Wednesday, August 13, 2008

Diane Suchetka's Continuing Anti-Doctor Crusade

I was wondering if there was anyone of rational mind and character who thought the implementation of the new "Never Events" policy of Medicare/Medicaid was a good idea. Little did I know, that special someone was located right here in my neck of the woods. Diane Suchteka is the healthbeat columnist for the Cleveland Plain Dealer and yesterday's piece detailing the new policy was just mindboggling. Enough is enough, she says. Save us from these awful hospitals and doctors who willfully harm us!

This is the same columnist who actually wrote a piece a few weeks ago stating that hospital errors are the seventh leading cause of death in the country, culled from some uncited, arbitrary source. In this article Ms Suchetka uses someone named Michael McCauley for a quote:

"These are conditions that are considered preventable," said Michael McCauley, media director for the Stop Hospital Infections Campaign run by Consumers Union, the nonprofit publisher of Consumer Reports magazine. "If hospitals were to set up efforts to follow these longstanding practices, the vast majority of these medical errors and infections could be prevented."


What's the Stop Hospital Infectious Campaign? Do they go by SHIC? Sounds like a fringe activist group to me. It's like writing a piece entitled "The Health Benefits of Anabolic Steroids" and using Barry Bonds and Mark McGwire as your sole sources. Or an article entitled "Cockfighting: Your Key to Social Networking" featuring juicy tidbits from Michael Vick. Where's the counterquote from someone actually involved in the delivery of healthcare? Giving equal weight to arguments is apparently something Ms. Suchetka isn't interested in.

And there's no argument here. The whole concept of "never events" is absurd anyway. Recently, DVT's after orthopedic procedures and wound infections after bariatric surgery were added to the list. This is inexplicable. And frightening for a healthcare provider. Venous thromboembolism can occur in up to 70% of patients after hip replacement if no prophylaxis is utilized. Even with the use of heparin or lovenox or coumadin, the risk still remains at around 5-10%. All scientific papers published on DVT prophylaxis talk about risk reduction. In no work of science will you read about a method of eliminating all risk of DVT after elective orthopedic procedures. As for the occurence of wound infections after bariatric surgery, only an absolute moron would advocate the stance that such occurrences are completely preventable. We have over 60 years of scientific research on surgical site infections. There are established norms and percentages for the development of wound infections after certain invasive procedures. The number isn't zero, no matter what how sterile or careful you are or how appropriately perioperative antibiotics are given. With bariatric surgery, you're dealing with patients who are obese and who often have diabetes; the two conditions most highly associated with surgical site infections. The list also condemns things like delirium and foley catheter infections and decubitus ulcers as completely preventable. In other words, when you slide a foreign body made out of rubber through your urethra into your bladder, the possibility that no bacteria will travel along the catheter to your bladder, thus setting up an infection ought to be zero..... Those sounds you hear in the background are knives being sharpened by thousands of personal injury lawyers across the country.

It wouldn't bother me so much if a piece like this appeared in some wack-job anti-medical establishment blog. But this is an article that will be read by thousands of people in Northeast Ohio. It's featured in a major midwestern newspaper. And it isn't appropriate. As a physician I aspire for perfection, but I can only aspire. The reality is that the human body is a remarkably complex machine, susceptible to a variety of uncontrollable factors. As much as we'd like to think we can standardize health care like a Ford Motor assembly line, the viccissitudes of human illness and suffering make it an impossible task. Can we be better? Of course. But to demonize adverse outcomes as "medical errors" and "preventable events" is to further alienate patients from physicians at a time when the very delivery of adequate healthcare for all is in a crisis.

40 comments:

rlbates said...

Great outburst, and so justified, Buckeye! I've made similar comments to family/friends lately. How can you list an event as a "never event" when no one has a way of getting there?

Frank Drackman said...

Who reads Newspapers anyway?

Guy said...

what about uti's after a catheter, you can try to prevent them but they sometimes happen.

I just won't put catheters in my patients then they can't get an infection.. too bad the hole in the bladder may be a problem but that one is covered.

I just think it's a popular way to save money but it doesn't cover that some things are impossible to get rid of. wrong site surgery, ok... leaving in instruments ok. but some of these others are just stupid and not preventable.

The Happy Hospitalist said...

did you see the recent published data, I think out of Canada that blamed the incredible rise in c diff infections post op to the policies of peri operative antibiotics being used in just about every surgery known to man. Unintended consequences once again. C diff while transmitted by fecal oral, is also known to colonize guts of healthy people, rearing its ugly head only when all the good bacteria have all been killed by our pwerful antibiotics. People come into hospitals with c diff and they leave with c diff and there is no way to tell whether they had it on admission or not. It's the equivalent of blaming a hospital (which means you are blaming nurses and doctors) for the patient developing an MI while in for pneumonia.Absurd. The whole DVT never policy is also sill as well.These are relays into lawsuits. You will see the lawyers pile on with VTE and c diff lawsuits and the culture of fear roles on.

WhiteCoat said...

Well put.
The uninformed drivel this woman puts forth is just a sampling of what the mindset the general public will develop once implementation of "never pay" for "never events" begins.
Sad

Bongi said...

never is an interesting concept. i can't help wondering what this woman does when she gets sick. after all going to evil doctors and dangerous hospitals would be out.

Anonymous said...

Well said Buckeye. Just another example of something/someone other than evidence based medicine dictating medical policy. A VERY slippery slope here. Will post-op pneumonia not be paid for in a patient with COPD, stroke, diabetes, MI yada-yada-yada. How about DVT in a 350 lbs. patient who had emergency orthopedic surgery, despite all precautions taken? Or C. difficile colitis in a patient being treated with broad spectrum antibiotics for sepsis of unknown cause? The list is endless. For those who think not paying for these complications is equivalent to not paying your lawn guy for cutting down the wrong tree are delusional. I'm not talking about amputating the wrong extremity or removing the wrong breast. No one says these are not "never events".

And those who say this will decrease malpractice suits, I think the opposite will happen. A new area of litigation will arise from this. One will see "C. difficile", "DVT", "UTI" on lawyers websites.

Worst of all of the unintended consequences, docs may decline aggressively treating or treating at all some patients with multiple medical problems who are more apt to develope complications.

Alice said...

The best part is that most of these "never" events are aimed at interventionalists. These UTIs, wound infections, DVTs, etc, happen most frequently in post-op patients. I say we all go on strike together. It should only take a day or two, if we run the PR well, for the public outcry to put an end to this nonsense.

Anonymous said...

How did you get "anti-doctor crusade" from Diane Suchetka's article? When I read the article, I thought she was talking about Medicare not paying for problems are caused by SYSTEM errors that are preventable if hospitals improve the way care is delivered at all levels.

Buckeye Surgeon said...

Frank- What are you, some sort of netroots fanatic?

HHo- Well put my friend. Thanks for the order sets BTW.

White Coat- Thanks for stopping by. I liked your piece on Kevins reader take. Especially the part about how these guidelines lack any reference to prevention. Like, tell me how to prevent a hyperglycemia complication and I would gladly comply. Just an empty, empty initiative.

Anon 8:56- Hospitals are inanimate objects. Structures made out of stone and mortar do not prescribe medicines or perform operations. We have these people called "doctors" and "nurses" who do the bulk of the actual work once you have been admitted to said "hospital". Blaming "hospitals" for errors is, in essence, blaming the humans intimately involved in the provision of such care.

Anonymous said...

Good thread buckeye. You should really write an op-ed to the Cleveland Plain Dealer. As you correctly pointed out, even with the best of treatment catheter related infections occur. Even with the best of treatment ortho post-op DVT's occur. I have NEVER EVER hve seen a study that shows DVT prophylaxis decreases the risk to zero (and I am heme). That is the fact. So my question to the idiots at CMS is how do they define a "never" event. Clearly in my (and medicines book) a "never" event is one that should never, ever, ever happen. Like, wrong site surgery or ABO incompatability (something I totally agree with). If all the studies show tht even with the BEST OF TREATMENT THE COMPLICATION OCCURS, THEN BY DEFINITION IT IS NOT A NEVER EVENT...PERIOD.
I guess I miss the good ole day's when reporters actually critically evaluated their stories for accuaracies. Diane Suchteka is not a reporter, she's a hack. I tire of "reporters" (and I am obviously using the term losely here) who don't even try to get it right. The simple fact as every doc in the trenches knows, is that many of these "never" events by definition are not "never" events. Now wait until the lawyers start sueing the ortho's/hospitalist's for post op DVT's/PE's as the idiots at CMS have termed them never events. I highly doubt any of these CMS morons has actually practiced medicine since Ronald Reagan was president.

Trisha Torrey said...

According to today's Wall Street Journal, you may be wrong about whether those central line infections are, or are not, preventable.

Quote from the article:

Beth Israel Medical Center in New York City reports that it hasn't had a central line bloodstream infection in the cardiac intensive care unit in over 1,000 days. Dr. Brian Koll, chief of infection control there, explains that the key is using a checklist that doctors and nurses must follow. Implementing the checklist cost $30,000 and saved $1.5 million in treatment costs. Lives saved: priceless.

Other hospitals -- from Johns Hopkins Medical Center in Baltimore to Sutter Roseville Medical Center in Sacramento -- have reached the goal of zero central line bloodstream infections.
.... and....

A recent survey from the patient-safety organization Leapfrog found that 87% of hospitals fail to consistently practice infection prevention measures.

I'm just sayin'...

Trisha Torrey
Every Patient's Advocate
http://patients.about.com

WhiteCoat said...

Trisha:

Central line infections: check

Now lets get on to the plethora of other infections: urinary catheters, Staph septicemia, C. diff.
While you're at it, give me a checklist for how to completely prevent dementia, patient falls, and DVTs.

Well ... I'm waiting.

Trisha Torrey said...

White Coat,

If you read the first sentence of my post, I was only presenting information about central line infections.

I'm not trying to pick any fights here. I believe we all have the same goals, don't we? The idea is for patients to leave a hospital in better shape than when they arrived, no matter who is -- or isn't -- picking up the tab.

Trisha

Alice said...

It's easy to have zero central line infections: just change your criteria for diagnosing them. My ICU is currently boasting of having no ventilator associated pneumonias for six months, when I'm treating two patients who have one. As long as you don't diagnose it, it's not a problem. Ostriches have a similar strategy for avoiding predators.

Buckeye Surgeon said...

Trihs-
Thanks for bringing up the central line issue. Great issue in the New Yorker a while ago about the work of Peter Pronovost and his checklist.

http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=all

Interestingly, despite the remarkable improvements in line infection rates with his techniques, two catheter infections still occured in his study. Never means never, however. The expectation is for ZERO complications and that's why we as physicians are all a little perturbed....

Anonymous said...

Whitecoat:
I would not waste a lot of time on trisha torrey. She often get's it wrong on her own website.

WhiteCoat said...

Trisha,

The problem is that you seem to accept the idea of "never events" as the "gold standard." By posting how two hospitals have reportedly reduced infections to "zero" in one small subsegment of patient care, you only increase the misinformation and the belief in the general public that all other "never events" should "never" happen. I'm picking the fight because you are using the classic "straw man" argument and you are doing a disservice to the medical profession and to the patients in the process. I know you're trying to help, but you're making things worse.

If you want the patients to "leave a hospital in better shape than when they arrived" then don't advocate a position that will decrease availability of health care and that will cause overt and/or covert discrimination against patients who are predisposed to a set of problems that are deemed "never" to happen.

You may be happy that "never events" are becoming a reality, but this policy is going to kill a lot more people than it will help.

I guarantee it.

Trisha Torrey said...

Alice -- your post actually contains more real "inside" info than the others -- the ostrich thing (or shall we call it exactly what it is? lying?) is never good.

Buckeye -- First, I would dispute that patients (and I can only speak for patients here, not professionals) believe these "never events" will never happen. We see it as a goal, like eradicating polio was a goal. In its day, polio would have been a never event! Will we ever get there? I expect it's pie in the sky.

Of course, that's not about the payers -- which is where you started. Patients are so removed from payment that most don't even realize how this non-payment issue will affect them.

Where you and I differ is not in the goals, but in the way we approach them. Anyone who reads my work finds that no matter how much I complain, or what problems I bring to patients to consider, I also attempt to find a way we can learn from the information.

An example: Within the complaints I have read about non-payment for infections, here and in other places, I find that one big hurdle is for patients who already have infections when they arrive at the hospital. C. Diff, MRSA. I know there are easy and inexpensive tests for MRSA -- but very few hospitals are testing on admission. I don't know about tests for C.Diff (Happy Hospitalist says there isn't a way to test on admission?) but it can't be that difficult to develop a test.

The point is -- demonstrate the patient had the infection on admission, and then it can no longer be shown to be acquired in the hospital and the reimbursements get made. Will it cost more to admit? Sure -- maybe $20. A very small investment for an excellent outcome.

The reason I do the work I do is because of my own HEINOUS (which is not a strong enough word) misdiagnosis four years ago. -- I was told I had a deadly cancer, and I did not. What I learned is that too many medical professionals think in straight lines and not nearly enough of them try to think of creative approaches to their work.

My bottom line? Instead of simply complaining, why not try to arrive at solutions that are win-win?

I'm not Pollyanna enough to believe that can always be possible, but I do challenge you all to stop pissing and moaning and to begin developing strategies and tools that benefit both patients and providers. Why not be heroes instead of exacerbating the problems?

Trisha Torrey
(don't bother reading any of the stuff on my website -- the master pisser and moaner, Anonymous, who doesn't have the cojones to give a real name, says too much of it is wrong.)

goatgirl said...

Trisha,

I have read your account of your cancer misdx.

You see it as black and white - they screwed up! - but in reality it's a lot more complex than that. There are more than three dozen different subtypes of lymphoma. Some of these categories behave so differently that on a molecular level, they are actually completely separate diseases. A physician might go through an entire career and not even encounter some of the rarer ones - yet you have your knickers in a twist because you think they somehow should have instantly, magically recognized your dx.

Some lymphomas are pretty straightforward, but the world is full of people who've had trouble getting a dx and getting an accurate read on the pathology.

I've had DLBC lymphoma. I ended up getting three separate pathology opinions, on the recommendation of the oncologists, because we had so much trouble nailing down the specific subtype. They bent over backwards to get it right.

The evil doctors who so heinously screwed up your case were motivated by the best of intentions, i.e. saving your life.

So who's not thinking outside the box?

P.S. I can't figure out why you're so angry because you didn't have cancer. Jesus H. Christ, I would have been *thrilled* if I'd been in your shoes.

Buckeye Surgeon said...

Trisha- I appreciate you stopping by but I have several problems with your take on the situation.

First of all, it's incredibly naive to think that the majority of Americans aren't going to interpret "never events" exactly as it's spelled out. Never. In other words, an event that is "never" supposed to happen. Why would they understand it as a goal rather than an end? Just look at Diane Suchteka....

Also, this controversy has nothing to do with payment. Our problem is with the terminology. Never is a very specific, definitive, non-negotiable term. It's one thing to reward healthcare providers for excellence and low complication rates and to explore methodologies for the reduction of adverse events such as bedsores and DVT's. But to create an environment of condemnation and blame doesn't do anyone any favors, patients and doctors alike......

What else ought to be a never event? Heart attacks? Progression of COPD? Death? You tell me. And let's say someone can be tested for CDiff upon admission but they arent manifesting any signs of acute infection (no diarrhea, benign abdomen). What now? What if we find out the incidence of cdiff in the general population is 80%? You going to give everyone antibiotic treatment? Isolate the whole hospital? Your solutions are simplistic and lack insight. Polio basically was eradicated because of the dedicated work of scientists and physicians. Not because FDR designated it as a "never event"....

WhiteCoat said...

Trisha -
If you dispute that people believe that "never events" will never happen, then you need to sample newspaper articles and comments to those articles throughout the internet. If you truly dispute the notion, why don't you put up a piece to clarify it on your web site?
You advocate extensive testing for these "never events" before patients receive treatment, yet you have little clue how much this testing will cost. $20 will get you a Kleenex and a Tylenol if you are lucky.
You won't find the information on the internet, but the cost for a C. diff culture runs about $200. Throw in a couple of $60 blood cultures and a $60 urine culture to rule out all the other "hospital acquired" "never events" and the patient is out almost $400 so the hospital can cover its ass. Who do you think is going to pay for all of this testing?
What if the patient develops symptoms after they arrive? Add another $400 to the cost. Still a "small investment"?
Through your experiences you engage in another straw man argument, namely: Your care was HEINOUS, so the entire medical system must be in shambles and no physicians think "outside the box."
There was a statistic out recently that there were 1 BILLION medical visits in the US last year. If we suppose (and I don't know the numbers for sure) that there were 1 million instances of malpractice last year, the incidence of malpractice is still 0.1%. Show me another industry with such numbers.
How do you expect medical providers to take time out to get "creative" when their payments are being cut each year and they have to pay increasing malpractice premiums, increasing office costs, large student loan debts, etc.?
It appears that your view is as narrow as that of the medical professionals you criticize. I agree with Buckeye Surgeon that you need insight into these matters before you propose solutions.

dr. bean said...

The only way to never have a complication to a procedure is to not do the procedure. Period.

I think we all agree that finding ways to reduce complication rates is a good thing.

These lists of "never events" however are completely unreasonable, unrealistic, and bizarre such that those of us who actually DO health care start to wonder if people who wrote them are in possession of their wits.

Of course they are. This is just bureaucratese for "we're not going to pay for it AND we're going to get patients mad at you so they won't get mad at us."

Remember the old "not medically necessary" BS we used to get from Medicare? Now they don't bother with that insulting bit of fiction and just say "non-covered benefit" or some such oxymoron. This latest bit of claims denial rhetoric however is a little more malevolent.

Trisha Torrey said...

Sorry folks -- have been out all day... returned to find the shift to attacking me instead of Medicare. Medicare thanks you.

I'll respond one at a time -- first to Goat Girl. In fact, they never wavered on the KIND of lymphoma I was diagnosed with. The point was that I was diagnosed at all with cancer when what I had was a benign tumor which was removed -- and I have had no recurrence or any problem at all since then (4 years later.) The bigger problem was that I was told two labs had confirmed the lymphoma, when that did not turn out to be true at all. In fact, the second lab ran a third test, called a clonality test, that showed I had no cancer. The problem was -- the oncologist never read past the diagnosis in the first lab report to realize another test and results were outstanding, then that same oncologist had the gall to tell me, despite results showing the contrary, that I should start chemo anyway. Errors compounded errors. He was just trying to save face once he was caught in his mistake. And had I not dug in my heals, I would have paid the price both through chemo and money. Was I happy I didn't have cancer? You bet!! But more than that (at the time) I was angry that the system had failed me like it did.

Surgeon -- you call me naive, and I'll give you that -- I am incredibly naive when it comes to all the problems that can crop up in the process of trying to get good healthcare. That said, I learn every day -- and I have learned from these posts. The difference between most patients and me is that I am aware, and sound the warnings, that problems occur constantly, daily, perhaps hourly, that cost lives. Most patients are just so unaware until they find a hiccup (or lose a loved one) themselves. I would rather sound warnings where they are not needed to make patients pay attention, than sit back and (naively) keep quiet about something that could have been prevented.

whitecoat -- I absolutely hear you on the point of reimbursements and the time you have to spend getting things right. no question. I'll help you with your statistic -- if there are 1 billion medical visits per year, divided by 5 million medical errors per year (that's the IOC's number), then the incidence is only 1/2 of 1%. Does that seem very low? Yes. but not low enough if you are one of the 5 million. Further, if you are one of the 44,000 to 98,000 that are killed by those errors -- well -- I'll bet your loved ones think it's far too high.

I'll also let you in on a piece of information that might help you understand why I get worked up about these infections. My mother in law acquired MRSA while in the hospital in early 2007 shortly after she had surgery -- and died a few months later. Yes, it's personal.

There are a couple of truths that I hope we would all agree on, no matter how we define never events, no matter how mad we are at the bureaucrats:

1. That we still ALL want what is best for the patient.

2. That having conversations about what will -- or won't -- work helps move the argument forward. It makes no difference whether we agree or disagree -- the outcomes will be the outcomes and if they truly do result, as commenters here have suggested, in extra lawsuits, or more deaths, or any of the other unintended consequences -- then changes will be made once again

Thanks to you all for putting up with me. I have learned from you and you, I expect, whether you want to admit it or not, have learned from me.

If nothing else, I provided you with entertainment for about 24 hours -- and I made you think.

Trisha

Anonymous said...

I say we stop closing the skin on laparotomy incisions for colectomies and pack them instead. Wound infections are a never event, right? Maybe something like that would convince the public that this never event nonsense will just push doctors to avoid risk to the detriment of everyone (particularly patients).

Anonymous said...

Trisha:

re: "-- and I made you think"

Yeah about how totally uneducated you are about medicine?


re: "But more than that (at the time) I was angry that the system had failed me like it did."

A system didn't fail you ONE ONCOLOGIST DID (according to you). This is the fact, if you have an issue with the medical care provided you, file a complaint with your state medical board. You shouldn't smear and make innuendo's on the internet. That is what people with "cojones" do. That is the purpose of your state medical board; to ensure competence in clinical practice.

More about your
"diagnosis" Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) as you know is a rare diseae described by Gonzalez et al in 1991. In your words on your website: "What I did learn was that everyone died. And died fast." According to the latest paper on SPTCL that is untrue (Blood 111(2):838-845). A retrospective/workshop study (the best we have in rare diseases) concludes that SPTCL is indeed at least two disease subsets based on T-cell phenotype. SPTL-AB with a 5 year survial rate of 82% and SPTCL-GD with a 5 year survival rate of 11%. In fact, according to the REAL classification, SPTCL-GD will note even be considered a "SPTCL". Feel free to pubmed the reference.

So what's my point?

My point is that lymphoma has become a more and more heterogeneous disease as we learn more and more about the biology of the disease. Sorry but this is a little more complicated than making widgets for Walmart. There is still more about the disease we DON'T know than we do know. HOWEVER, compared to 30-40 years ago the survival rates are much higher based on what we do know. Making a diagnosis of a rare T cell lymphoma is not like figuring out how is gong to win dancing with the stars. Personally I use AFIP or Mayo when there is any question with diagnosis. Also, this is a good case where a patient is better served in the Ivory Tower (sorry buckeye) than with a community oncologist. Your issue should be with one oncologist not "the system". In fact wasn't it another oncologist who made confirmed the incorrct diagnosis (with the NIH path). You have turned this misdiagnosis into a vendetta against "the system" (whatever that means). Well I am here to tell you, I, buckeye, and others don't sit behind computers pontificating about what should be done. We sit on hosptial committee's and protocol committee's figuring out the best care for our patients. That is on top of our day to day grind of being docs. Day in, day out everyday. This is a just a little more than playing weblog patient advocate. Buckeye, whitecoat, and others have already discussed how stupid your idea is to test every patient for C. Diff. Let alone that you don't seem to have any clue as to the real cost of pan testing, the problems with false postives (and negatives), and exactly what to do with the results. Additionally, your "blog" is littered with doc reply's to your incorrect statements. You rail about responsibility but seem to accept none for your own writings. If you really want to help us then I recommend you become truly educated and become one of us. Google is not an education. Become an RN, BSN, MPH, MD/DO. Get a real education on the subject, not a google glossover. Then you will really understand the issues we face.

PS: the 44,000-88,000 IOM numbers you quote have been parroted for a decade and are now a part of the lay press as gospel. I am not saying they are wrong, I am saying these figures come from extrapolated data FROM THE EARLY 1980'S (how many chevettes do you see on the road now). Review the medical journal letters to the editors of the era, there were significant questions as to where these numbers came from. Another example of your inability to critically read and understand the medical literature.

doctor trousers said...

it's so very very easy to accuse a faceless "system" of failing, that it should be perfect. But the system is made of thousands of fallible human beings, who make errors, (and I make the distinction between an error and a mistake). We cannot erase human errors from the healthcare system until it is run by machines only.

And more personally, do you really think that we don't try to prevent Never Events? Is our image so polluted that people seriously think we would wilfully DO HARM???? It would be stinking easy not to prep someone properly before catheterising, not to get a new catheter because you accidentally touched it with your "dirty" hand, or to not bother charting DVT prophylaxis. Do they really think we don't try hard to minimise these events? Do they really think we continue on our emotionally draining, financially unrewarding careers if we truly didn't like our patients enough to want them well?

Sheesh. Give us some credit. I'm sure as hell not doing it for the chicks, the money and the cred. I do it because I actually like making people better. Duh.

CancerDoc said...

There seems to be a suggestion that doctors want these "never" events to happen, or that it is through our own arrogance that we are unwilling to employ the techniques that will keep these events from happening. I argue both those premises.

I work in a rural community which does not have the benefit of ID or GI support. I decided to do a little self-education on C. diff this morning. C. diff colitis is something I frequently consider and frequently diagnose given my patient population (lots of lung cancer, lots of empiric antibiotics while on chemotherapy; chemotherapy which is, of it's own right without antibiotics, a risk factor for C. diff.)

I started with the CDC website. Guess what. There was no information about how to make C. diff a "never" event. I did find a presentation suggesting more research is needed to determine how antimicrobials might be used to "stem this growing epidemic," though.

As I expanded the scope of my search, I found that there is not even a good definition of community acquired vs. healthcare acquired C. diff. In a publication from the CDC, they define health care acquired C diff as infection that occurs within 4 months of hospitalization. In another paper, I found the definition as within 3 months, and another suggested TWELVE months.

I did find information about an emerging trend towards community acquired C. diff (i.e. C diff in people who don't have the usual high risk features of old age, antibiotic exposure, health facility exposure). The isolated strains have been more virulent (carrying two toxins). Perhaps, only the more virulent strains can be pathogenic in non-compromised hosts. However, in my mind, it raises the question of whether or not our failure to diagnose C diff in the community population has been our failure to put that on the differential.

According to the last ID doctor who came to our community to give a CME lecture, in the nearest large city, the vast majority of MRSA is now community acquired (the figure of 80% sticks in my mind). Please tell me, with THAT burgeoning epidemic, how we are supposed to make these infections in chemotherapy and surgically compromised patients a "never" event. Really. I want to learn.

E said...

great post buckeye!

as far as trish goes, i think most of the other posters already covered it.

DrCris said...

Very interesting discussion, Buckeye. I loved your take on this. In Australia we have a similar list of events, but they are called "critical indicators". If you wait long enough, critical events will happen, that shouldn't, and are preventable. But humans aren't robots, and hospital systems aren't perfect either.

I am all for creating a big investigation with wrong site surgery (which we hope would be never, but will happen with enough throughput). But falls? DVTs? That's bizarre. I can't see how those things can be never events.

The Aesthetic Blog said...

As a follow-on to Trisha's comments and the references to Betsy McCaughrey's Wall Street Journal op-ed piece from August 14, 2008.

The author, Betsy McCaughey, is a former Lt. Governor of New York State runs the organization RID (the Committee to Reduce Infection Deaths), and is on a campaign to force a kind of "zero tolerance" of patient infections of any kind at all hospitals. Sounds good on the surface, but what she's advocating is simplistic, perhaps simpleminded.

McCaughey, who is referred to as "Dr." in some online sources, is not articulating all sides of this important issue -- and as you and many others here state eloquently, is ignoring basic facts about the why/how of hospital infections and related phenomena that other doctors can articulate very clearly.

So... who exactly is McCaughey? A clue can be found at the Tapped blog:

"...[Is] this Betsy McCaughey the "Elizabeth McCaughey" who as a fellow at the Manhattan Institute wrote the legendary article, "No Exit," in The New Republic in 1993, in which she claimed to have read the entire Clinton health care plan and adduced all sorts of nightmare scenarios? Is this Betsy McCaughey the "Betsy McCaughey Ross" who, solely on the credential of having discredited the Clinton health care plan, was chosen as the Republican nominee for Lieutenant Governor of New York in 1995, becoming probably the first person ever to make news from that position by, for reasons never explained, standing up for the entirety of Governor Pataki's 1997 State of the State address? The same Betsy McCaughey who then became a Democrat, ran for governor, and divorced and sued her husband, Wilbur Ross, when he refused to bankroll her campaign?

"Yes, all the same person. And her new gig, the "Committe to Reduce Infection Deaths"? A good cause, to be sure: make sure doctors wash their hands. But the actual activities are vague and the "committee" itself consists of folks like Erica Jong, Tina Brown, Sir Harold Evans, the architect Richard Meier, and various other New York socialites."

Anonymous said...

Did you write a letter to the newspaper?

Anonymous said...

If this goes on, no many of us will be brave enough to treat sick people.

Buckeye Surgeon said...

Thanks for the info Aeshtetic...very interesting.

OregonDoc said...

Great post.

The originators of the "Never Event" phraseology are the National Quality Forum. They define the "Never Event" as "errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility". Certainly this sounds well and good. If there are serious and preventable errors that are not prevented and lead to serious ramifications for the patient, something should be done. However, a problem arises in identifying the criteria for such an event.

In the NQF appendix that spells out such criteria, they include:
1. Unambiguous - clearly identifiable and measurable
2. usually preventable - recognizing that some events are not always avoidable.
3. Serious
4. Adverse OR indicitave of a [system failure]

Unfortunately, the way any reasonable person will interpret a never event is one that does NOT recognize that "some events are not always avoidable". It also lends itself to the interpretation that this would ALWAYS be the indicative of a system failure.

So, what would be a better criteria for a "never" event? An event that is serious, unambiguous, and absolutely avoidable through systemic practices. One that comes to mind is Retained Surgical Instrument... but let's look at the data shall we?

Estimates of retained instrument report an incidence of anywhere between 1/5000- 1/10000 surgeries have a retained instrument. Current preventative measures commonly include an instrument count before and twice after every surgery as well as an "cavity sweep" before closing. Inaccurate counts prompt a post-operative x-ray. Nearly every surgical instrument as well as laps, sponges, guaze contain radio-opaque banding that allows for identification. However, despite these measures, retained foreign bodies occur. Instrument counts are prone to false-positives and account for extra expenditure in OR time and x-ray. Even routine post-op x-ray, studied in some locations and instituted as policy in others, reduces but does not eliminate risk of retained foreign body. There are several studies that have identified the threshold for identification of retained needles as 10mm in size by postop xray. Needles are the most common miscounted item. The possibility exists that there are a large number of postop retained needles, that even if detected, we are unlikely to find on re-exploration. And are unlikely, according to one AAORN study, to cause any patient harm.

So how could you even justify setting the expectation that a retained instrument -- one of the most shocking medical errors -- as a "Never" event? There is a known and absolute chance of this error occurring regardless of all reasonable and cost-effective measures to prevent it from occurring.

Sentinel Event. Yes. Never Event, unreasonable and ill-informed.

Anonymous said...

trisha: yep, we can test patients for MRSA on admission. we do in illinois icus. So what? What should we do about carriers? Deny them care? Treat them? How? Does it help? No answers to that question. Same as screening patients for c. diff: it's part of normal gut flora in many, many people. it becomes pathologic in certain circumstances, unfortunately.

in response to the posts about no catheter infections and no cases of pneumonia: if it sounds too good to be true, it is.

Anonymous said...

I think this is an excellent example of the interference of bureaucracy in medicine. Of course (pretty much) everyone has good intentions in handling the problem but to say that since nothing else is working, we're going to start punishing the hospitals and health care providers is a bad idea at best.

Do you think docs like missing diagnoses? Or having MRSA crawl all over the places in which they work? I can only imagine the embarrassment of a surgeon that leaves an instrument behind in a patient. Forcing hospitals to pick up the tab on mistakes that, to some degree, will always exist only serves to drive up health care costs.

With that said, that is by no means a license of complacency for hospitals and health care providers to not try to lower the stats as much as possible.

dharmesh said...

Normally I wouldn’t comment on posts but I felt that I had to as your writing style is really good. You have broken down a difficult area so that it easy to understand.

lebistourie said...

Soon the group will morph into the Stop Health Infections Tribunal, and we will all be in it!

melissa said...

this is one of the worst things that could happen and only the start trust me- i am now a patient i spent 13 years on the business side of medicine and hospitals/physician and then i had a baby via csection 7 years ago- i remained sick and about a year or so ago it was suggested i have a foreign body left inside of me it has been confirmed december of this year and i cannot find anyone to remove it- no surgeon wants to help esp since it wasnt their error- now imagine being threatened that they wont get paid for these events a patient will never get help ever and it doesnt help if you continue to take money away from doctors there will be nothing left I just dont get whats happening to this world- i just wanted a surgery so i can get better and become an advocate for both doctors and patients and try to connect that mistakes can happen its how its handled that makes it repairable or a travesty- this new issue will only make it worst
mdelmastro@verizon.net