DC Medical Malpractice & Patient Safety Blog

As noted many times on this blog, nurses are the patient safety mainstays of good hospital care. So should hospitals be required to maintain a minimum nurse-to-patient ratio? California has done so, and nurse Theresa Brown wrote an op-ed recently in the New York Times discussing a proposed federal mandate (which seems to be going nowhere).

Now several nurses have interesting responses to the mandate issue in the Times' letters column, including this one:

As a staff registered nurse on a busy medical telemetry floor in a Midwestern hospital, I can certainly sympathize with Ms. Brown’s assertion that mandatory nurse-patient staffing ratios can improve patient care and save lives. But I disagree with legislative action to accomplish this end.

Patient acuity and staffing, as Ms. Brown well knows, are complex and individual issues that require thought and attention rather than bureaucracy. Nurses are not warm bodies with a nursing license. Nursing excellence and better patient outcomes can be achieved only with a well-educated, properly trained nursing staff dedicated to our profession.

Mandating staffing ratios will further destroy the idea that nurses can speak for themselves. Our voices are already a dim whisper in a discordant health care debate. The fragmentation of our care, increased patient complexity and the existing nursing shortage compound our difficulties in providing safe care, but one arbitrary staffing law will not fix this.

As an R.N., I’ve safely cared for seven surgical patients at night, and have had days when three acutely ill patients seemed too many. Our professional judgment as nurses is sophisticated enough to determine our staffing needs, and a well-run hospital will support quality care at every level, especially nurse-patient ratios. Let us not as nurses turn over yet another decision to someone else, especially legislators.

Jennifer Abraham
Normal, Ill.

Many other nurses favor mandatory minimums and look for other ways to assert nurses' autonomy.

One solution might be to require full disclosure of average nurse-to-patient ratios in hospitals. That would let patients readily see which local hospitals try to cut dangerous corners with their staffing.

It's such a relief to get a family member home from the hospital that many of us don't realize how crucial the next few weeks are in making sure the patient stays home and gets healthy. Hospitals don't always help the situation by giving out confusing and cryptic discharge instructions.

For this especially vulnerable time, patients and their family caregivers need to be very clear -- before leaving the hospital -- on the following key areas:

1. Is professional therapy needed? Physical therapy, occupational therapy, wound care and other types of care can sometimes be managed at home, as long as you have a caregiver willing to come to the house. If not, the patient may need to go to a transitional place first: a nursing home or rehab facility.

2. When is the next doctor appointment and who with? Don't leave the hospital without a specific appointment with the patient's primary care doctor. The hospital should help set up this appointment. The sooner after discharge this visit happens, the better the patient's odds of avoiding a readmission to the hospital.

3. What medicines need to be taken, and when? Insist on a specific list that takes into account whatever the patient was taking before the hospital stay and also whatever they need now.

4. Who do we call with any problems? The hospital's discharge instructions need to list a contact name and number, and also should say the types of problems that are worth a call.

5. What else do we need to do? If a family member is expected to give care -- like changing a dressing or helping the patient to walk -- make sure those instructions are precise and in writing.

The bottom line on all the above is that family members, especially when it involves an elderly patient, need to be very very clear on everything they need to know and do.

Here is a downloadable model form of a written discharge instruction sheet. This is from the Society of Hospital Medicine, a group of doctors who specialize in hospital care. Patients and families can use this template to make sure there are no gaps in what they need to know for a successful transition home.

The number is 1-800-MEDICARE (800-633-4227). It only applies if the patient is on Medicare, but it also works for protests of discharge from nursing homes too. The operator will send you on to your local Medicare QIO -- Quality Improvement Organization, a little-known patient safety organization that has power to investigate and reverse dangerous decisions by hospitals and other caregivers that want to send home a patient too soon.

Thanks to Karen Jones of the Oregon QIO for posting this phone number in a NY Times blog on patient discharge planning. She adds:

For more information about the QIO program activities, including a 14-state care transitions project aimed at reducing hospital readmissions, visit http://www.cms.gov/QualityImprovementOrgs/.

More about QIO's is in my book, "The Life You Save." The QIO is also useful if something bad has already happened to a loved one in a hospital or nursing home. You can request an investigation by the QIO, and thanks to a legal precedent won by Public Citizen, the QIO is required to tell you the results of their investigation. (In the old days, the QIO's were directed by the central Medicare office to invoke the veil of "confidentiality" to keep patients in the dark about what had really happened to them.)

The greatest fear for any patient in the hospital, and the biggest nightmare for their families, is that something will go wrong suddenly and no one will respond until it's too late. Beeping monitors are no help if their alarms go unheeded. Patient safety experts know that one basic way to keep patients safe and prevent death or injury from malpractice is to have enough nurses on hand.

How many is enough? Nursing leaders got the state of California, after a 10-year fight with the hospital industry, to mandate minimum nurse-to-patient ratios: one nurse for every five post-surgery patients, one nurse for every two intensive care patients, one nurse for every four children in the pediatrics ward.

If you have a family member in the hospital, these numbers are worth keeping in mind. Ask the bedside nurse how many patients he or she is in charge of. And don't let hospital management confuse the issue by pointing out how many aides they have. Aides can plump pillows and give other comfort measures. But only a nurse can recognize when a patient is in peril and give lifesaving treatment.

A new study by a nursing professor at the University of Pennsylvania, Linda Aiken, asserts that mandatory minimum nurse-to-patient ratios like California's could prevent as many as 14 percent of post-surgery deaths in New Jersey hospitals and 11 percent in Pennsylvania.

Another important outcome of ensuring that nurses aren't overwhelmed by too many patients is that nurse burnout and job turnover go down, and overall quality of care improves, according to the study.

Theresa Brown, an oncology nurse in Pittsburgh, has an op-ed piece in the New York TImes asking why bills in Congress to mandate minimums nationally haven't gone anywhere.

Saving money, of course, is the issue. But that's a penny-wise answer. Saving lives can be a lot cheaper in the long run.

If you had chicken pox as a kid, you have a one-in-three chance of developing shingles in your old age, and that can spell months or even years of searing pain. There's an effective vaccine to protect against shingles, but it's seldom used, and therein lies a story of the inadvertent clash between patient safety and insurance reimbursement practices.

Shingles is a re-eruption of the old chicken pox virus (known as herpes zoster) that sits dormant in the body of anyone who had childhood chicken pox. Shingles hits about one million Americans each year, and it's very hard to treat. It can go anywhere in the body, and victims often say the pain is worse than bearing a child -- and it lingers much longer too.

A new vaccine, approved by the FDA in 2006, can cut the risk of shingles by more than half, with just a single shot in the arm. The vaccine is now recommended by the Centers for Disease Control for anyone over age 60.

But only around one in twenty people are getting the shingles vaccine, according to a survey of primary care doctors by researchers at the University of Colorado, published in the Annals of Internal Medicine, and discussed by Dr. Pauline Chen in a column in the New York Times.

The culprit is money. The vaccine costs $160 to $195 per dose, and both private insurers and Medicare require patients to pay up front and get reimbursed later. Many doctors' offices, which lose money when even one in ten patients doesn't pay their vaccination fee, have stopped stocking the vaccine, and it's not much easier to get by taking a prescription to a pharmacy, according to the article.

Dr. Laura Hurley, the lead author of the new study, told the Times:

“Shingles vaccination has become a disparity issue. It’s great that this vaccine was developed and could potentially prevent a very severe disease. But we have to have a reimbursement process that coincides with these interventions. Just making these vaccines doesn’t mean that they will have a public health impact.”

Elderly people are particularly vulnerable to shingles because they often have a less robust immune system to fight off the virus. And if you've known anyone who has had an episode of it, the cost of the vaccine seems cheap compared to the suffering that could be avoided.

Here's an informative web page from the CDC with answers to common questions about the shingles vaccine.

Sometimes patients sign up for surgery with an experienced surgeon who then allows a doctor in training, with far less experience, to do the actual surgery. If this hasn't been disclosed up front by the surgeon and agreed to by the patient, the switcheroo is called "ghost surgery," and it's not acceptable. But exactly that has now occurred at the prestigious Cleveland Clinic, according to allegations in a new malpractice lawsuit reported by Diane Suchetka in the Cleveland Plain Dealer.

Retired Air Force Colonel David Antoon says in his legal complaint filed in court that he, his wife, and the surgeon, Dr. Jihad Kaouk, signed a consent form in advance agreeing that only Dr. Kaouk would do the surgery to remove Mr. Antoon's prostate gland. He alleges in the suit that he has been left incontinent of urine and sexually impotent as a result of Dr. Kaouk allowing junior doctors to do the surgery.

The patient also contends that the hospital ombudsman who investigated his informal complaints told him there was no such consent form in his records at the hospital.

Surgical volume is critically important to a good outcome for prostate surgery, as previously reported on this patient safety blog. The author of one study in the Journal of the American Medical Association said he didn't feel comfortable about his own competence with the "robot" device now widely used for prostate removal until he had had several hundred cases under his belt. So it's understandable why Mr. Antoon would feel outraged that his wishes weren't followed.

I discussed "ghost surgery" in my book, "The Life You Save." Here is my advice for how you can avoid having this happen to you:

First, have a good discussion with the surgeon about who is going to do the critical parts of your surgery. If you don't feel comfortable turning over those aspects of the surgery to a doctor in training, then say so.

Second, follow up by putting it in writing. One simple way to do so is on the consent form. It usually says something like "I authorize Dr. Jones and/or his designee to perform _____ [type of surgery filled in here] on me." All you have to do is cross out the phrase "and/or his designee" and initial your cross-out.

Third, if you're in a teaching hospital, you might want to consider some compromise that lets trainee doctors do the non-critical parts of the procedure. But you have every right to insist that only the experienced doctor do the delicate, critical work. If the surgeon resists your wishes, you may have to go to another surgeon.

A new report comparing the United States to other industrialized countries has a depressing list of all the ways that America outstrips other countries in money spent but lags behind in health quality results. For example:

* Per person, the U.S. spends twice as much on health care as on food, and much more than the average Chinese person spends on EVERYTHING. (See slide #1 of the interactive graphic of the McKinsey Global Institute report here.)

* "Branded" prescription drugs are 77 percent more expensive in the U.S., and because we use a more expensive mix of drugs than other countries (being quicker to adopt new and expensive drugs), the average spending on drugs per person is more than double other industrialized countries. (Slide #8.)

* We lag behind 22 other advanced countries in life expectancy but spend around $650 billion more per year than our population's mix of health conditions would predict. (Slide #4)

* Administration costs -- paperwork, claims processing, etc. -- are on average five times more expensive in the United States. (Slide #9.)

* The care in the U.S. is much more intense than elsewhere -- more expensive surgical procedures, more diagnostic tests, but we spend less on prevention than elsewhere.

* We also are shifting more to outpatient care instead of care with overnight stays in hospitals, but that has not cut costs. The outpatient care is much more profitable for providers than inpatient care, and it tends to be more intense.

The New York Times did some arresting graphics on the McKinsey report. Click here to see them. Note that the U.S. appears as a red dot, "peer" European economies like Germany and the UK are yellow dots, and other industrialized countries are gray dots.

The red dot never wins on these graphs -- except on expense.

Recent news on this blog about unnecessary heart stents in Baltimore and overly complex back surgeries across America may give some readers the wrong idea. This malpractice and patient safety blog is not about good versus evil and picking a doctor to trust because you decide he or she is a "good" trustworthy person. Instead, it's about recognizing that doctors are human too and are subject to the same self-interest as the rest of us -- and this can subtly tilt them to make recommendations for treatments that may not really help us.

I was struck by this when reading a letter to "The Ethicist" column in the New York Times Magazine. The writer was a husband whose wife had been told she needed a CT scan, and the doctor sent her to a radiology lab that he owned. The husband said: "I'm OK with this lab -- I say you either trust the specialist or you don't -- but my wife is not so sure."

Columnist Randy Cohen responded by quoting bioethics professor Katie Watson of Northwestern University:

"I trust my physicians not to be criminals who intentionally order unnecessary tests to feed their yacht habits. I also trust them to be human beings, which means they're vulnerable to subconscious influences and incentives just like the rest of us."

That's exactly right.

This is not to excuse those doctors who create conflicts of interest for themselves that they could easily avoid. There's no reason to buy a CT scanner for your office when there are plenty of others available.

Nor is it to excuse the doctor for failing to disclose up front to the patient that he has an ownership interest in the imaging machine. Patients shouldn't have to cross-examine their doctors to get this basic information.

But it is to say that patients need to learn how to be sophisticated consumers of the medical industry. This is not a question of "do I trust or don't I?" And it's not a matter of trading naive trust for paranoid suspicion. It's just to recognize that we're all human, and that the medical industry unfortunately has many built-in conflicts of interest for doctors that require patients to look out for themselves when it comes to getting sound medical advice.

So ask lots of questions, do your own research, and get second and third opinions. You'll be healthier for it.