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

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

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

Inpatient Practice

The Most Dangerous Procedure In Medicine

danger-signAlright, from the title of this post, I’m sure you are trying to guess what it is. Open heart surgery? A craniotomy? Separation of conjoined twins? Wrong. The most dangerous procedure in medicine is the hospital discharge.

From the time a patient is admitted to the hospital, the medical resident or the hospitalist has one mission – to get that patient discharged, preferably alive. That’s because the discharge is the ultimate goal of a patient’s hospitalization.

We are singularly focused on discharge. As soon as a patient hits the nursing unit, we are pressing the admitting physician to enter a projected discharge date so that the hospital’s case management machinery can start working to get that patient out of the hospital. We analyze hospital length of stay for each physician, rewarding those who keep their length of stay index below one and chastising those with a length of stay index greater than 1. We put enormous resources into getting discharges out of their hospital room by noon so that we can make room for the next patient.

So why aren’t we patting each other on the back for every hospital discharge, after all, the fact that the patient is being discharged means that they are getting better so we were successful, right?

The problem is that there is so much that can go wrong when we discharge a patient. Here are just a few of them:

  1. Medication reconciliation. Everybody talks about it but nobody does it very well. In order to keep our hospital costs down, we have a relatively limited number of medications in our hospital pharmacy formularies, limited to those drugs in each category that we are able to get the best pricing on. The problem is that these are not the drugs that the patient will be taking at home which are dictated by their insurance company’s formulary. And so the drug that the patient got better taking in the hospital is often different than the drug that the patient will pick up at the drug store. Even more of a problem, the patients frequently assume that they are supposed to take both the drug that is on their hospital discharge instructions and the drug that their primary care physician had prescribed for them prior to their hospitalization. I can’t even count the number of times that one of my patients who had been taking Advair for years comes into the office after a hospitalization taking both Advair and Symbicort because Advair wasn’t on the hospital formulary and the hospitalist put them on the equivalent Symbicort when they were in the hospital.
  2. Medication access. This has gotten a little better as patients have had better access to health insurance under the Affordable Care Act. But it is still common for a drug to be prescribed at discharge from the hospital that the patient can’t afford once they go to pick it up at their local pharmacy. So what do they do when faced with a bill for a $300 antibiotic? They don’t buy it. And then they get sick again.
  3. Nursing & doctor care. When they are in the hospital, patients are getting vital signs every 6 hours and seeing the hospitalist once or twice a day. As soon as they leave, that changes to seeing their primary care physician 3 weeks from now. We monitor patients up the wahzoo in the hospital and then release them into the wild the minute that they walk out the door.
  4. Oxygen. This one is a pet peeve of mine, as a pulmonologist. We check the patient’s oxygen saturation by oximetry every day or multiple times a day in the hospital – almost always when they are resting quietly in bed. But they are not resting quietly at home, they are walking around, climbing stairs, carrying groceries, etc. And their oxygen saturation is a lot different when they are doing those activities. I’m always dismayed when a patient shows up in the office for their hospital follow up and the nurse checks their oxygen saturation right after they walk 50 feet from the waiting area to the exam room and the saturation is 76%. When you go back to the hospital record, it was always in the 90’s because it was always measured after the patient had been lying in bed for an hour.
  5. Medical follow-up. If a patient gets discharged on a Saturday morning, the case managers (if they are even in on Saturdays) can’t schedule a follow-up office visit with the patient’s primary care physician. So instead, the discharge instructions will typically say something like: “Please call your primary care physician’s office on Monday to make an appointment to be seen within 3 days.” Here’s what usually happens: the patient forgets to call, the physician is out of town for 2 weeks, the physician doesn’t have any available appointments until December, or the patient doesn’t even have a primary care physician.
  6. Communication with the outpatient physician. So lets be optimistic and the patient does call and get an appointment to see his primary care physician the next Tuesday. He shows up and his doctor asks him why he is there. The hospital policy is that a discharge summary has to be dictated within 5 days of discharge and the hospitalist hasn’t gotten around to dictating it yet. The patient says he was in the hospital because of high blood pressure. The primary care physician checks his blood pressure and it is normal so he sends the patient out. Two weeks later, when the discharge summary finally arrives in the mail, it says that the patient was admitted with hypertension and chest pain and was found to have an ejection fraction of 15%, an aortic dissection, and syphilis and that he should see his PCP for treatment.
  7. Diet. No human being ever gets put on a regular diet in the hospital. It is usually some combination of low salt, carbohydrate limited, caffeine-free, diabetic no added sugar, 15 gram protein diet. Its no wonder they all hate our hospital food, its nothing like what they eat at home. And so the patient with heart failure goes home and what’s the first thing he does? Open up his pantry and pull out a jumbo bag of Doritos and then wash it down with a liter of original Coke. When you ask him about it the next day when he’s back in the emergency department, he’ll tell you quite honestly that the discharge instructions didn’t say anything about avoiding Doritos.
  8. Pending tests. As soon as a patient is out of sight, they are out of mind. And so the chest CT scan result that was pending at the time of diagnosis comes back showing a “large lung mass that should be considered lung cancer until proven otherwise”. But the patient is gone so nobody sees the report. Or maybe the final culture from the bronchoscopy that the pulmonologist did comes back with Cryptococcus. But the report goes to the hospitalist who doesn’t know what Cryptococcus is and assumes it must be a part of normal flora.

There are a thousand things that can go wrong when a patient gets discharged. And that’s why the discharge is the most dangerous procedure in medicine.

October 31, 2016

Inpatient Practice

The Documentation Game

board-gameOur hospital finished the last year with an inpatient mortality index of 0.54, a fantastic accomplishment. That means that we provide great care and we play the documentation game well. If the hospital mortality index is 1.0, that means that you had exactly the number of inpatient deaths that other hospitals have on average, after those patients are adjusted for their case mix index (CMI; a way of quantifying how sick the patients are). If your mortality index is > 1.0, then you had more deaths than the average hospital and if it is < 1.0, then you had fewer deaths than average. Another way of stating this is that the mortality index is the ratio of observed: expected mortality. At 0.54, our mortality index is one of the lowest of all hospitals in the country.

There are two ways you can keep your mortality index down: you can have few deaths (observed mortality) or you can document that you take care of a lot of sick patients. The best performing hospitals do both. As an example, your mortality index will be high if you have a young patient who came in for an elective cholecystectomy die (low expected mortality). On the other hand, if you have a 90-year old who has leukemia, is in heart failure, and is on dialysis come in for an emergent appendectomy and he dies (high expected mortality), your mortality index does not go up so much.

So if you want to be a best-performing hospital with a low mortality index, it is not good enough to just take great care of your patients, you have to document how sick they are. That’s where documenting secondary diagnoses that are present on admission becomes critical… and that’s where most physicians fall short. The hospital coders have to be able to pick those diagnoses out of the admission history and physical examination so it is necessary that the history and physical exam contain the precise words that indicate those secondary diagnoses that can significantly impact the case mix index. Words matter: you can’t just write “potassium = 3.0, will give KCl”, you have to actually write “hypokalemia, will give KCl”.

Here are the top secondary diagnoses that affect the expected mortality score:

  1. Anemia (specific type of anemia and whether it is acute or chronic)
  2. Acute respiratory failure
  3. Coagulopathy (including use of anticoagulants)
  4. Heart failure (systolic or diastolic; acute or chronic)
  5. Chronic kidney disease (including the stage number)
  6. End-stage renal disease
  7. Diabetes (including whether it is type I or type II, controlled or uncontrolled, and what organs have manifested complications)
  8. Hyperkalemia
  9. Hypokalemia
  10. Hypochloremia
  11. Hypomagnesemia
  12. Hypophosphatemia
  13. Hyperphosphatemia
  14. Hypocalcemia
  15. Hypercalcemia
  16. Hyponatremia
  17. Hypernatremia
  18. Dehydration
  19. Hepatitis (A, B, or C; acute or chronic)
  20. Liver disease
  21. Protein calorie malnutrition (mild, moderate, or severe)
  22. Metastatic cancer (including what organ it metastasized to)
  23. Decubitus ulcer (including the stage number)
  24. Pleural effusion
  25. Pulmonary edema
  26. Neurological or brain/spinal conditions
  27. Sepsis
  28. Shock
  29. Transfer from an acute care setting
  30. Requiring mechanical ventilation

We were all trained in medical school that the history and physical examination was all about our diagnostic impression and medical management. But the H&P is additionally an integral part of the documentation game. In the documentation game, the physicians are the players for the hospital and the physician gets more points for the more secondary diagnoses he or she documents. The winner is the hospital that documents that its patients are really, really sick and then discharges them alive.

October 29, 2016

Inpatient Practice

Reducing COPD Readmissions

On average, about 1 out of 5 patients admitted to the hospital with COPD in the U.S. get readmitted within 30 days. There is a wealth of medical literature analyzing COPD readmissions. For example, we know that patients at risk for readmission include:

  1. Patients without physician follow-up within 30 days of discharge
  2. African Americans
  3. Older patients
  4. Divorced/widowed patients
  5. Those with longer initial hospital stays
  6. Patients in nursing homes
  7. Patients with anemia (hemoglobin < 8)
  8. Patients with renal failure
  9. Patients receiving cancer chemotherapy
  10. Patients with low health literacy
  11. Patients on Medicaid
  12. Patients taking > 5 different medications

There are a lot of reasons why they get readmitted. Some of the reasons include:

  1. Insufficient outpatient follow up
  2. Medication errors
  3. Poor transfer of information to primary care providers
  4. Inability to pay for medications
  5. Inadequate transportation
  6. Incorrect inhaler technique
  7. Lack of a “rapid action plan”

Interestingly, only 28% of patients with an initial hospitalization for COPD are readmitted with COPD. More than half of those readmitted are for non-respiratory conditions such as heart failure, arrhythmias, intestinal infection, sepsis, and electrolyte disturbances. Also, readmissions occur pretty quickly with 50% of readmissions occurring in the first 2 weeks after discharge. So what can we do to reduce COPD readmissions? Successful strategies employ interventions both during the hospitalization and after hospitalization.

During hospitalization:

  • Screen patients for readmission risk factors
  • Communicate with primary care providers
  • “Teach back” to educate patient (respiratory therapists can be valuable)
  • Use interdisciplinary clinical teams
  • Start on maintenance long-acting inhalers
  • Start on roflumilast (if indicated)
  • Discuss end-of-life wishes
  • Comprehensive discharge planning
  • Ensure patients can get and manage their medications
  • Schedule an outpatient follow up visit
  • Make sure patients have a nebulizer

After discharge:

  • Promote self-management (emergency action plans)
  • Follow-up phone calls
  • Develop and use transition clinics
  • Home visits for patients with transportation barriers
  • Electronic medical record management of information
  • Establish community networks
  • Use telemedicine when appropriate
  • Arrange spirometry testing
  • Enroll in pulmonary rehab
  • Smoking cessation

We started a nurse practitioner-run pulmonary transition clinic at our hospital and were able to reduce COPD readmissions to 12.5%. However, we did see a sizable no-show rate and those patients who failed to show had a very high (27%) readmission rate. The specific actions that occur in our transition clinic include:

  • Clinic appointment within 5 days of discharge
  • Assess response to treatment
  • Follow up lab and radiology tests
  • Arrange pulmonary function tests
  • Medication reconciliation
  • Refer to indigent patient medication assistance programs
  • Arrange pulmonary rehabilitation
  • Smoking cessation
  • Insure correct use of inhalers

Readmissions cost all of us in the long run since they increase insurance/Medicare/Medicaid costs. Care coordination and education are key elements of any readmission reduction strategy. Respiratory therapists are often in the best position to champion patient education in the hospital. Ultimately, it requires a culture change in our approach to COPD – culture always trumps hospital policy.

October 14, 2016

Inpatient Practice Outpatient Practice

You Can’t Get The Flu From A Flu Shot

vaccinationIt is flu shot season and my goal each year is to give more influenza vaccines in my clinic than any of the other pulmonologists. So, I offer it to all of my patients and continue to be amazed at how many of them decline because “Every time I get a flu shot, I end up getting the flu”. There is no live virus in a flu shot so you are just as likely to get the flu from a flu shot as you are likely to get pregnant by taking a birth control pill.

So why are patients so sure that they’ll get an infection from the flu shot. There are two main reasons. First, they may have had some muscle pain at the injection site or even some mild myalgia after a previous injection – this is a reaction to the vaccine and not an infection. If anything, it means that the vaccine is working because your immune system is mounting a response to it.

The other reason patients think that they get the flu from a flu shot is from superstition. The average American gets 2-4 upper respiratory infections (“colds”) per year. Lets just say it averages out to 3 colds per year. That works out to 1 cold every 17 weeks. In other words, statistically, 1 out of 17 patients will get a cold within a week of getting a flu shot purely by chance. Because they associate that cold with the flu shot, they incorrectly deduce that the vaccine caused the cold (which they equate to the flu). By the same argument, 1 out of 17 patients will get a cold within a week of Easter but you don’t hear patients telling you that they got the flu from the Easter bunny.

As it happens, if it wasn’t for influenza, I never would have been born. My grandmother’s first husband was one of the 21 million people who died of the “Spanish” influenza epidemic of 1918-1919. She then remarried to my grandfather so if her first husband hadn’t died of the flu, I wouldn’t be writing this post now. In the United States, about 23,000 people die of influenza each year; some years more and some years fewer, depending on the specific strains that go around that year.

It is particularly important for all healthcare workers to get vaccinated so that they don’t become a vector to transmit influenza to vulnerable patients. A few years ago, I admitted one of my patients with pulmonary fibrosis to the hospital with worsened shortness of breath. On admission, I did a bronchoscopy and sent PCR testing for influenza – it was negative. We determined that he was in heart failure and he improved over the days with diuresis. He lived alone and had no relatives so during his hospital stay, he had no visitors. After about a week, he became suddenly worse with hypoxemia and high fever. I repeated the bronchoscopy and this time, his influenza PCR was positive for influenza A. Based on the incubation period, he had to have acquired his influenza in the hospital. Since he didn’t have any visitors, he had to have acquired it from one of the doctors, nurses, or therapists. He never made it out of the hospital and died of his influenza in our ICU.

So, I’m pretty passionate about getting everyone who works in the hospital vaccinated for influenza each year. I don’t care so much whether they get influenza but I don’t want them transmitting it to a patient who would be more likely to die from it.

October 12, 2016

Inpatient Practice

A Consult Is Not A Sign Of Weakness

stop-consults-signTwo days ago I got an urgent email from one of our case managers asking if I could see a patient with asthma in the office ASAP. She was in the hospital with her third asthma exacerbation in 2 months and the case manager was trying to keep her from being admitted yet again. Although my practice is primarily interstitial lung diseases, I do try to help out with other pulmonary diseases when I can. I pulled her up on our electronic medical record and found that she had never had an inpatient pulmonary consult with any of her previous asthma admissions.

So, why in the world would a patient with a disease that is this difficult NOT have a consult by a specialist? I think it is a reflection of how residents are often trained. Going back to my own internal medicine residency, the mantra of the senior residents was that “A consult is a sign of weakness”, meaning that if you ordered a consult to an internal medicine specialist, it meant that you weren’t smart enough to handle that problem yourself. It wasn’t just my own specialty of internal medicine – a senior surgery resident told me that he didn’t get medical specialty consults because “A surgeon can do anything an internist can do plus we can operate”.

Over the years, those attitudes have become embedded in the culture of American medicine. What we forget is that the practice of medicine is a skill and like any skill, if you want to be good, the practice of medicine takes practice. Let me give you the analogy I use with my medical students. If you want to learn to ski, you can’t just read a bunch of books about skiing. You can’t just watch a bunch of videos of experienced skiers. And you can’t just strap on skis, go to the top of the slope and then try to get to the bottom over and over again. Truly learning a skill takes all three: didactic education, observation of skilled practitioners, and practice on your own.

In some residencies, the didactic education will be awesome, for example, many academic medical centers. In some residencies, there will be extraordinarily experienced clinicians that you will observe, for example, many community hospitals. In some residencies, the interns and residents are often on their own and get a lot of “sink or swim” experience taking care of patients independently, for example, some VA hospitals. Each resident needs a different optimal mix of didactics, observation, and practice to reach his or her potential. But all residents need each of them in some combination.

The thing that sets a specialist apart is that he or she has had a lot more practice with a specific group of diseases. And that practice can translate into more nuanced care, particularly for those difficult-to-treat cases. Furthermore, the specialist that sees the patient in the hospital is often the one who will be seeing that patient in the outpatient clinic and that translates into better continuity of care.

The literature confirms that inpatient consultation improves outcomes in difficult cases. A study presented at the Society of Hospital Medicine showed that inpatient cardiology consultation reduced the 30-day readmission rate for heart failure from 26% to 15%. A study of inpatient geriatrics consults showed a reduction in 6 & 8 month mortality rates. A study of inpatient palliative medicine consults showed a reduction in readmissions from 15% to 10%.

As a specialist who sees both inpatient and outpatient consultation, I don’t believe that there is any question too small or medical problem too minor and so I will never criticize another physician for requesting an inpatient consult. However, I will criticize a physician for not getting an inpatient consult when they should have. A patient with a medical illness who is being repeatedly readmitted is more complex and takes a lot more of the consultant’s time than a patient with the same disease but more minor symptoms who never gets admitted to the hospital. Insurance companies recognize that, for example, a level III inpatient new/consult visit has 3.86 work RVUs whereas a level V outpatient new/consult visit has 3.17 work RVUs. The implication is that it takes more time and more complexity to take care of that problem if it is bad enough to result in a hospitalization than if the patient is in an ambulatory office setting. So, I don’t want to see that really sick patient in the office, I want to see them in the hospital where I will have more time to do the evaluation and more diagnostic and therapeutic resources immediately available.

An inpatient who is challenging enough that they need to be seen by a specialist immediately after discharge is challenging enough that they should be seen by that specialist while they are still in the hospital. Because a consult is not a sign of weakness.

October 8, 2016

Inpatient Practice

PrEP Your Hospital To Prevent HIV

aids-209370_960_720I’ve been waiting for 35 years but finally, we have a way to prevent HIV infection. HIV and AIDS has been the defining illness in world health over the course of my career.

June 1981: I had just finished my first year of medical school the month that the CDC first reported an outbreak of a rare infection called Pneumocystis carinii in 5 young previously healthy gay men.

May 1983: I was finishing up my third year of medical school the month that the AIDS virus was first discovered.

July 1984: I was an intern in our MICU and treated the first patient with Pneumocystis pneumonia in our hospital, a hemophiliac man with AIDS acquired from a blood transfusion.

March & April 1987: I was finishing my residency when the FDA approved a Western blot test to diagnose HIV and approved AZT, the first medication to treat AIDS.

October 1987: I was a first year pulmonary fellow when I got sprayed in the eye by bronchoalveolar lavage fluid from a patient with AIDS in our ICU when a jet of BAL fluid managed to find a quarter inch gap between the goggles I was wearing and the bridge of my nose during a bronchoscopy. I was enrolled in a CDC study of mucosal exposure to HIV in healthcare workers and had to have an HIV test monthly for a year. I spent a year not knowing if I had acquired a terminal disease but fortunately, all 12 of my tests were negative.

Today, HIV is no longer an automatic death sentence like it was 30 years ago but it remains an enormous burden of morbidity, mortality, and financial cost throughout the world. Currently, 1 out of every 99 Americans will become infected with HIV at some time in their life. For gay hispanic men, it increases to 1 out of every 4 and for gay black men, it increases to 1 out of every 2. It can be controlled but it can’t be cured so our challenge is to prevent people from getting infected in the first place.

Now we can finally do it with PrEP: Pre-Exposure Prophylaxis. When used regularly and combined with condom use, up to 90% of HIV infections can be prevented. The drug is Truvada and it is a once-a-day pill. It isn’t cheap, about $1,500 per month. The challenge to all of us is to identify patients at risk of getting infected and then talk to them about prophylaxis.

Historically, disease prevention has been the purview of of the primary care office practice but if we are really going to be successful controlling HIV in our lifetimes, then we need to look beyond primary care and seek out other opportunities to identify at-risk patients and get them on PrEP. We often think of our emergency departments and our acute care hospitals as places where we treat disease and not where we prevent disease. But going forward, our emergency department physicians, our hospitalists, and our hospital-based nurses are going to be in a great position to at least ask patients about high-risk behaviors and then direct them to practitioners who can get them started on PrEP.

During my first year of pulmonary/critical care fellowship, I did 350 bronchoscopies and the overwhelmingly most common reason for bronchoscopy was AIDS with pneumonia. Those patients are all dead now as are dozens and dozens of others that I’ve cared for over the past 30 years. I’ll consider it an enormous success if I never have to see another man or woman die of AIDS again.

The bottom line is that our hospitals need to be prepared to PrEP.

September 26, 2016

Inpatient Practice

Variability Creates Vulnerability

As I mentioned in a previous post, we just had our every-3-year JCAHO site survey. One of the surveyors made a comment that “variability creates vulnerability” and that phrase really stuck with me. So what does this mean? Let me give you an example. If you get on a plane, the pilot is going to go through a series of pre-flight checks and the flight attendants are going to give you a short speech about how to fasten your seatbelt and what do do in the event of a water landing. I’ve heard it dozens of time from dozens of flight attendants and it is always the same. I’ve also flown with dozens of pilots and each time, the pilot’s check list is also the same.

Not everything in the hospital can be standardized but the more you can reduce variability in practice, the less variability in outcome that you will have. Let me give you three examples.

The best outcome in CPR happens if you do chest compressions 100-120 times per minute. In order to ensure that this happens, our doctors and nurses have to go through BLS (basic life support) or ACLS (advanced cardiac life support) every 2 years. However, in the excitement of a true cardiac arrest, it can be hard to avoid going either too fast or too slow. At our medical center, we have recently started to use devices attached to the patient during CPR so we can analyze the compression rate during the code after the fact. When we first started auditing codes, I was surprised how commonly the chest compression rate either exceeded 120 or fell below 100. It turns out that this is pretty common at every hospital in the world – one’s sense of time becomes very altered when one’s adrenal glands are pumping out adrenaline at an ounce a minute during a cardiac arrest situation. We found 3 strategies to ensure correct timing of compressions – 2 that are expensive and 1 that is cheap. There are now automatic CPR compression devices that will compress the chest at a set rate and these are pretty fool-proof; we have one of these in our ER. The newer generation of the CPR monitoring devices don’t just record the compression rate but they can give a real-time read-out of compression rate during CPR. The least expensive option is to down-load a free metronome app to your smartphone and set it at 110 beats a minute and then turn it on during CPR to synchronize your chest compressions.

Our hospitalists are expected to place central venous catheters (“central lines”) and most of them learn how to do it during their residency. But there can be a lot of variability of the quality of training from one residency to another and hospitals will use different central line kits with different supplies in those kits. So 2 new hospitalists may use very different technique to put a central line into the same right internal jugular vein. To solve this, we developed a checklist for each of the steps that we expect during a central line placement and we have our hospitalists get proctored placing central lines during their first 6 months of employment to be sure that no matter where and how they were trained in central line placement, that they place it using the same procedural steps at our hospital.

Making sure you have the correct patient in your operating room and that you perform that operation on the correct anatomic part of that patient seems like a pretty straight-forward thing but every week in the U.S., there is a wrong-site surgery. Imagine waking up after anesthesia to find out that your good hip just got replaced instead of your bad hip or that you got your gallbladder taken out rather than your appendix. One way to prevent this is the “time-out” where everyone involved in the procedure stops what they are doing and confirms the patient, the sedation plan, the anatomic location, the specific procedure, etc. But time-outs only work if everyone is paying attention and you don’t miss any steps in the time-out. Therefore, the time-out should be scripted and just as predictable as the flight attendants’ pre-flight speech, no matter if you are in an OR or an endoscopy suite and no matter who is assisting during the procedure.

You can’t standardize everything in your hospital but you can standardize a lot of things. So look around you and see what you can do to reduce variability in order to reduce your vulnerability to bad outcomes.

September 13, 2016