Friday, June 3, 2011

The Unintended Consequences of Algorithmic, Bureaucratic Medicine

Whenever someone is scheduled for an operation, the assigned nurse is required to fill out a "pre-op checklist" to ensure that all safety and quality metrics are being adhered to. Before the patient is allowed to be wheeled into the OR we make sure the surgical site is marked, the consents are signed, all necessary equipment is available, etc. One of the most important metrics involves the peri-operative administration of IV antibiotics. SCIP guidelines mandate that the prophylactic antibiotic is given within an hour of incision time to optimize outcomes. This has been drilled into the heads of physicians, health care providers, and ancillary staff to such an extent that it occasionally causes total brain shutdown.

Let me explain. For most elective surgeries (i.e. hernias, lap choles) I give a single dose of antibiotics just before I cut. For elective colon surgery, the antibiotics are continued for 24 hours post-op. This is accepted standard of care. You don't want to give antibiotics inapprpriately or continue them indefinitely.

But what about a patient with gangrenous cholecystitis or acute appendicitis? What if, in my clinical judgment, I want to start the patient on antibiotics right away (i.e. several hours before anticipated incision time) and then continue them for greater than 24 hours post-op, depending on what the clinical status warrants? I should be able to do that right?

Well, you'd be surprised. You see, at two different, unaffiliated hospitals I cover, the surgeons have seen that decision-making capability removed from their power. If a young patient comes in with acute appendicitis and I feel that it would be prudent to continue the Zosyn an extra couple of days, an automatic stop order is triggered in the department of pharmacy and the antibiotic is stopped after 24 hours, no matter what. Unless the surgeon specifically writes "please do not stop this antibiotic after 24 hours; it is being administered for therapeutic purposes, not prophylaxis", the antibiotic will not be sent to the patient's floor for administration. As a result, patients end up being treated sub-optimally, and potentially harmed, due to an over-emphasis on "protocol" and "quality care metrics".

Similarly, the 60 minute timeline for preoperative antibiotic administration can be problematic. I have had patints come into the ER with appendicitis or cholecystitis and, in my pre-op orders, write for Zosyn or whatever, to be started ASAP, no matter what time the operation is scheduled. Not too long ago, I admitted a gallbladder over the phone at 2am. I gave the nurse admitting orders which included one for a broad spectrum antibiotic.

When I saw the patient in the morning, I added her on to the OR schedule. By the time a room opened up, it was about 1030AM. The OR nurse asked me if I wanted to give an antibiotic for the case. I told her that the patient was already on antibiotics as part of her admit orders for treatment. The nurse shook her hand. It had never been given; the floor nurse held it so that it wasn't administered until 60 minutes before the scheduled OR time, just like the algorithm dictates--- despite the fact it had been ordered nearly 8 hours prior to the case, not for peri-op prophylaxis, but for treatment of an established pathology. And there it was, the cefotetan, hanging on her IV stand. Now nothing bad happened but here you have a situation where health care providers are so terrified of violating Quality Assurance Protocol that they end up withholding necessary treatment. It's just astounding.

As surgeons, we have bitched and moaned. You would think that these issues would be quickly rectified. But no. It is the responsibility of the surgeon to write qualifying statements for therapeutic antibiotics because the default mode is to override a licensed physician's clinical judgment. This is what I'm talking about when I say that blind allegiance to a top-down, systems analysis-driven algorithm can turn everyone involved in health care into a bunch of mindless drones.

Errata- In a previous iteration of this post, I mistakenly substituted NSQIP for SCIP. I mix them up all the time. The above version is now correct.

12 comments:

Health Train Express said...

Jeff, glad to see you are blogging more regularly, must be the night shift with little buckey. BTW neat kid !! Congrats !

Josh said...

Happens every day. The other manifestation is the surgeon or anesthesiologist just giving a dose of Ancef in the OR to someone already on a therapeutic antibiotic. People just shrug their shoulders and say, "So we don't a strike against us", even though the SCIP protocols don't apply in this situation.

Anonymous said...

Buckeye, I admit burocracy sucks, I remember when they started requiring a separate "Consent for Anesthesia" which was a total waste of time, paper, and Flumazenil, cause signing the surgical consent implies that your OK with gettin some anesthesia, but if I had a dime for every patient I had to help scrawl there "X", I'd have about as much money as Lebron James/Jim Tressell/Terrell Pryor...

Frank "SEC RULES!" Drackman

Skeptical Scalpel said...

Great post. I agree with you completely. My favorite thing about the pre-op checklist is when it's 2 am and you've just brought a patient with a knife sticking out of his abdomen to the OR. True story.

Circulating nurse: "Let's do our time out. Have you marked the skin?"

Me: "Yes. I wouldn't want to confuse him with any of the other patients with knives sticking out of the abdomen"

Joe said...

What eventually happens with bureaucratic edicts is they become ignored and compliance is lip service. This is in fact the worst of both worlds - 1) They are absorbing the overhead and 2) They are not doing the checking, and 3) It all becomes a laughed at lie.

Exactly the opposite of intentions is what bureaucracy delivers. In almost all cases!

Anonymous said...

You are spot on Joe.

-SCRN

Joe said...

BTDT SCRN.

There is often no follow up to see if the dictates of bureaucrats cause harm or help. Indeed these same folks cry out for "evidence based medicine" except when you ask them for the evidence upon which they base their dictate.

That is the most confounding thing about the wonks too. Their policy is often supported at best by minimal, conflicting or extrapolated research. More often their reasoning is supported simply by story-like anecdotes or wishful thinking while they reject adverse event reports as meaningless.

Maddening! Worse, patient endangering.

Checklists and alerts and reminders are GREAT, and I mean that, but overriding a doctor's orders by policy enforced by a computer system? Who is liable for damages in that case, the MD?

Alice Robertson said...

If doctors feel powerless...what is a patient to do? And the changing tide will mean more cost cutting and not only do patients feel like a blur in the sea of faces....doctors shall to. It seems our entitlement mindedness is not creating better care....just hunger for more.....

You have identified a problem...but we still feel helpless....

Kellie (General surgeon) said...

Arrgh, happens so often. Scary and I have told my hospital administration and the pharmacy that if my patient has a postoperative abscess or complication that I think can lead back to the antibiotic being stopped by a NON-PHYSICIAN, or prevented being given to the patient by the same, I will be sure to tell the patient what exactly happened.

Besides, SCIP protocols do crap to change the postoperative infection rates, even when adhered to rigidly.

Anonymous said...

Everybody's world is being affected - in the ED we have the good old 4 hour to antibiotics for pneumonia rule - all based on some pretty weak data showing a small improvement in LOS without any M and M changes. The result - tons of people getting unnecessary abx in an era of ever widening antibiotic resistance.

Anonymous said...

I do see your overall point, but I see here a failure of user interface, not a failure of checklists. Of course, as an aerospace engineer, I'm rather biased towards checklists (though they're not the be-all end-all everyone thinks they are- ask a military pilot if they consult a checklist before executing a bombing run, and they'll laugh in your face). But still, if two glaring options were present at the bottom of every order: "Do exactly as instructed" or "Do as instructed under standard protocol", this problem of hidden bureaucracy could be mitigated, and perhaps even turned into part of the solution: double checking meds and the like isn't a bad thing, no?

Anonymous said...

Reading this as a non-physician, it seems the flaw isn't the computerization, but the design of the system. Why are there only single check boxes that are either toggled on or off, where an omission or automatic check can lead to errors? Shouldn't every option have two check boxes? One for "Follow standard protocols", whatever they may be, and one for, "Follow physician-specific orders," with a text entry field to specify those orders? Then, if neither box is checked, it can flag that you missed something so nothing is overlooked, which seems to be the main point of automating the system, to ensure nothing is forgotten/overlooked in the orders. If there are physician-specific orders, this could also flag a follow-up call at the time they are to be carried out if anyone else has a doubt about the reasoning...that would add a double-check to the system, rather than an automatic override that adds no checks in the system, just a new source for potential unchecked errors.