Party animals 11:21

No one wants a hospital-acquired infection—a wound infection, a central line infection, or any other kind.  But today, the level of concern in American hospitals about infection rates has reached a new peak—better termed paranoia than legitimate concern.

The fear of infection is leading to the arbitrary institution of brand new rules. These aren’t based on scientific research involving controlled studies.  As far as I can tell, these new rules are made up by people who are under pressure to create the appearance that action is being taken.

Here’s an example.  An edict just came down in one big-city hospital that all scrub tops must be tucked into scrub pants. The “Association of periOperative Registered Nurses” (AORN) apparently thinks that this is more hygienic because stray skin cells may be less likely to escape, though there is no data proving that surgical infection rates will decrease as a result.  Surgeons, anesthesiologists, and OR nurses are confused, amused, and annoyed in varying degrees.  Some are paying attention to the new rule, and many others are ignoring it.  One OR supervisor stopped an experienced nurse and told to tuck in her scrub top while she was running to get supplies for an emergency aortic repair, raising (in my mind at least) a question of misplaced priorities.

The Joint Commission, of course, loves nothing more than to make up new rules, based sometimes on real data and other times on data about as substantial as fairy dust.

A year or two ago, another new rule surfaced, mandating that physicians’ personal items such as briefcases must be placed in containers or plastic trash bags if they are brought into the operating room.  Apparently someone thinks trash bags are cleaner.

Now one anesthesiology department chairman has taken this concept a step further, decreeing that no personal items at all are to be brought into the operating room–except for cell phones and iPods.  That’s right, iPods, not iPads.  This policy (of course) probably won’t be applied uniformly to high-ranking surgeons or to people like the pacemaker technicians who routinely bring entire suitcases of equipment into the OR with them.

What’s particularly irrational about this rule is that cell phones likely are more contaminated with bacteria than briefcases or purses, even if they’re wiped off frequently.  And I have to ask how an iPhone 6+ meets eligibility criteria while the barely-larger iPad mini doesn’t.  Again, please show me the data demonstrating that this will reduce infection rates, unless someone is making it a habit to toss briefcases and iPads onto the sterile surgical field.

Show me the money

I wish I could say that the driving force behind hospitals’ fear of infection is simply the wish for patients to get well. Unfortunately, it’s probably driven as much by financial motives as benevolent ones.  Today, Medicare won’t pay for care related to surgical site infections, and it fines hospitals whenever too many patients need to be readmitted within 30 days of discharge.  In 2014, a record 2610 hospitals–including 223 in California–were penalized, and will receive lower Medicare payments for all patients over the next year, not just those who were readmitted.

What does this mean at the grassroots level?

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3 COMMENTS

John Snow MBBS

Karen please tell us that you are collecting all these posts into a book that will soon be sold to the general public! PS: Note the irony that all these arbitrary and untested rules that are being thrown at doctors come from the same people that think doctors should be sued anytime we even think of using some treatment or drug that is not "evidence based medicine". We live in an Alice in Wonderland environment and you could help awaken the public to its absurd detrimental ...Read More
Nice post. I share your concerns and frustration. A couple of observations. We may be seeing the sleeve issue crop up again, only this time from the WHO. (Without any clear data I could see) WHO has decided sleeves and clothing provide infection risk, and in addition to asking doctors to launder neckties frequently and keep them clipped/pinned, they are making a recommendation for arms to be bare below the elbow. A bummer if you wear a suit or live in a cold climate... Also, I actually ...Read More

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EHR

“I’m here to say ‘Yes, they can,’ which is different from ‘Yes, they always do,’” says James Moore, MD, President-Elect of the California Society of Anesthesiologists (CSA).

To the contrary, enthusiasm for electronic medical records (EHRs) is part of a “syndrome of inappropriate overconfidence in computing,” argues Christine Doyle, MD, the CSA’s Speaker of the House.

The two physician anesthesiologists (and self-identified “computer geeks”) squared off in a point-counterpoint debate in New Orleans as part of the American Society of Anesthesiologists (ASA) annual meeting, with Dr. Moore defending the benefits of EHRs and Dr. Doyle arguing against them. Dr. Doyle chairs the ASA’s Committee on Electronic Media and Information Technology, while Dr. Moore leads the implementation of the anesthesia information management system (AIMS) at UCLA.

Legibility, accuracy, quality

Dr. Moore defined safety in anesthesia care as “minimizing patient injury resulting from or occurring during anesthesia, and keeping surgeons from harming patients any more than they have to.” He said that computerization contributes to safe anesthesia care by improving legibility, offering clinical decision support with readily available reference information, and providing alerts and reminders.

Computer tracking of the anesthetized patient’s vital signs is more accurate, Dr. Moore said. It prevents the “normalization” of blood pressure that tends to appear on the paper record. Quality reports are easier to generate and outcomes are easier to measure with EHRs in place, he noted. “Postop troponin levels and acute kidney injury are easy to track.”

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5 COMMENTS

Clark Venable

Amen.
EHR and CPOE are a disaster. In the age of physician shortages, it is unwise to make doctors slower and less efficient by requiring them to do peripheral items and not direct patient care. These thing were sold to us as an integrated system in which we could access records from other systems easily. That never materialized....nor was it intended. Instead these are instruments to make RAC audits easier, track physician behavior, limit ordering choices, and ultimately implement algorithmic medicine.

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The anesthesia care team has a long-standing record of safety

“Fighting against those who want to change things is a futile strategy,” declared Jason Hwang, MD, MBA, keynote speaker at the opening ceremonies of the American Society of Anesthesiologists’ annual meeting in New Orleans on Saturday, October 11. “You can’t defend a profession by putting up regulatory and payment barriers to stop the barbarians at the gates.”

Dr. Hwang is a co-author of  The Innovator’s Prescription: A Disruptive Solution for Health Care, the winner of the 2010 Book of the Year award from the American College of Healthcare Executives. An expert on the subject of disruptive innovation, Dr. Hwang told the audience of anesthesiologists from more than 90 countries that the Perioperative Surgical Home (PSH) concept offers an integrated solution to healthcare that can help the profession of anesthesiology adapt, survive, and prosper.

He used the example of Apple Inc. to illustrate how a company can thrive while other huge competitors failed because they yielded to “the irresistible temptation to keep doing what they already did best.”

Faster horses, bigger hard drives

If Henry Ford had asked customers what they wanted, Dr. Hwang said, they would have answered “faster horses”. If you asked people what they wanted from their computers 10 years ago, they would have answered bigger hard drives, more memory, and faster processors. Nobody would have said they wanted a phone. But Apple redefined the business with smartphones and tablets that created their own market, and Apple controls the entire integrated product.

Anesthesiology’s chief problem has been complacency with the status quo, Dr. Hwang said. Profitability has been greatest in the operating room, while the areas of preoperative and postoperative care were ripe for encroachment by hospitalists and other practitioners.
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3 COMMENTS

Jared

After I initially commented I seem to have clicked on the -Notify me when new comments are added- checkbox and now wwhenever a comment is added I recieve four emails with the exact same comment. There has to be an easy method you can remove me from that service? Cheers!
Wonderful article! This is so insightful about anesthesia, and it really gives an overview about the future of anesthesia. With so many current advances in technology, the future of anesthesia is certainly open. Thanks so much for sharing this info!

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Joan Rivers 3

The ear, nose and throat specialist who treated comedian Joan Rivers on August 28 has been identified as Dr. Gwen Korovin, a prominent New York physician who is known as a voice doctor to many entertainers and Broadway stars including Hugh Jackman and Julie Andrews.

With a physician who is an expert in airway anatomy at her side, and all the technologic advantages of a modern clinic in Manhattan’s upper east side, the 81-year-old Ms. Rivers must have anticipated an uneventful procedure. Instead, she stopped breathing and suffered cardiac arrest. The question remains:  What went wrong?

Credentials questioned

Several sources have reported that Dr. Korovin had not completed usual credentialing procedures at Yorkville Endoscopy, and did not have privileges to do anything but observe on the day Ms. Rivers was treated.

In fairness, the credentialing process at a hospital or ambulatory surgery center (ASC) simply reviews documentation that the physician is qualified to perform procedures, and grants the physician privileges to practice there. Physicians choose where they want to work, and don’t necessarily maintain privileges at more than one hospital or ASC.  A lack of privileges doesn’t imply a lack of experience or training; it simply means that the physician hasn’t gone through credentialing steps at that facility.

In Dr. Korovin’s case, her attorney’s statement notes that she “maintains privileges at one of the city’s most prestigious hospitals.” Her prominence in Manhattan may have led to an assumption that her credentials at Yorkville Endoscopy were in order, although it is the responsibility of each facility and its medical director to make sure.  Dr. Lawrence Cohen, Ms. Rivers’ gastroenterologist, was the medical director of Yorkville Endoscopy at the time of Ms. Rivers’ treatment, and has since resigned.

Critical lack of oxygen?

Ms. Rivers suffered cardiac and respiratory arrest while at Yorkville Endoscopy for evaluation of why her voice was getting raspier. She was resuscitated and transferred to a nearby hospital, but died a week later after discontinuation of life support.

Initial autopsy results were inconclusive, according to CNN’s report of a statement from the medical examiner’s office, meaning that no obvious cause of death was clear, and more tests will be done.  This information appears to rule out some causes of sudden cardiac arrest such as pulmonary embolism, the formation of a large clot that stops blood flow through the lungs.

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5 COMMENTS

Ven Bodavula

Hi Karen Did Joan rivers gastroenterologist decided to hit two birds with one shot. He wanted to do a UGI and convinced this famous ENT surgeon and voice doctors of celebrities to drop in and examine the upper airway at the same time. That's why this ENt doc has no privileges at the yorkville endoscopy center. As you said VIP syndrome. Ven
If it's true, your DENTIST is a rare gem. And by the way: a tracheotomy was not needed. The placement of an intra-tracheal tube, would have been enough.

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Vocal folds

Since the death of comedian and talk-show host Joan Rivers, more information has surfaced about the events on the morning of August 28 at Yorkville Endoscopy. But key questions remain unanswered.

News accounts agree that Ms. Rivers sought medical advice because her famous voice was becoming increasingly raspy. This could be caused by a polyp or tumor on the vocal cords, or by acid reflux irritating the throat, among other possible causes.

So Ms. Rivers underwent an endoscopy by Dr. Lawrence B. Cohen, a prominent gastroenterologist, to evaluate her esophagus and stomach for signs of acid reflux. At the same time, a specialist in diseases of the ear, nose, and throat (ENT) reportedly examined her vocal cords (also known as vocal folds).

We don’t know exactly how much or what type of sedation Ms. Rivers’ may have received, though several news sources have reported that she was given propofol, the sedative associated with the death of Michael Jackson. No physician who specializes in anesthesiology has been identified on the team taking care of Ms. Rivers, and we don’t know who was in charge of giving her propofol.

It seems clear that at some point during Ms. Rivers’ endoscopy and vocal cord examination, there was a critical lack of oxygen in her bloodstream.

Was laryngospasm the cause?

Giving sedation for upper endoscopy is tricky, as any anesthesia practitioner will tell you. A large black endoscope takes up space in the mouth and may obstruct breathing. Any sedative will tend to blunt the patient’s normal drive to breathe. But most patients breathe well enough during the procedure, and go home with no complaints other than a mild sore throat.

News reports have speculated that the root cause of Ms. Rivers’ rapid deterioration during the procedure could have been laryngospasm. This term means literally that the larynx, or voice box, goes into spasm, and the vocal cords snap completely shut. No air can enter, and of course the oxygen in the bloodstream is rapidly used up.

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8 COMMENTS

Robert Rosenlund

The clinic spokesperson said " AN anesthesiologist was at a patient’s bedside throughout A procedure." not that one was present at THIS particular procedure. If there had been an anesthesiologist present, the GI doc, the ENT doc and the center would have already blamed him/her and would have plastered their name all over the media. Why didn't the ENT do a trach? Prob because as an endoscopy center, there were no trach sets, maybe not even a simple scalpel to do an emergency cricothyroidotomy, since ...Read More

Msmith

Nurses should not do ANYTHING they do not have the knowledge, skill or judgement to do. We are taught this from day one. As a nurse in an ICU setting I refuse to push propofol unless an anesthesiologist , CRNA or an MD experienced in managing airways is present (Or the patient is on a ventilator, I.e. airway protected). RN s do not intubate and need to be aware of the implications of giving this potentially dangerous drug. You need to be able to ...Read More

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