especially true in pediatric ICUs where newborns and children with severe brain damage and no hope of ever breathing on their own, feeding themselves, or having any form of conscious thought end up on permanent life support. Many times, ICU physicians will consider TPS as a “great save” since the patient didn’t die in the ICU but in reality, we didn’t make the patient live longer, we just made them die longer.

Obviously, a lot of this is just plain silly. Moving patients around for the purposes of ensuring that they don’t die on the hospital’s books is often uncomfortable for both the patients and their families. Doing unnecessary tracheostomies and PEG tubes just so we can get the patient out of the ICU alive is not always what the patient wants. Our hospitals should be places patients go to receive care. Care can mean healing them from an illness or accident. But care can also mean providing comfort and alleviating pain in the last hours of life. As long as we consider any death that happens in the hospital as a marker of poor hospital quality, we are ignoring our responsibility to really care for the patient. Palliative medicine has taught us that dying is not necessarily bad but dying badly is always bad. Our goal should not be to prevent anyone from dying in the hospital but to anyone who comes to our hospital from dying badly.

April 29, 2017

Inpatient Practice

Improving Patient Satisfaction

Last month, Christy Dempsey, the Chief Nursing Officer of Press Ganey, visited our medical center to discuss strategies hospitals can use to improve patient satisfaction. She had some really insightful comments. Improved patient satisfaction doesn’t just improve your hospital’s scores on the Medicare Hospital Compare website, but it also results in lower length of stay and lower readmission rates.

The 3 most important factors that affect inpatient satisfaction are (1) a perception of teamwork, (2) nursing courtesy, and (3) cleanliness. From the patient’s perspective, “teamwork” = “safe work”. For cleanliness, it doesn’t necessarily mean brand new & spotless; instead, patients think of “clean” as “safe” so patients will perceive your hospital as being clean if they feel that they are safe in the hospital. Some of the simple things that you can do that will improve patients’ perception of cleanliness include:

  • The brighter the light, the cleaner the room and hallway will feel
  • Avoid clutter in the hallway.
  • Be sure that the staff break rooms, nursing station, and conference rooms are not cluttered – inevitably, patients will peek into these areas when they are walking by and the break room door is open.
  • Anything on the walls needs to be in frames – do not tape paper notices and memos to the walls.

The 3 most important factors contributing to patient loyalty in the outpatient setting are: (1) confidence in the provider, (2) the providers work well as a team, and (3) communication.

In the hospital, patients want to perceive that the doctors and nurses exhibit compassion. There are 6 key ways that your staff can do this:

  • Acknowledge suffering.
  • Coordinate care – make sure the patient perceives that everyone is on the same page. One great way of doing this is with physician/nurse rounds or multidisciplinary rounds.
  • Use the right body language – it is not just words that you use to communicate with the patient – body language matters.
  • Recognize that the patient’s anxiety equates to the patient’s suffering.
  • Autonomy reduces suffering. When the patient is admitted to the hospital, they are relinquishing their autonomy and have a loss of sense of control. Little things can make a difference, such as asking the patient what time they want to have their bath or their walk in the hallway.
  • Caring transcends diagnosis.

One of the toughest questions on the HCAHPS survey relates to the hospital being quiet at night. As providers, we equate “quiet at night” to mean “noise at night”. But for the patient, “quiet at night” means “minimal interruptions at night”. Make sure that the staff minimize waking the patient up at night by coordinating nocturnal vital sign checks to happen at the same time as their nighttime IV antibiotic dose. If your hospital practice is to draw routine daily labs at 4:00 AM… then stop. Try to give the patient as much uninterrupted sleeping time as possible each night.

Another HCAHPS survey question that hospitals struggle with is pain control. Be sure that the doctors and nurses set patient expectations for pain control and that the pain score goal is not a “zero” – patients are going to have pain if they are post-op or admitted with fractures and the goal is not to completely eliminate their pain but instead to make the level of pain tolerable. In this sense, your staff have a lot more influence on pain control than your medications do.

Communication with the patient by both doctors and nurses are also a part of the HCAHPS survey. Taking a few seconds to learn something about the patient other than their disease and symptoms can make a big difference in how the patient perceives communication. Do they have grandchildren? What are their hobbies and pastimes? Where did they grow up? Communication with the patient can be improved with scripting but don’t script the exact words, script the sentiment. It is important, however, avoid faking emotions since this will cause burn out in the nurses and physicians. Unfortunately, you can’t teach compassion – you either have it or you don’t so it is important that you identify compassion in nurses and doctors when they are first applying for their jobs.


  • The patient is scared
  • The patient has lost all control
  • The patient hurts
  • The patient needs information
  • The patient needs compassion

Improved patient experience is not only good for the patient, but it is good for your nurses and doctors. For example, nurses job satisfaction correlates better with patient experience than with staffing adequacy. A favorable work environment correlates with fewer patient falls and pressure ulcers than the staffing in that environment.

April 12, 2017

Emergency Department Inpatient Practice

Disaster Drill Management

This week, our city staged a mass-casualty disaster drill. In preparing for it, I found that there is very little written about the medical director’s responsibilities in disaster preparation. The scenario was this: terrorists explode bombs at Mapfre stadium (home to the Columbus Crew professional soccer team) and John Glenn Airport then attack civilians with guns. At the same time, a truck runs into a crowd at Otterbein University and then the driver gets out and starts shooting into the crowd. In this year’s mock disaster, there are 500 trauma victims that are then dispersed to hospitals throughout Central Ohio.

The Joint Commission requires U.S. hospitals to do at least 2 disaster drills per year and each one is a little different. For example, we’ve had a simulated plane crash at the airport and a simulated super-flu epidemic in the past. The hospital sets up a command center and everyone wears a vest with a tag identifying that person’s role – incident commander, medical director, logistics director, communications director, public relations, etc. The medical director’s job can be summarized in two words: inventory and coordinate. Inventory available physician resources and coordinate to direct those resources to where they are needed. Here is how I approach it:

Designate on-site physician leaders in key areas. They don’t necessarily have to be specialists in those areas but they need to be knowledgable about those particular physicians and their needs. So, for example, a hospitalist could coordinate for the ICU and an anesthesiologist could coordinate the surgeons. The key physician areas are:

  • Emergency department
  • Intensive care unit and critical care
  • Surgery
  • Anesthesia
  • Hospitalists and medical specialists

Inventory physician assets. Find out who you have currently on-site in the hospital and who can be called in from home or outpatient locations. Don’t forget about residents or fellows. Start by paging all of the physicians who are scheduled to be working in the hospital that day and tally who you have from what specialties. Then page all of the physicians from specialties that you anticipate needing to determine who could come in to the hospital immediately if it was a real disaster. It is a good idea to use administrative staff to do this because it can be time consuming for you if 100 doctors are trying to respond to your pages. Also, do not have physicians call in to a phone number to confirm their availability because with a lot of physicians all trying to call in at the same time, they will just get a busy signal. Instead use text messaging and/or email. Because normal transportation routes may be impassable in a disaster, be prepared to give physicians that are driving to the hospital advice on the best routes to take to get in. The highest priority include:

  • ER physicians
  • General surgeons
  • Critical care physicians
  • Anesthesiologists
  • Orthopedic surgeons

Depending on the specific disaster, you may also need hospitalists, radiologists, oral maxillofacial/ENT surgeons, ophthalmologists, or infectious disease

Inventory dischargable/transferable patients.

  • Contact each admitting service/hospitalist to determine how many patients could be discharged immediately in order to free up bed capacity.
  • Determine how many patients can be transferred out of the ICU and PCU immediately to lower acuity hospital units.
  • Inventory emergency department patients who could be moved to other locations immediately (medical boarders waiting for an inpatient bed, psychiatric holds, etc.).
  • Determine number of level 1, 2, 3, 4. & 5 patients in the ED and how many of the low acuity patients could be moved out of ED bays immediately to create ED capacity.
  • Determine how many operating rooms you currently have open and how many you would have if you canceled all of the day’s elective surgical cases. For those operating rooms that currently have a surgery taking place, how long will the surgery take to complete so that you can use that OR for disaster victims?

Identify and inventory alternative treatment locations. What areas in the hospital could be converted to ICU-level care? For an ICU bed you basically have to have medical gases, monitoring equipment, and enough room to fit the patient plus equipment such as a ventilator. The PACU (surgical pre-op/post-op area) is a natural fit but it will likely be used for operating room support so other hospital locations may be more prudent. In our hospital, 2 areas that could be converted to ICU areas include the cath lab recovery rooms and the endoscopy suite recovery rooms.

What locations could be converted to non-surgical treatment areas? In a mass casualty event, there will be a lot of minor injuries, the so-called “walking wounded”. You will want to direct those victims to other locations so that you don’t clog up the emergency department and the operating room. Think “outside the box” to determine what units could be used for caring for minor injuries. For example, ambulatory clinic space can be used for treatment of minor abrasions and burns. At our hospital, we have a outpatient wound center and it can be converted to a temporary burn unit.

Work with the rest of the disaster center leaders to inventory equipment and supplies that your physicians will need. As the physician lead in the disaster command center, you will often be the one most knowledgable about needed resources:

  • Mechanical ventilators will be needed to support victims needing to go the ICU; if there are a lot of surgical casualties, you may also need additional ventilators in the PACU because the anesthesiologists may not have sufficient time to extubate patients in the OR in order to expedite patient flow in and out of the OR. If you don’t have enough ventilators and BiPAP units in the hospital, how many can your medical supply vendor get you on short notice? Many communities (including Columbus) have emergency depot supplies of gas-powered ventilators that are not very fancy but will work in a pinch.
  • IV fluids will be needed and often in large amounts. How many bags of lactated Ringers, saline, and plasmalyte do you have in stock?
  • What is your current supply of blood for transfusions including number of units of O negative blood?
  • Tetanus toxoid supplies in the pharmacy?
  • Trauma tourniquets – how many do you have and where are they located?
  • Central line kits – how many do you have in your hospital’s inventory?

Coordinate patient flow from ED triage physicians to appropriate inpatient/OR locations. In a true disaster, there will inevitably be some degree of unanticipated chaos. You will need to ensure adequate physician staffing at hospital locations managing victims and re-direct physicians to needed locations. The most effective way to do this is to use your various physician site/specialty leaders to give you on-site reports. Make sure you have their cell phone numbers loaded into your cell phone and use group texting so all of your physicians are getting up to date information.

Do a debriefing with your physicians. Find out what went well and what you can improve on the next time.

A great reference for disaster management is: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement. October 2014:

April 6, 2017

Inpatient Practice Procedure Areas

Optimizing Hospital Inventory: Sometimes Something So Simple…

Ever have one of those moments when someone presents a new idea and you think, “That just makes way too much sense”? This week, I listened to a presentation by one of our health system’s supply chain directors who presented a new way of managing terminal distribution supplies.

If you have worked for more than about a week in a hospital as a physician or a nurse, then you have had the experience of walking into a supply room on a nursing unit and seeing something like this. Bins of supplies stacked on top of each other and overflowing with syringes, gauze pads, and telemetry leads. Its a mess. If you can even find the bin you are looking for, there is a good chance the person before you took the last one of the items that you wanted. And when you have a JCAHO site survey, the surveyors always head straight to the supply room when they walk into a nursing unit and then dig their hand into the most full bin and pull an item from the bottom of the bin… and the date on it will inevitably be expired, resulting in a citation. Supply rooms were like the first day I walked into the hospital as a 3rd year medical student in 1982 and supply rooms are like that now, 35 years later, in 2017.

So, here was the solution from our supply chain genius. Instead of having one large bin for each item, have 2 small bins, one in the front and one in the back. You stock each bin with a projected 5-days worth of that item. Each bin is bar-coded for inventory management. This is known as a “Kanban” inventory control system

When you use up all of the item in the front bin, you pull the empty bin and leave it out for your central supply personnel to pick up. You then pull the back bin forward and start to use items from it. The central supply staff re-stock the empty bin and replace it behind the front bin. Here’s what happens:

  1. Your central supply personnel know exactly how fast you are going through each item so that your nurses don’t need to ‘guesstimate’. By using the bar code on each bin, you can monitor item use on the computer real-time.
  2. You can adjust the number of each item at your terminal distribution supply room based on use, thus optimizing your space utilization.
  3. The supply room becomes less cluttered.
  4. The square foot requirement in the supply room actually drops.
  5. You dramatically reduce the risk of having expired items in your supply room.
  6. You eliminate all of the time that the nurses are “taking inventory” of everything in the supply room and give them back time to do patient care.
  7. You save money

There are some caveats, however. The nurses have to be trained so that they always remove items from the front bin and know to pull the empty bins out for re-stocking. If your patient population on any given nursing unit changes, then your product use rate can change, so you have to continually monitor how quickly you are going through bins in each supply room.

This is one of those ideas that when you hear it, you ask yourself, “So, why didn’t I think of this before?”.

March 31, 2017

Inpatient Practice

HCAHPS Survey Demystified

The HCAHPS survey measures patient satisfaction with inpatient care. It is sent to patients after discharge with instructions to fill it out and mail it in a pre-paid envelope. The results are posted on the Medicare Hospital Compare website where you can see how your hospital performs compared to other hospitals in the same state and other hospitals nationwide. HCAHPS stands for “Hospital Consumer Assessment of Healthcare Providers and Systems”. The survey takes patients an average of 7 minutes to complete. The survey is sent out to a random sample of patients recently discharged from the hospital and can be sent anytime from 2 days to 6 weeks after discharge. The average response rate is usually around 32%. Here are the HCAHPS questions. The first 14 questions are answered by “Never“, “Sometimes“, “Usually“, or “Always“:

  1. During this hospital stay, how often did nurses treat you with courtesy and respect?
  2. During this hospital stay, how often did nurses listen carefully to you?
  3. During this hospital stay, how often did nurses explain things in a way you could understand?
  4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?
  5. During this hospital stay, how often did the doctors treat you with courtesy and respect?
  6. During this hospital stay, how often did doctors listen carefully to you?
  7. During the hospital stay, how often did doctors explain things in a way you could understand?
  8. During this hospital stay, how often were your room and bathroom kept clean?
  9. During this hospital stay, how often was the area around your room quiet at night?
  10. During this hospital stay, how often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?
  11. During this hospital stay, how often was your pain well controlled?
  12. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?
  13. Before giving you any new medicine, how often did the hospital staff tell you what the medicine was for?
  14. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?
  15. During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?
    • Yes
    • No
  16. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?
    • Yes
    • No
  17. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?
  18. Would you recommend this hospital to your friends and family?
    • Definitely no
    • Probably no
    • Probably yes
    • Definitely yes
  19. During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.
    • Strongly disagree
    • Disagree
    • Agree
    • Strongly agree
  20. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
    • Strongly disagree
    • Disagree
    • Agree
    • Strongly agree
  21. When I left the hospital, I clearly understood the purpose for taking each of my medications.
    • Strongly disagree
    • Disagree
    • Agree
    • Strongly agree

There are also some other questions about the patient’s perception of their health, their race, their preferred language, and their education level. You can find the full HCAHPS survey here.

The Medicare Hospital Compare website takes these 21 questions and combines some of them into a total of 7 composite topics, 2 individual topics, and 2 global topics that are then reported on the website. The reported topics are:

  1. Nurse communication
  2. Doctor communication
  3. Responsiveness
  4. Pain management
  5. Communication about medications
  6. Discharge information
  7. Care transitions
  8. Cleanliness of hospital environment
  9. Quietness of hospital environment
  10. Hospital rating
  11. Willingness to recommend hospital

One of the problems with the HCAHPS survey is that it suffers from the same phenomenon that high school and college tests suffer from: grade inflation. So, for example, question #17 asks the patient to rate the hospital overall on a scale of 0-10. Medicare divides the answers in to “top box” (9 or 10), “middle box” (7 or 8), and “bottom box” (0-6). A score is calculated from the percent of patients rating the hospital in the top box (in other words, the percent of patients giving the hospital either a 9 or a 10). The average score nationwide is a 72 and the top 5% of hospitals have a score of 87 with the bottom 5% of hospitals having a score of 57. So, if your community is filled with people who think that on a 0-10 scale, 5 is average, your hospital is doomed. On the other hand, if your community is filled with people who think that 8 is average on a 1-10 scale, then you’re in good shape.

The data from all of the questions are then added to a number of other measures of hospital quality, such as mortality and readmission rate, to give a final star rating where hospitals are assigned an overall score of 1-5 stars. In December 2016, the distribution of star ratings for all hospitals in the U.S. is shown in this graph.

Medicare ties HCAHPS scores to hospital reimbursement. This fiscal year, 2% of a hospital’s Medicare payments are tied to HCAHPS so it motivates hospitals to get as high of a score as possible. At our hospital, I get a monthly analysis of our performance on each of the 11 HCAHPS topics and they can vary wildly from one month to another. There are all sorts of strategies used to improve HCAHPS scores including staff education and expansion of specialty services such as pain management services. There is also a lot of speculation about the best time to mail out the surveys – should you wait a few weeks after discharge so that the patient forgets about what the bathroom looked like? Or should you mail the survey out right away, 2 days after discharge before the patent gets their hospital bill?

Regardless, doing well on the HCAHPS survey is not just about improving patient care in your hospital but about improving the patient’s perception of care in your hospital.

March 10, 2017

Hospital Finances Inpatient Practice

So, How Should You Pay Hospitalists?

Hospital’s priorities are usually not aligned with how we pay hospitalists. In fact, the two are often in direct conflict with each other. In my last post, I argued that the RVU is not the best measure of productivity for a hospitalist. In this post, I have some ideas of how hospitals can align hospital priorities with the hospitalist’s income.

CMI-Adjusted Census

The first thing we need to do is to get away from the model of a rigid census cap/expectation per hospitalist. In a previous post, I discussed why the work required to take care of 15 patients at one hospital does not equal the amount of work required to take care of 15 patients at another hospital. In fact, a census of 15 patients on one floor of any given hospital is not the same as 15 patients on another floor. Quite simply, this is because the amount of physician work necessary to take care of one patient is not the same as the amount of work necessary to take care of another patient. One way of determining the proper census per hospitalist is to do a CMI-adjusted census (CMI = case mix index). The idea is that the higher the CMI, the sicker the patient and presumably, the more time required by the hospitalist to care for that patient. Let’s look at the CMI of 3 hypothetical hospital services:

Service 1: CMI = 1.30. This service admits general medicine patients but also admits to the ICU.

Service 2: CMI = 1.10. This is service admits non-ICU general medicine patients.

Service 3: CMI = 1.00. This service mainly covers lower acuity medicine patients, generally with single-issue medical problems and about half of patients being observation status patients. They have a short length of stay.

Let’s start with an assumption of 20 patient encounters per hospitalist and then divide the census by the CMI. So, for service #3, we would have 20 ÷ 1.00, which would be 20 patient encounters per hospitalist per day. On the other hand, for service #2, we would have 20 ÷ 1.10 = 18 patient encounters. Service #1 would be 20 ÷ 1.30 = 15 patient encounters. Notice that I used hospital encounters in this analysis and not daily census. Because of the differences in length of stay (and therefore differences in patient turnover) for each of the 3 services, the daily census could be the same for each of the services (eg, 13). Moreover, if you have night coverage hospitalists who are doing admissions to these services at night, the service census at the midnight census tally might be 15 for each of the services. Surgical patients inherently have a higher case mix index because of the surgical procedure so you cannot apply the same analysis for staffing surgical patients as you would with medical patients.

CMI-adjustment does several things to align the hospital and the hospitalists:

  1. It rewards the hospitalist to compulsively document in the chart all of the mundane co-morbidities that affect the CMI score but really don’t affect how the patient gets managed. So, for example, if a patient has a sodium level of 144 (normal 133-143) on admission, the hospitalist is going to ignore it since it is not clinically significant – adding “hypernatremia” to their admission note is extra work and why bother typing in the extra line of text if it is clinically irrelevant? However, since by adding the word “hypernatremia” to their note, the CMI goes up slightly and so the hospitalist is granted a slightly lower census target.
  2. The hospital’s financial margin improves because the higher the CMI, the more the hospital gets paid for that patient admission.
  3. The hospital’s length of stay index improves because the index is determined by the actual length of stay adjusted for the CMI.
  4. The hospital’s mortality index improves because the actual mortality rate is adjusted for the CMI to give the publicly reported mortality index.

Outcomes-Based Bonus Plan

Historically, bonus plans were based on productivity. At the end of the day, the productivity that really matters is total cash collections. However, we all know that when performing the same service, you get paid more for a commercially-insured patient than you do for a Medicare patient. You get paid even less for a Medicaid patient and you get paid practically nothing for most uninsured patients. So, the RVU has evolved to be a better measure of physician work effort than cash collections in order to remove the disincentive of taking care of the uninsured and Medicaid patients in the hospital since the hospital has to have someone take care of these patients.

In medicine, we often define true value in the service that we provide by the equation: value = quality ÷ cost. In other words, you can increase your value by increasing your quality or by decreasing your cost. So, what the hospital really wants is for the hospitalist to improve value of healthcare, by either improving quality (particularly in those publicly-reported quality measures on the Medicare Hospital Compare Website) or by improving the hospital’s financial margin. The financial margin in turn, can be improved by either increasing the revenue per patient-day in the hospital or by decreasing the cost per DRG. Therefore, bonuses should be based on some combination of:

  1. Query responsiveness. Hospitals have coding staff that comb inpatient charts looking for those co-morbidities that add up to a higher case-mix index for any given patient. The problem is that even if those co-morbidities appear in the lab results (for example, hypernatremia in the previous discussion) or appear in a non-physician’s note (for example, the dietician who mentions “protein calorie malnutrition” in his/her note), it only counts toward the CMI if a physician (or nurse practitioner or physician assistant) puts it in their note. So, hospitals have evolved a query system where co-morbidites identified by coders are reported to the hospitalist as a query and then the hospitalist decides whether or not it is valid and then addends their note accordingly. This is extra work for the hospitalist and so if they are not incentivized to answer the queries, they are going to ignore the coders and then the CMI ends up being lower.
  2. Patient discharge time. The earlier you get patients out of the hospital, the earlier in the day that bed can be filled by the next patient. However, you don’t need to get all of the patients discharged early in the day – your housekeeping staff can’t clean all of those rooms at the same time. The strategy is to get some of the patients out by 11:00 AM, some more out by 1:00 PM, etc. so that you have a steady flow of discharges throughout the day in order to accommodate the steady stream of patients waiting to be admitted into those beds. So, pick some numbers that work best for your hospital, for example, 20% of discharges by 11:00 AM and 40% of discharges by 1:00 PM.
  3. Mortality index. Because the mortality rates are one of the publicly reported items by Medicare, the hospital wants patients to die anywhere but in the hospital. For those patients who are anticipated to die, transferring a patient to a hospice facility to die is ideal. The danger of using mortality index for hospitalist bonuses is that sometimes, it can work against you from a hospital expense standpoint. For those patients who are clearly going to die in the ICU, the hospitalist could be incentivized to try to keep that patient alive a little longer in order to buff them up just enough to survive the transport to inpatient hospice or to have them die on another hospitalist’s shift so that the death doesn’t count against them. In this situation, earlier withdrawal of life support would have resulted in the hospital not having the expense of those extra days treating the patient in the ICU and the patient (and family) would have been spared making an inevitable unpleasant and uncomfortable death last longer.
  4. 30-day readmission rate. Hospitals get penalized by Medicare if this is too high. The hospital wants all of its rooms to be full, but to be full of patients who were not there in the past month. Hospitalists can often reduce the readmission rate by putting more time and effort into the discharge process (see post on The Most Dangerous Procedure In Medicine).
  5. Lower length of stay. This is a tricky one. If you discharge a patient prematurely, that patient is more likely to be readmitted within 30 days and is more likely to be dissatisfied if they perceive that they were thrown out of the hospital too early. So, length of stay should never be the sole metric for a bonus plan and should only be used when coupled with hospital readmission rates and with patient satisfaction. Also, length of stay lends itself to gaming the system since it is based on the midnight census. So, a patient admitted to the hospital at 11:30 PM already has a 1-day length of stay a half hour later at midnight. In order to improve his length of stay, the hospitalist will procrastinate putting the admission orders in for anyone showing up in the ER in the evening. If that order is placed at 12:01 AM, you just knocked a day off of that patient’s length of stay.
  6. Patient satisfaction. For inpatients, this is measured by the “HCAHPS” survey questions that are reported on the Medicare Hospital Compare Website. Some of these questions are specific to physician practice and can be used in a hospitalist bonus plan; other questions pertain to the patient’s overall perception of the hospital which measures the physician’s performance as a member of a larger team of providers in the hospital.

Billing Benchmarks

You can’t do away with RVUs completely, otherwise, the hospitalist would either not bother to submit their charges for patient encounters or they would bill everyone as a level 1 visit, thus reducing the necessity of all of the painful documentation required to bill higher levels of service. So, there has to be some why to hold the hospitalist accountable for turning in their bills and to insure that they are actually billing for the level of service that they are providing. Most electronic billing programs will allow you to see what the distribution of level 1, 2, and 3 CPT codes for any given physician. This distribution can be compared to internal benchmarks of all of the other hospitalist or to external benchmarks, such as the Vizient benchmark data for academic medical centers.

The Bottom Line

Ultimately, the strategy is to align the hospitalist’s reward system with the financial margin of the hospital. To do this, you need to think beyond hospitalist census caps and RVUs.

March 7, 2017

Hospital Finances Inpatient Practice

You Can’t Pay Hospitalists By The RVU

Every year about this time, hospitalists begin their contract negotiation with hospitals for the upcoming fiscal year. I’ve been on both sides of the negotiation table over the past 20 years. As with any negotiation, to be really successful, one party needs to not only know what the other party really wants but they need to know what it is they, themselves, really want. All too often, because we know neither what the other side wants nor what it is that we really want, we fall back on negotiating about money. The problem is that money is often not the most important thing that either side values.

What the hospital really wants:

  1. A positive financial margin at the end of the year. This is what the Board of Trustees really cares about and you can improve the margin in two ways: increase your revenue or decrease your expenses. But sometimes spending a little more on one expense item/department can greatly reduce the expense of another item/department. This becomes very difficult because large hospitals are often administratively compartmentalized and each compartment is held individually accountable for its financial bottom line and often for the hospital to make money overall, one compartment has to lose money. If the hospitalist is trying to see as many patients as possible and pump out as much in billings, then this may or may not be in alignment with the hospital margin. By paying a little more for the hospitalist, the hospital can often save more money if the extra amount of time that the hospitalist can now spend on the patient translates into a shorter stay and less expensive testing.
  2. Higher patient satisfaction. This is one of the publicly reported measures that hospitals are judged and compared to each other on the Medicare Hospital Compare website. If the hospitalist is primarily motivated by patient volume, what the patient thinks about the hospitalist (or the hospital) becomes relatively unimportant. RVUs are a quantity contest, not a popularity contest.
  3. Shorter length of stay. A shorter length of stay results in a more positive financial margin. If you can get a patient out of the hospital one day earlier, then that patient doesn’t consume expensive hospital resources (medications, lab tests, nursing time, meals, etc.) and, more importantly, you can get another paying patient in that room quicker. If the hospitalist’s goal is to maximize RVUs, then it can be paradoxically better for that hospitalist to keep the patient in the hospital one more day because that extra day in the hospital will involve relatively little time on the hospitalist’s part thus resulting in earning low-effort RVUs.
  4. Lower readmission rates. The hospital is penalized if 30-day readmission rates are excessively high. The hospitalist is rewarded if the 30-day readmission rate is high: it not only means more RVUs, but you can copy most of your previous history and physical exam making the admission quick with more low-effort RVUs. One of the key drivers in whether a patient gets readmitted shortly after discharge is the amount of time and effort spent in the discharge process. If the hospitalist has the time it takes to personally speak with the patient’s primary care physician, do a careful medication reconciliation, and ensure that all post-hospital tests and appointments are scheduled, that patient is less likely to be readmitted. The problem is that the hospitalist is going to get paid the same amount in RVUs whether or not they go to all of that extra effort to ensure a good discharge.
  5. Patients being discharged from the hospital earlier in the day. From the hospital’s perspective, an earlier discharge hour means that another patient can fill that bed earlier from either the ER or the OR and so patients don’t have to wait as long in the post-op recovery room or in the ER to get a bed. From the hospitalist’s standpoint, getting those patients out earlier in the day means that he/she will have to work a lot more intensely early in the morning and if paid by the RVU, you end up with the same amount of money in your pocket whether you discharge that patient at 10:00 AM or 4:00 PM and it is a lot easier to take your time and get the patient out at 4:00.
  6. Higher case mix index. The higher the case mix index (a measure of the severity of disease of the patient), the more the hospital gets paid. The case mix index also affects the publicly reported mortality index  (mortality rate adjusted for case mix index). So, the hospital wants a higher case mix index and the only way to do this for non-surgical admissions is for the physician to document all of the little co-mobidities that the patient had on admission (such as hypomagnesemia, malnutrition, etc.). When paid by the RVU, the hospitalist is not motivated to go to the extra effort to document all of these co-morbidities because he/she is going to be paid the same and ferreting out all of these (often obscure and unimportant) findings takes extra time and effort.
  7. Patients moved out the ER to the floor rapidly. The hospital has to report the amount of time the patient spends in the ER waiting for a bed and needs to keep that number as low as possible to avoid public embarrassment. Furthermore, the quicker the hospital can get that patient out of the ER, the sooner another patient can be placed into that ER room. To do this, the hospitalist needs to see the patient and write orders on the patient so that the patient can move from the ER to the nursing unit. The hospitalist who is paid by the RVU could not care less how quickly the patient gets out of the ED since they get paid the same, regardless.
  8. Avoidance of unnecessary expensive tests and treatments. For the hospital, fewer tests on inpatients equates to a higher financial margin. The hospitalist paid by the RVU could not care less.
  9. Lower mortality index. Neither the hospital nor the hospitalist wants to have one of their patients die. But patients are going to die, regardless. Most of the patients who die in our hospital are “DNR-CC” or “DNR-CCA”, meaning that they are anticipated to die and have elected to not be resuscitated when their heart and lungs stop working. There are two ways to lower your mortality index: (1) increase your case mix index by documenting all of the obscure co-morbidities or (2) get the patient to die somewhere other than in your hospital, most commonly at an inpatient hospice facility. For most of these patients, dying at home is neither practical nor desired by the family. If a DNR patient dies in your hospital, it is included in the hospital’s mortality rate but if that same patient dies at a separate inpatient hospice, the death doesn’t count against the hospital’s mortality rate. Once again, the mortality index is publicly reported on the Medicare Hospital Compare website. For the hospitalist paid by the RVU, arranging the transfer of a dying patient to a hospice facility takes a lot of work and it is easier to just care for that patient in the hospital until they die; plus, the hospitalist can bill for a few more days of inpatient care.
  10. Avoidance of complications. Healthcare associated infections and surgical complications are publicly reported on the Medicare Hospital Compare website so the hospital wants to keep the numbers down. Even more importantly, hospital complications are costly and can lower the hospital’s financial margin. For the hospitalist, the RVU pays the same, with or without complications. In fact, if a patient has a complication, the hospitalist can bill a higher level of service thus generating more RVUs.
  11. A sufficient number of doctors to provide care to the patients at any given time. The hospital wants to optimize patient throughput whereas the hospitalist paid by the RVU wants to optimize patient volume. There comes a point, however, where too high of patient volume results in reduced patient throughput. For more explanation, see the post on The Starling Curve of Physician Productivity.

What the hospitalist really wants:

  1. To feel that they are valued as professionals. The hospitalist invested 11 years of post-high school education to become a hospitalist and they want to be recognized for that effort. What the hospital often thinks it needs is a warm body with the initials M.D. or D.O. One advantage that our hospital has in the local market is that all of our hospitalists get an OSU faculty appointment, even if it is an unpaid appointment. Being able to say that you are an Assistant Professor at the Ohio State University is enormously valued.
  2. Adequate work-life balance. Physicians of the baby boomer generation went into medicine with the expectation that they were going to work very long hours and have very few days off. Most hospitalists are in the millennial generation and trained in an era of ACGME-legislated duty hour limits and emphasis on life outside of work. Baby boomer doctors have no problem carrying their pagers 24-hours a day and being called on their days off work. Millennial doctors want to turn their pagers off when they leave the hospital and not turn them on again until their next shift.
  3. To have sufficient time during the day to do their job well. Physicians are professionals and they want to take pride in a job done thorough and a job done well. To do that, they have to have enough time that they don’t have to cut corners in patient care. Insufficient time to do one’s job leads to burn-out.
  4. A reasonable salary. Notice that I didn’t say the highest salary. Most hospitalists are not choosing a job because it pays the best but because it is the best place for them to work. In fact, if a hospitalist is choosing a job purely based on salary, you probably don’t want that hospitalist in your hospital. A hospital with a terrible “churn and burn” environment with excessive hospitalist work loads and high turnover will have to pay more to attract a hospitalist than a hospital where the hospitalists feel valued and treated as professionals.
  5. To heal patients’ disease and suffering. Lets face it, college students who decide to go to medical school are intelligent… really intelligent. And to get into medical school, they’ve got to be hard working… really hard working. They are going to spend 4 years racking up $180,000 in medical school debt then get paid a little more than minimum wage as a resident for 3 years. With their intelligence and work ethic, they could have gone into engineering or IT and made more money over the course of a lifetime than a doctor. The reason that they went into medicine in the first place was a desire to heal and help.
  6. A collegial work environment. Most hospitalists want to work in a team of like-minded physicians and they want to work with people who they know will back them up if they have a family emergency or they get sick. They want to know that when they have 3 patients crashing at the same time, that one of their partners is going to come over to help out without being asked. They also want to work with consultants who are going to partner with them in the care of their patients.

There isn’t a lot of overlap between these two lists. So, what we usually do is fall back on things that we can understand and easily quantitate, like the number of patients a hospitalists sees per day, the number of shifts per year, salary, and RVUs (Relative Value Units) billed. But by doing this, neither side really gets what they want and both sides end up being less satisfied than they could be. What is the solution? I have some ideas and I’ll outline them in the next post.

March 4, 2017


Inpatient Practice Medical Economics

What Machiavelli Would Say About Hospital Length Of Stay

Machiavelli famously said to the prince: “It is better to be both loved and feared but if you can only be one, be feared”. I’ve been wondering what Machiavelli would say about time of hospital discharge versus length of stay?

Hospital length of stay is measured by the length of stay index. This adjusts the length of stay (in days) for the patient’s diagnosis. Because sicker patients are expected to be in the hospital for more days than less sick patients, the length of stay index makes more sense than just the plain length of stay. A patient who was in the hospital for the expected number of days for that patient’s diagnosis would have a length of stay index of 1.00. A patient who was in the hospital more days than would be expected would have an index of greater than 1.00. And if that patient was in the hospital for fewer days than expected, the index would be less than 1.00.  We benchmark our hospital’s length of stay to Vizient, which is composed of most of the academic medical centers nationwide. Our medical center’s goal is a length of stay index of 0.95; we have been proud that our hospital’s length of stay index last year was only 0.88.

But here is the problem with length of stay. If you are going to get a patient out of the hospital a day earlier than expected, that usually means you have to cram a lot of testing, consults, treatments, and case management into that last hospital day. That means that the patient is going to get out of the hospital later because you are waiting for that test result, or that last antibiotic infusion, or the discharge arrangements to a nursing facility.

In addition to the length of stay, the other metric that we watch carefully is the time of day that patients are discharged. Ideally, you like to get  your patients out of the hospital early in the day so you can have a bed available when the next patient needs to be admitted. Think about hotels – they usually want you to check-out by 11:00 AM so they can get the room cleaned and ready for the next guest arriving in the afternoon. The reality is that hospitals only have so many environmental services employees and so there is a limit to the number of rooms that can be cleaned at any one time. Therefore, what you like to see is an even distribution of patients being discharged over the course of the day so that rooms can be cleaned as soon as a patient leaves without having to leave the room dirty for hours waiting for environmental services.

Often, getting the patient out early in the day is in direct conflict with shortening the hospital length of stay. It is kind of like a game of Whack-A-Mole; if you get the patient out of the hospital a day early, that patient is more likely to leave later in the afternoon (or in the evening) rather than early in the morning. Therefore, shortening the length of stay will usually push back the time of discharge.

So, what is a hospital to do?

You have to be realistic. the goal is NOT to get all of the patients out by noon (like a hotel) but rather to get some of the patients out before noon so you can get those rooms cleaned and then get a few more patients out by 2 PM so you can then get those rooms cleaned, etc. Hospitals are not like hotels – in a hotel, most of the guests arrive between 4 PM and 8 PM but in a hospital, patients show up in the emergency room and are getting admitted 24 hours a day.

I think if Machiavelli was alive today, he would say: “It is better to have both a short length of stay and an early average hospital discharge time but if you can only have one, have the short length of stay”.

February 22, 2017

Inpatient Practice Medical Economics

Is A Nurse Practitioner Cost-Effective?

One of the most common requests that I get this time of year is for a doctor or a service to ask for hospital support for a nurse practitioner or physician assistant. In each instance, you have to do an analysis to determine if adding an NP or PA for inpatient management is financially worth it. In Ohio, although PAs and NPs have different training, they have similar scopes of practice and are often used interchangeably. So in this post, when I refer to nurse practitioners, it can also mean physician assistants.

In most situations, you want to ensure that by using an NP, that you are at least breaking even with the cost of the NP by the revenue generated by the NP. In Ohio, NPs can write prescriptions and bill independently. In the hospital, there are two ways that NPs can provide care with regular daily visits. (1) They can do a “shared visit” so that they do part of the encounter and documentation and the physician does part of the encounter and also does part of the documentation – in this case, the reimbursement is 100% of the physician’s reimbursement. (2) They can do an independent visit in which case the physician does not need to see the patient or document anything – these are reimbursed at 85% of the physician’s reimbursement.

NPs can either be hired by the hospital or hired by the physician. The key difference is that if they are hired by the hospital, then they are a hospital employee and as such, none of their documentation can be used for the physician’s note in order to bill a daily hospital visit. Therefore, if a physician wants an NP to help with daily rounds and note writing, then the physician has to hire the NP. Otherwise, it is a Stark violation. This primarily applies to medical admission patients – since surgeons get paid by a global fee for a given surgery, they are not required to have the same degree of individual documentation for billing daily encounters and so documentation by a hospital-employed NP doesn’t affect the physician’s reimbursement for the surgery. For hospital-employed NPs, there are creative ways that the physician can lease a portion of the NP’s time from the hospital but the NP would still need to generate enough income to pay for the portion of time that the physician leases.

In our hospital, there is a bylaw that requires that a patient has to be seen by a physician daily. Therefore, having an NP on an admitting service limits them to doing shared visits – they cannot see patients independently without a physician also seeing that patient. However, on a consult service, the NP can see a patient without the physician also seeing the patients, since the admitting physician is also seeing/documenting a daily visit on that patient. Therefore, an NP on a consult service can either do shared visits or independent visits.

Lets take the situation when the NP is on a consult service and is seeing patients independently. The average NP salary is $100,000; add in 25% benefits and that comes to $125,000. NPs tend to usually work closer to a 40-hour work week so let’s say they see inpatients Monday through Friday and the physician covering the weekend sees all of the patients the NP was following during the weekdays. We will further assume that the NP works 46 weeks a year (4 weeks vacation and 2 weeks of holidays over the course of the year).

Therefore, the salary/benefits cost of the NP is $2,717 per worked week or $544 per worked day. In order to break even on the cost of that NP, the NP would need to generate $544 of revenue per day after expenses. In a private practice, there are relatively fewer overhead expenses but in an academic practice, there are a bunch of expenses, for example: Dean’s tax, departmental expenses, divisional expenses, malpractice, billing/administrative expenses, etc. All told these typically run about 21%. So, taking into account overhead, the NP would need to bring in $688 per worked day to fully break even.

In most practices, the physician will see the initial consult on a patient and the NP will see the return visits to that patient – a consult is usually a request for the learned opinion of an experienced specialist who has spent additional years of training to become an expert in an area of medicine and so the physician usually does the initial visit and lays out an impression and plan for that admission. So, we’ll assume that the NP is seeing only return visits and bills, on average, level 2 returns (CPT 99232) – Medicare pays $71 for this level of visits; adjusting this for the 85% reimbursement received by NPs for independent visits, this equates to $60 per encounter (a little less for Medicaid and a little more for commercial insurance). Therefore, based on Medicare reimbursement, the NP would need to see 11.5 inpatient return visits per day in order to pay for his/her salary. That would work out to about 40 minutes per return visit encounter which is very achievable (assuming that the consult service is large enough to support this volume of return visits).

Physicians have higher salaries than NPs and thus the cost per hour of a physician’s time is greater than the cost per hour of an NP’s time. Therefore, NPs can be cost effective when doing very time-intensive activities such as palliative medicine, smoking cessation counseling, diabetic education, etc. Also, you have to take into account what the physician will be doing if they don’t see the return consult visits. If the gastroenterologist will be able to do more colonoscopies or the cardiologist will be able to read more stress tests, then you can afford to lose money on an NP’s salary and still come out ahead because you are able to do a lot more of a more highly reimbursed activity than you otherwise would.

So, putting all of this together, what can we conclude:

  1. NPs need to see an average of 11.5 return visits per workday in order to break even financially.
  2. It can be cost-effective for an NP to see fewer than 11.5 return visits per day on procedure-oriented services such as surgery, cardiology, or gastroenterology since the NP frees up the physician to do more procedures that pay more per hour than return hospital visits.
  3. The practice’s payor mix affects the number of visits necessary to pay the NP’s salary – a practice with little Medicaid and a lot of commercial insurance may only need the NP to see 9-10 visits per day whereas a practice with a lot of Medicaid may need the NP to see 13-14 visits per day.
  4. It is financially more advantageous to have NPs do time-intensive activities (such as counseling, arranging follow-up testing, etc.) instead of having physicians do these.
  5. It is financially more advantageous to have NPs see uninsured/charity care patients since the cost of the NP’s time is less than the cost of the physician’s time.

If the NP is doing a shared visit (either with the admitting service physician or a consult physician), then the number of return visits needed to cover the NP’s salary is less – 9.7 per day. However, since the physician still needs to see each of these patients and do a component of the progress note documentation for each of these patients, that physician’s time now needs to be considered since all of the revenue from those 9.7 encounters will be going to cover the NP’s salary.

February 5, 2017

Inpatient Practice

Hand Washing Deniers

We do monthly audits of how compliant our hospital personnel are with hand hygiene. Last month, our hospital hit 97% and the month before, 98%.  The policy is that everyone (doctors, nurses, physical therapists, housekeeping, etc.) has to sanitize their hands when entering a patient room and again when exiting a patient room. No exceptions. Our audits are done by incognito auditors who walk around the hospital watching to see if anyone goes in or out of a room without sanitizing their hands.

In addition to our own internal compliance audits, the Ohio Hospital Association sends “secret shoppers”, who are nursing students, out to Ohio hospitals to do additional audits of hand hygiene compliance. This year, hospitals in Ohio are at 84% compliance which doesn’t sound all that great until you compare it to the national average of 68%.

Until about 15 years ago, hand hygiene meant using soap and water. This was a problem for people like me – in a 19-bed ICU, I would wash my hands more than 100 times a day. Consequently, especially in the winter, my hands were constantly chapped, cracked, and bleeding. Not only was this a deterrent to regular hand washing, but it was disturbing to patients to be examined by a physician with crusty, bleeding hands. Now, we use alcohol hand sanitizer that is mounted on the wall outside every patient room and this is far less damaging to the skin of the hands which helps promote compliance.

Hand washing in medicine seems like such a no-brainer. But it wasn’t always that way.

The history of hand washing dates to 1847 in Austria. At that time, Louis Pasteur was still working on his thesis in chemistry and had not yet discovered bacteria. There was a Hungarian physician named Ignaz Philipp Semmelweis who was working in the maternity Department of the Vienna Lying-in Hospital. Semmelweis observed that the number of cases of peripartum fever and the mortality rate was higher in one hospital ward than another. When he looked closer, he determined that the key difference was that the ward with the high death rate was staffed by medical students whereas the ward with the lower death rate was staffed by midwife students. It turned out that the medical students were coming directly from lessons in the autopsy room to the delivery room, whereas the midwife students did not attend autopsy lessons. This same year, his close friend, Jakob Kolletschka died after being accidentally poked by a medical student’s scapal while performing an autopsy. Kolletschka’s autopsy showed the same findings as the woman who were dying of post-partum fever in the maternity ward.

Semmelweis then found that the number of cases of fever could be reduced if medical students washed their hands before contact with pregnant women. He proposed some type of “cadaveric material” brought from the autopsy room caused the fevers and deaths. When he lectured about his discovery, he met with considerable hostility by his peers, so much so that he was ostracized by the Viennese medical community and his ability to practice obstetrics was severely restricted. He spent the next 14 years developing his theory about hand washing and ultimately wrote a book in 1861. Unfortunately, his book received very poor reviews by a medical community that was strongly opposed to his theory and he suffered a nervous breakdown resulting in him being committed to an insane asylum where he soon died after being beaten by attendants.

We’ve really come a long way and now no one is going to commit you to an insane asylum for washing your hands before taking care of patients. But the story of Dr. Semmelweis does illustrate just how hard it can be to change practitioners beliefs about measures to improve quality of care.

Deniers exist in every corner of medicine and science. In 1492, people were convinced that Christopher Columbus was going to sail off the end of the world, because, of course, the world was flat and only an imbecile would thing that it was round. In the 16th century, Copernicus’s theory of heliocentrism of the universe was derided as “absurd” and the Pope banned publication of his books. In the 17th century, when Galileo championed heliocentrism, he was placed on house arrest. In 1925, substitute teacher John Scopes made the mistake of teaching human evolution in a public school and he was famously found guilty and fined. In my own lifetime, in the town of Lancaster,  just south of Columbus, all of the children get cavities; that is because the town’s leaders were convinced that fluoridation of the water did not protect against dental caries and moreover, it would cause cancer – so 1969, they banned fluoridation of city water; in 2004, they voted to continue the ban.

In my first month of medical school, a professor told me that 50% of everything I was about to learn was false. In hindsight, most of what I learned still holds true (the aortic valve still has 3 leaflets and there are still 5 toes on people’s feet) but there was a lot of dogma of 1980 that turned out to be totally wrong: to prevent SIDS, babies should sleep on their stomach; beta blockers are contraindicated after a myocardial infarction; amyl nitrate causes AIDS, etc.

We now look back on the hand-washing deniers of 1847, who emphatically stated that Semmelweis’s recommendations were ludicrous, as being ignorant deniers of what seems to us to be the obvious. But it does make me wonder, how many of the things that I currently think are ludicrous will in the future turn out to be correct after all? When you are a human, you have to work hard to keep from being a denier, it seems to be in our nature.

December 27, 2016