Wednesday, October 22, 2008

More never event absurdity

Just when I was starting to calm down about the controversy surrounding "never events", the New York Times unloads a masterpiece of naivete and contempt. Reading this, my eyeballs almost popped out of my skull. One would think that the editorial staff of such a renowned, prestigous newspaper would exhibit a little more intellectual rigor when composing such a denunciatory op-ed piece. I almost thought Diane Suchetka had infiltrated the NY Times hierarchy.

And now, from the other side of the political spectrum, comes a piece from the National Review (arch conservative publication)that uses the concept of never events in such a way to elucidate the danger of government managed health care delivery. (Thanks to Alice at Cut on the Dotted Line)

To review: "never events" are a new designation for "avoidable" complications that arise during hospitalization. Certainly, wrong site surgery ought not to happen. But the list of never events includes such things as urinary tract infections, surgical wound infections, falls, pressure sores, c difficile colitis, delirium, deep venous thromboses and other similar such events that often arise in the setting of critical illness. Interestingly, you will not find a publishable work of science that describes how to reduce the risk of these events to zero. Why? Because it's impossible. If you put a rubber catheter into your bladder, I don't care how sterilely it's done, eventually a certain percentage of them will cause a urinary tract infection. It's a foreign body, for godsakes. And DVT's are not entirely preventable. Everything we know about prophylaxis with Lovenox/heparin/compression hose talks about risk reduction. There are no magic formulas or medicines or healing balms that will completely eliminate the risk of blood clots. It's absurd. The entire concept is absurd.

Basically, this an attempt to cut costs and distribute blame under the guise of "patient safety". And the ironic thing is, it won't cut costs at all. If anything, we're going to see doctors ordering more tests to prove that the patient had a pre-existing condition prior to admission to the hospital. The rise of community acquired MRSA and even c diff infections mandates this.

Furthermore, these viewpoints articulated by two prestigious national publications illustrate a shocking lack of understanding of the terminology with never event proposals. It attempts to lump together true medical errors (wrong site surgery, blood transfusion reactions) with undesired outcomes that occur despite preventative measures. A bad outcome should never be assumed to be a consequence of a "mistake". It's like sending Josh Beckett down to the minor leagues just because he gives up a home run to a good hitter. Take for example decubitus ulcers. All it takes is 30 minutes of unrelieved pressure from a mattress against your buttocks to compromise capillary blood flow to skin and subcutaneous tissues. Now imagine a 500 pound post op gastric bypass patient flat on her back on an air mattress. It takes 6 people to rotate her every two hours. She gets a pressure sore anyway. At what point was her care compromised? Please demonstrate the error. Ought we to have zero gravity chambers available for such scenarios?

The other fallacy has to do with this idea of "physicians making money off their own errors". Give me a break. Let's say I note a wound infection after a colon surgery. I open the incision a bit and drain the pus. I don't charge for it. The patient goes home with wound care instructions and gauze. Or let's say I diagnose a DVT after a low anterior resection. I put the patient on anti-coagulation and maintain the INR at 2-2.5 for 6 months. I don't charge for it. It all falls under the post operative global billing period anyway.

So let's dispense with this idea that physicians are just racking in the dough taking care of typical post op complications. The entire argument is fallacious and disingenuous. And as long as respected publications like the NY Times and the National Review continue to promulgate this nonsense, the sooner the general public will accept it as the conventional wisdom. Very frightening indeed.....

39 comments:

shuttleman58 said...

Perhaps a parallel issue here is the one that plagues many professions where risk is involved. It is the concept that we can reduce risk to zero. As an aerospace engineer, I have encountered it many times. If it moves, there is risk. Flying or space travel will never be zero risk. Anymore than driving a car can be. But as a society we are being conditioned to expect it.

As a doctor, you can do risk reduction but you can't make all aspects of medical care zero risk.

rlbates said...

Well said, both you Buckeye and you shuttleman58!

Anonymous said...

From the critical care nurse POV, it is nearly impossible to comply with all of the required prophylaxis. For starters, pts refuse their TEDS and SCD's. And perhaps more relevantly, there is an inadequate amount of staff available to turn all the patients as frequently as they need to be turned. Some of the bastards declare they actually want to sleep!!! Imagine! Hospitals need to hire more nurses and nurse assistants if they want to come close to meeting these outrageous goals. Buckeye surgeon, you are right on.

shadowfax said...

You're half right. I completely agree that "Never events" is a misleading name and should be changed. I further agree that the policy is poorly thought out because it does not discriminate between preventable errors and the irreducible risk of complications of hospitalization.

The point you are missing is that it only applies to the facility. Facilities are paid by DRGs, and if you admit a patient for an appy, and the patient develops a DVT in house, the hospital will be paid for the appy but the DVT modifier will be disallowed. However, your fee will be unchanged. For internists, I believe this also will include being paid for the extra days of hospitalization required. Similarly, for a medical patient being followed up by their internist, they will bill and get paid for the DVT follow-up.

Buckeye Surgeon said...

Shadowfax- I know what you're saying. I was just responding to the NY Times piece that implies doctors are raking in cash for their errors: "The policy focuses exclusively on hospitals, as directed by Congress, and lets doctors off scot-free."

Anonymous said...

But the issue here shadowfax is that a post-op DVT is NOT A NEVER EVENT (excuse the double negative). Everything related to DVT/PE's in the hospital is related to risk reduction not elimination. ASH sent a letter to CMS arguing against the stupidity of listing DVT's as never events based on the evidence. It went nowhere. I guess the opinion of the premier hematology organization in this country on a hematologic issue is meaningless to the idiots at CMS. Also, just how long do you think it will be before the lawyers start suing for these "never" events that ocurred. Take a look at this from a JD website:

http://www.zifflaw.com/NYInjuryLawBlog/ny-medical-malpractice-lawyer-explains-medicare-never-events


Scary stuff.

HudsonMD said...

First by looking at the list, there are really only a few “never” events that can be and should be totally preventable: foreign body after surgery, air embolism, and blood incompatability. The other ones listed are complications that can happen even with the most rigurous preventive measures. Doctors are not making it big or getting rich by keeping patients in the hospital longer because of complications. Thas is absurd. Infections happen, blood clots happen. THis is part of being critically ill. When proper precautions are taken and these events still happen there is nothing you can do. This is absurd legislation.

Bianca Castafiore said...

Thank you, for between your riposte to the NYT, and Shadowfax's explanation, I finally have the issue understood. Better, for me, at least, to have the threads of the argument carefully teased apart, than to be thrown full tilt into a blogger's outrage. That said, what a bunch of hooey you all are having to deal with!

Anonymous said...

You know what's gonna happen now, don't you? There'll be such a rush to discharge patients home much sooner so these problems can not be attributed to as "complications." They'll, of course, be readmitted but will not be counted as complications because, hey, they weren't in the hospital when the problem arose.

half tangent said...

A half-tangent here: what good would it do if we just stay in the closet and talk (or gripe, if you will) among ourselves? Opinions are shaped by experience, observations and preferences; everyone are entitled to their opinions, and columnists and members of the general public to theirs too, after all.

This is not the first time Dr. Buckeye brought up this topic. I wonder whether there is actually anything we can DO to alter such widespread yet misguided conceptions either at administrative or general public's levels. If not, many of your predictions (worst nightmares?) will likely materialize, to most of our dismay of course, b/c the momentum still carries the train forward. Any thought on ACTIONS?

Buckeye Surgeon said...

Half-tangent-
You make good points. Action always trumps an obscure blogger in ohio. I'm not sure what the answer is though. Writing letters to the editor? But how can that compete with an Op-Ed piece from the NY Times?

It's just so frustrating to watch: the elite publications in this country writing impassioned, but unvetted and irresponsible, pieces that completely misunderstand the gist of why the policy is ludicrous. And it's not like this is a difficult issue to comprehend. I do believe the average citizen understands that perfection is not yet attainable in modern medicine. But these articles in eminent newspapers choose to gloss over that reality and promote the more sensationalistic stance that "medical errors" are a threat to our livelihood without defining the parameters of what an "error" actually is.

One more thing for Shadowfax-
Don't you see the threat of a line like "...the policy focuses exclusively on hospitals, as directed by Congress, and lets doctors off scot-free" as in the Times article? The natural progression of that sentence is to "make doctors pay" for undesired outcomes as defined by Medicare. And how? Well, you get an infection after gastric bypass or knee replacement, then the doc doesn't get paid. The implication seethes under the surface of the piece. Just wait and see how many surgeons will refuse certain patients, not based on insurance or ability to pay, but rather on how fat they are or if they have too many risk factors for getting an infection.....

half tangent said...

Hi Dr. Buckeye,
Obscure blogger or not, what you n’ people say here DOES have a valid point, and such unfounded comment from major news outlets should not stay unopposed. I made a simple count, and there seemed to be at least half a dozen MDs and RNs here supporting what you pointed out. That’s quite a substantial counterweight from within the system, vs. the arm-chair commentator from outside the healthcare system. Who else’s opinion would count if experienced field doctors and nurses aren’t vocal enough to speak out for the record? Patients? Concerned freelancers? Lawyers?

platensimycin said...

I agree with Half-tangent. Another tangent here; please bear with me: What can Toyota and Healthcare possibly share in common? Not much, we reckon; after all, car components are readily replaceable while body parts aren’t.

Thinking outside the box, Brits are crossing industry lines and asking whether there’s anything applicable for their NHS. As it turns out, the keyword is “kaizen,” and whether we are willing to commit ourselves to
continuous quality improvement and take the risk to “halt the whole assembly line” without giving our colleagues the half-threatening “this had better be good!” Both a top-down and bottom-up approaches are needed, after all.

Anonymous said...

Anon 11:51 here:
Sorry half-tangent et al but buckeye is right. CMS is not interested in what real doctors think (I will leave out the flak MD's working for CMS as they don't appear to be real docs). As an example I will give you one line from the ASH letter against postop DVT's/PE's being never events

"We are writing you today to express our significant concerns regarding HAC candidate: Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) which we do not believe is an appropriate HAC candidate since these are conditions that can neither be always detected or prevented by the use of guideline-concordant practice."

The whole ASH letter to CMS is at this link.

http://www.hematology.org/policy/testimony/2009-IPPS.pdf

Did CMS listen to the premier US hematology organization on a hematologic issue based on the evidence? Why of course not. Just why do you think they are going to listen to 5-10 or a hundred random practicing docs? There has NEVER EVER been a paper that shows thromboprophylaxis lowers the risk of DVT/PE to zero. NEVER, NONE, ZERO. By defintion this is not a nbever event. It is a real risk of hip/knee surgeries. This whole thing is a travesty. Wait until the JD's start sueing for these never events (see the above link from my 11:51 comment). This is going to be a big money maker to slimeball JD's in the end. Malpractice? not if the was appropratie treatment. But that doesn't, apparently to the idiots at CMS.

platensimycin said...

Hi Anonymous 11:51,
Yes, I see your point, and in many incidences CMS does act like a tight-budget idiot/*sshole. Wouldn’t you wonder how all these nonsense is are going to end, though? If change is what we want (trying not to sound like an election catch-phrase), where will our inaction lead us? I think that’s the point Half-tangent tried to get across.

half tangent said...

If every profession is a parallel universe in its own right, we all need to be encouraged to reach beyond the universe we find ourselves in.

Jenna said...

Governement-run healthcare is a horrible idea. The government is inefficient with everything. It will be difficult to see the provider you want to see; it will take forever to get an appointment, etc...Think about it: you don't trust the post office to get a letter out on time- why would you trust the government with your health?!

Anonymous said...

Sorry half-tangent but I don't see how you propose stopping this idiocy by CMS.

Anonymous said...

Sorry Anonymous but I don't see how you propose stopping this idiocy by CMS, either. In fact, i don't think either you or anyone else has a plan yet, so stop picking on her simply because she is the one who brought it up.

Anonymous said...

Sorry anon 10:24, maybe I am dense but I don't see how a "parallel universe" statement is a proposol or my response is "picking on her". Actually as I pointed out above ASH specifically argued against DVT's/PE's as never events in the post hip/knee arthoplasty setting. Did you read the link? Let me repeat. CMS specifically ruled against the premier hematology organization on a hematologic issue? CMS ignored the evidence and the experts. Based on that lack of thought the only proposal I can think of is to fire ones who set up this list and replace them with docs who actually practice medicine. I will not hold my breath on that one. Otherwise one realistic comprimise would be to require events such as DVT in this setting, decubs, catheter related infections be reported and evaluated by health care workers who would determine if there really is an issue with the hosptial, RN's, MD's and requiring fixing the problem (and at that time deny payment) or not. But that idea would actually make sense and the Gods of CMS have spoken so the point is moot. Just bend over docs.

Anonymous said...

While I agree with the absurdity of the new Medicare ruling, I on the other hand, welcome my hospital's new found "mission" to scrutinize nursing's role in preventing some of these errors. Funny how the threat of holding back the greenbacks motivates change.

Our hospital's ER can accomodate 14 patients and these days routinely places up to 22 patients into the cramped hallway. We are now admitting patients in the hallways on the inpatient units. And these patients have no benefit of wall suction/oxygen/callbell units.

Nursing has been operating on "speed up" for a long time. This means we're throwing all kinds of foreign objects into bodies and we're doing it as FAST as we can. IV's-we stopped letting the alcohol/betadine swab dry a long time ago-there's no time. Urinary catheters-one swip of betadine will have to do because there's too much on my plate. Turn the patient?-did I do that 8 hours ago?

And we're taking care of your invasive lines placed too. A once occlusive central line dressing now open and mushy?-I'll get to it when I can. An intubated patient's mouth drooling purulence? A chest tube once secured now wobbling around with wet tape? An epidural dressing sweated off?

I'm sickened at the decline and now I welcome the scrutiny.

Anonymous said...

I'm all for the zero gravity chambers, although the thought of a 500 pound post op gastric bypass patient floating in air makes me feel a bit queasy.

jb said...

Shadow- you mentioned something about docs not getting penalized for never events. Not true for the surgeon. The post-op visits are bundled into the fee, so if our patient has a PE and stays an extra week, we have to see the patient daily as long as he stays for no extra pay, respond to dozens of nursing calls, and likely get sued. Not exactly a free ride.

curious mind said...

Docs, is PE predictable/avoidable? i thought Virchow's triad (stasis, damage to vascular epithelium and hypercoagulability) suggests that it is?

Anonymous said...

Curious Mind: One can "predict" your typical ortho hip/knee arthroplasty patient's would have all three criteria of Vichow's triad hence the aggessiveness of anticoagulation in all of these patient's in the post-op setting (see the guidelines). The problem here is the DVT/PE even in the seting of postop anticoagulation in these patients. NO study (ZERO) has ever lowered the risk to zero. By definition this isn't a never event then as the ASH memorandum sent to CMS (which CMS ignored). Predicting something an avoiding it are two very different subjects.

curious mind said...

Have a little difficult understanding what you were trying to say, Doc/Anonymous.

"NO study (ZERO) has ever lowered the risk to zero." That sounds a more like an excuse than a reason. Why not do some studies that DO make the difference? There's something called "inferior vena cava filter". It's invasive, but does it work to cut down the incidence of DVT-turn-PE?

Anyway, don't believe docs should be penalized for every in-hospital OOPs, but there's got to be a way to predict/prevent something as live threatening as PE, don't you think?

Anonymous said...

Buckeye:
I largely agree with your analysis as to the "never events" issue. As an attorney, I have turned down lots of infection and ulcer cases(really bad injuries too) because of the reality that many were not preventable despite the best of care. I've also accepted one or 2 over 20 years because the ulcers were preventable(in a nursing home setting)

I disagree w/ some of your previous posts that this will be some new sort of "cottage industry" litigation for us. Except for wrong site surgery or leaving large towels behind patients' lungs or other obvious calamities, I don't think things will change: certain complications are preventable with good care, and others are not, and each circumstance is different, no matter what the genuises at Medicare have decreed.

One final note: I have seen Drs and hospitals that were paid for their obvious, indisputable errors. In cases of obvious negligence, they should not be paid.

I predict that this rule will be so unworkable that it will eventually be scaled back to prohibit paymeny for obvious, indisputable errors. We may all be 93 and suffering from our own decub. ulcers by the time this happens, but that's my take on it--from someone on the other side of things.......

Buckeye Surgeon said...

curious mind-
Your point is nonsense. Surely you're not implying that everyone who gets admitted to the hospital ought to get an IVC filter? Ought we to perform CABG on every patient over age 70 to ensure that there are no unexpected heart attacks during a hospitalization?

Anon 10/29-
I appreciate your take but unfortunately, this "cottage industry" is already springing up. check this out: http://www.zifflaw.com/NYInjuryLawBlog/ny-medical-malpractice-lawyer-explains-medicare-never-events

I do believe that most people try to act in a reasonable and just faashion. But there are others.... And the terminology of "never event" only adds fuel to the fire of frivolous and ridiculous malpractice claims..

curious mind said...

Doubtful that that's actually what i "implied", Dr. Buckeye.

Simply replied to Anon's "NO study (ZERO) has ever lowered the risk to zero" statement. Let's try not to read between the lines, shall we?

Buckeye Surgeon said...

curious: There are no studies that will demonstrate a way to reduce DVT's to zero. That's not an excuse. That's just the way it is. Human physiology if you will. Maybe I'm not following you but I just don't see your point. You were the one who brought up "IVC filter" as a way to prevent PE. There are defined indications for filters and the mere presence of a DVT is not one of them.....

Anonymous said...

in military medicine, IVC filter is indicated on patients that have shattered lower extremities; it is a mean (albeit an invasive one) to prevent pulmonary embolism.

tyro said...

Even IVC filters do not lower the risk of PE to zero and they do nothing for VTE disease in general. In addition, they are invasive and prone to migration.

It appears from your post that you have not yourself made the decision to place an IVC filter. Neither have I, but as a resident I've assisted and followed. The idea of a shattered trauma patient somehow having their risk of VTE lowered to zero while also having a zero risk of UTI while zonked on Propofol so they can't pee and no wound infection when they were dragged along the ground by their motocycle and no pneumonia even though they barfed on the ambulance because their BAL was 0.35...you get my point.

EVERY medical treatment is a balance of risk and reward. Should I stop doing LP's because it can cause headaches? Perhaps I should stop intubating. If the airway is difficult and I have to do a second pass the risk of hypoxia is about 11% or so. I guess I'll just let them die. The helicopter will fly me to the accident site and I will say, well, I'd hate to intubate this young pregnant woman who is having trouble breathing. She might get pneumonia and a UTI. Wouldn't want a NEVER event to occur.

People have the right to ask. They have the right to know that it was a hospital acquired infection, or that a mistake occurred. But to just say as a blanket statement that they won't pay...it's offensive and counter-productive and frankly will lead to foleys not being placed and surgeries not done.

Anonymous said...

Perhaps Dr. Buckeye or other docs can shine more light on what inferior vena cava (IVC) filter does and what its limitations are. A simple online search tells us (the public/laymen) that there are some models that are retrievable after placement. Don't think anyone here claims any method to be able to lower the risk of pulmonary embolism (PE) to ZERO; we are simply talking about lowing the risk to acceptable level on high-risk patients.

Anonymous said...

Buckeye:
I checked out the link you referenced about a "cottage industry" of attorneys springing up to gobble up these new "never event cases" http://www.zifflaw.com/NYInjuryLawBlog/ny-medical-malpractice-lawyer-explains-medicare-never-events

It was simply a firm commenting on the issue, just like you are doing the same here. And I'm telling you that just as hospitals and doctors are struggling to decipher the intended and unintended consequences of this new paradigm, so are many of us. It really will not change my analysis of cases I look at, and the quantum of proof necessary in a climate where Drs win 76-80% of all malpractice cases. Just one lonely man's view of things on the other side...

Buckeye Surgeon said...

Anon-
Fair enough. But you have to admit that the wording of "never event" is confusing and may lead to more patients seeking "opinions from attorneys" with regard to these issues. The language of the new designation is simply inflammatory.

Anonymous said...

A couple of points:
1: Though it intuitively make sense that trauma (such as military/car accident) patients would get an IVC filter before a long hospitalization (and multiple procedures) as has been happening of late, my understanding is that there have not been large randomized trials on the subject in this setting. Granted I have not researched the subject thourghly, correct me if I am wrong. Ethically a large randomized trial may be an issue. That stated, the trend now is for high-risk (MVA trauma, severe military, severe orthopedic injury) to get a retrievable filter. Elective orthopedic patients do not fall into that category and hence do not get the filter. An IVC filter does not negate the risk of PE and does nothing for the risk of a DVT. A PE could arise from the upper extremities, above the IVC, or come from a clot that went through the filter. A filter does not lower the risk to zero. IVC filters are typically made to be retrievable but I have seen multiple patients whose filter went beyond the one year cutoff. Guess what, they now have a permanant filter. Filter struts have migrated through the IVC wall (obviously not good). Also, severe lymphoedema has ocurred related to clotting of the and below the filter. I suspect trying to get one of these filters out is a vascular surgeon's worst nightmare. In short, Filters are not indicated except for high-risk or known PE settings.

2: Sorry anon 9:34 but IMO you are wrong. Let's look at some of the language from this blog writer

"These are events that should NEVER occur in a proper medical setting. In other words, if the medical providers are doing what they are supposed to be doing, these events should NEVER, EVER occur." ........ "In other words, if the Dr’s or hospitals screw up and hurt someone, Medicare is saying the Dr’s or hospitals don’t get paid"......

......"Hallelulah! Now that makes sense– instead of the medical providers getting paid more when they screw up, now they get paid nothing when they screw up."

"Looking over the list of events that should NEVER occur, I am not surprised to see many of the types of events for which I have handled medical malpractice cases over the last 20 years....
– pulmonary embolish after surgery,
–infections, etc.
......
Although I am not surprised to see these things on the Never list, it makes me wonder why the Dr’s, Hospitals, their insurance companies and defense lawyers, fought me tooth and nail for year after year attempting to claim each and every one of these things could happen even though no one screwed up. Hmmm, I wonder….. I always thought that was a crock of bull.....

Please Anon 9:34 this article is NOT a firm "JUST COMMENTING" on the issue. This writing is literally dripping with inflammatory and accusatory language. You don't use inflammatory language like "Screwed up", "crock of bull", etc, when "just commenting" about an issue (except maybe in law but not the real world). Mark my words practices are going to use these "never events" as described by medicare to aid in malpractice suits. Come on now, be a little less biased and open your eyes. Surgery on the wrong part, instruments left in a body cavity, ABO blood incompatability clearly fall into the Never event category. Post arthroplaty DVT/PE's? No way. Tell me who would YOU believe on the subject of DVT's/PE's in this setting being nevr events? CMS...federal employees in Washington who haven't managed a patient in years (if ever) or the American Society of Hematology? Personally I think the answer is obvious, but then again I am a doctor in practice not a lawyer or government flaky.

Anonymous said...

Along the same line: "Arrogant, Abusive and Disruptive — and a Doctor," declared one NYTimes author. How much more eye catching (or heartburn inducing) can it get?

platensimycin said...

Likewise, doctors author NY Times articles too - "The Six Habits of Highly Respectful Physicians" by M.W. Kahn MD

Thomas A. Sharon, RN, MPH said...

Certainly there is a clear delineation between events that should never happen like leaving a 70 year old man (post surgery) lying in his excrement for four hours to punish him for defecating in the bed, and complications that are sometimes unavoidable like DVT's or bladder infections with indwelling catheters. There are clear cut cases on both ends and there are cases that fall some where in the middle where we really can't know whether it was avoidable or not. The fact that DVT's and bladder infections are on the NE list give rise for some concern. The solution is to take all of the necessary precaution to prevent those complications and document it. If your going to assert that the complication was unavoidable despite the best of care you will have to prove it with your documentation. Otherwise make sure your malpractice premiums are paid up.

Doctors, nurses and corporate executives have to be accountable and accept responsibility for the fact that medical and nursing error is the fifth leading cause of death in the America today. Taking responsibility, providing meticulous care and documenting everything is about all you can do. But if you do that and hire a QA consultant to look over your shoulder once in a while all of a sudden the unavoidable stops happening.