Patient Safety--Your Lifestyle

“Jaded Julie, I have some good news and some bad news.”

“(Oh, no! Here we go again.) Proceed, Professor. I’ll be hanging on every word.”

“The bad news is that the likelihood of our emerging from this game called ‘life’ unscathed is zilch, i.e., the ultimate mortality rate is 100%. The good news is that most of us will have a chance of influencing the ‘how’ and maybe even the ‘when.’”

“Okay, Curmudge. First you said that we are doomed, and then you sounded as if you had found the Fountain of Youth. Which is it?”

“I doubt that there’s much we can do to extend our life, but there are lots of ways to avoid shortening it. If you believe your life is to follow some sort of grand design, you should avoid a lifestyle that might circumvent the plan.”

“I’ve got it, Curmudge. I read Dr. G’s book (1), and she comes down pretty hard in favor of a healthy lifestyle. As a medical examiner, she is able to describe in intimate anatomic detail what your insides look like when things go wrong. I wouldn’t want to be caught dead looking like that.”

“Nobody would, Julie. However, most of us simply ignore what we know about healthy living. What we need is a good jolt of reality to bring us to our senses. Dr. G does that. Here are some quoted or paraphrased examples:

‘Where healthy lungs are pinkish, a smoker’s lungs are gray and ribboned with black pigment.’

‘The tumor (from advanced lung cancer) …pushed through the wall of his lung into his pulmonary artery. Like a bursting dam, blood began to flow through the hole, filling his lungs.’

‘In the mouth of the corpse was some dark brown material that looked like coffee grounds that we doctors call coffee-ground vomitus. It’s often a sign of gastrointestinal bleeding. In the retroperitoneum there was a pus-filled abscess (from MRSA).’

‘Diverticulitis is a potentially lethal condition often associated with a low-fiber diet and lack of exercise. This condition begins as diverticulosis, the presence of pockets or protrusions in the wall of the colon. Diverticulitis can sometimes lead to perforation of the bowel and an infection in the abdominal cavity.’

‘One who is 100 pounds overweight is characterized as morbidly obese. Diagnosis using an ultrasonogram is more difficult when it is taken through layers of fat. People who are obese run a higher risk of coronary heart disease, stroke, high blood pressure, some cancers, diabetes, gout, arthritis, gallstones, infertility, injuries due to falls, sleep apnea, fatty liver disease, and post-surgical blood clots.’

‘Methamphetamine has a decomposing effect on the body while you are still living. Many addicts have black, rotting teeth, worn down to stumps. They tend to scratch nervously (because of a sensation of imaginary bugs crawling under their skin), causing sores and lesions on their bodies.’”

“Enough, Curmudge! You have my attention. Aren’t there some lifestyle lessons that are less graphic?”

“Of course. Here’s one: ‘Chewing tobacco contains 28 carcinogens.’”

“You know, Curmudge, chewing tobacco was pretty popular during the Civil War. Maybe that’s why all of the Civil War veterans are dead.”

“I can’t fault your data, Julie, but I do question your conclusion.”

“A final question, Curmudge. What does lifestyle have to do with patient safety?”

“The best way to be a safe patient is not to be a patient at all. We hope to achieve that by living a healthy lifestyle and, as we’ll discuss next week, minimizing accidents and trauma. It’s as we said in our discussion on January 29, ‘To avoid a hospital-acquired infection, stay out of the hospital.’”

Affinity’s Kaizen Curmudgeon

(1) Garavaglia, Jan. How Not to Die: Surprising Lessons on Living Longer, Safer, and Healthier. (Crown Pub., 2008)

Patient Safety--Human Factors

“Curmudge, everything we’ve talked about in the past two months has to do with human factors in patient safety. You do remember, don’t you?”

“Of course. But today ‘human factors’ is just a euphemism for, ‘No one is perfect, but some people are less perfect than others.’”

“A euphe…what? Well it does sound nicer than, ‘Some people mess up.’”

“Okay, Jaded Julie, let’s start with the ‘no one is perfect’ premise. Can you balance on just one foot?”

“(I guess I’d better humor the old guy.) Yes, but for only 10 or 20 seconds.”

“My next question would be, ‘Why not all day?’, but I already know the answer. Perfection is transient; you get tired and distracted; and you are demonstrating necessary fallibility (1). Humans are not infallible. That’s why we can’t say, despite our best efforts, that there will never be another medical error. Of course we must make those best efforts so that the inevitable errors are few and far between.”

“What about diagnoses, Curmudge? Everyone knows that they are not always correct. I have read that about 15% of all patients are misdiagnosed (2). Condition A is unlikely to be cured if an incorrect diagnosis suggests that it is Condition B.”

“Diagnosis is a BIG topic, Julie; it’s discussed at length in Groopman’s book referenced below. He advises patients to ask their doctor these three questions when he/she is making a diagnosis: (a) ‘What else could it be?’ (b) ‘Could two things be going on to explain my symptoms?’ (c) ‘Is there anything in my history, physical examination, laboratory findings, or other tests that seems not to fit with your working diagnosis?’”

“It seems as if the errors that occur in surgery are the ones that make headlines. Although it is rare, wrong-site surgery is hard to overlook. But even a little nick of the wrong organ can make recovery a lot more difficult. These must be caused by reasons other than necessary fallibility.”

“Right, Julie. Two other types of errors are those that are knowledge-based and those that are skill and experience-based (1). One would expect a surgeon to have the requisite knowledge, but of course he has to perform the surgery on somebody to gain skill and experience. If you are going in for surgery, ask the doc how many times he has performed the procedure. If it will be in a teaching hospital, request the attending physician; let the residents learn on someone else.”

“Teamwork must be critical in the OR. Is it?”

“Teamwork is certainly essential, but recent literature suggests that it is not the major source of surgical complications (3). ‘After surgical technique, most surgical error was caused by human factors: judgment, inattention to detail, and incomplete understanding, and not to organizational/system errors or breaks in communication.’ Fortunately, complications and mortality can be reduced by use of surgical checklists (4).”

“I don’t know about you, Curmudge, but after hearing what you said, I’m afraid to get sick.”

“As usual, Julie, you’ve got that right. Being healthy beats being sick any day. Maybe we both should go back and read Jan Garavaglia’s book that we referenced two weeks ago (5).”

Affinity’s Kaizen Curmudgeon

(1) http://www.emsresponder.com/print/Emergency--Medical-Services/Fallible-MEDICINE/1$5773
(2) Groopman, Jerome. Why Doctors Make Mistakes. AARP p.34-35 (September/October 2008). Based on Groopman’s book How Doctors Think. (Mariner, 2008)
(3) http://www.ncbi.nlm.nih.gov/pubmed/18847639
(4) http://www.mdconsult.com/das/news/body/117277367-2/mnfp/0/204709/1.html?nid=204709&elshs_ca1=enews&elshs_ca2=email&elshs_ca3=20090120&date=week&pos=&general=true&mine=true
(5) Garavaglia, Jan. How Not to Die: Surprising Lessons on Living Longer, Safer, and Healthier. (Crown Pub., 2008)

Patient Safety--Falls

“So you know something about falls, Curmudge?”

“I am familiar with their effects, Jaded Julie. Mrs. Curmudgeon has a propensity to be vertically challenged.”

“Propensity? Vertically challenged? That must mean that she falls a lot.”

“Regrettably, she tends to fall on her face. She sometimes gets a giant hematoma over one eye or the other. Her face gets discolored, her eye is swollen shut, and she looks like a battered woman. And I get an undeserved reputation as a wife-beater. Surely we can do a better job of shielding our patients from falls than I have done for my wife.”

“We are, Curmudge. Our Fall Assessment and Prevention Kaizen Event in the summer of 2008 was classic Lean. We had a great team that represented a cross-section of disciplines in the hospital. They broke into two simultaneous events to tackle the fall assessment process and standard work for use of fall prevention tools and techniques. Each collected data and considered the present state and desired future state for patient fall assessment and prevention.”

“So what did the data on the present state tell us, Julie?”

“For our three hospitals, the overall fall rate was 3.77 falls per 1,000 patient days. That’s not too bad, but experiencing a fall every 34 hours shows the need for improvement. We’d like to get the fall rate down to 3.4 in 2009 and 2 in 2011.”

“After evaluating our present state, I presume that the team developed a path forward.”

“They created a fall assessment tool for identifying those patients at high risk of falling and also a plan for communicating the tool to our nurses. Standard work was developed for implementing fall prevention techniques and for post-fall assessment and care. A Fall Alert Team was created to respond to all falls within the hospital. The fall prevention protocol will include 1-hour checks of all patients and 30-minute checks for fall-risk patients. The checks will include the Four Ps (Pain, Potty, Position, and Prevention). Some patients will need 15-minute checks or 1:1 care. Technical aids, such as motion sensors, will also be utilized.”

“Other hospitals have most likely tackled the problem of patient falls. Has their work been described in the open literature?”

“You know full well that it has, Curmudge. Ascension Health, the largest not-for-profit health care system in the country, has conducted an extensive program to prevent falls and eliminate falls with injury (1). Their key strategies were:
Assessment and re-assessment of patient risk factors for falls,
Visual identification of patients at high risk,
Communication of patient fall risk status, and
Education of patients, families, and staff about fall prevention.”

“The paper reminds us that falls are the leading cause of injury deaths among adults aged 65 and older. Our team undoubtedly benefitted from the report of Ascension’s experience.”

“Curmudge, our hospitals are making good progress in minimizing inpatient falls, but what can we do to help your ‘vertically challenged’ wife?”

“Maybe I can convince her that wearing a gait belt is the latest fashion. Then I can grab it when I see her start to fall.”

“Yeah, Curmudge. And you’ll both end up in a pile on the sidewalk.”

Affinity’s Kaizen Curmudgeon

(1) Lancaster, A.D., Preventing Falls and Eliminating Injury at Ascension Health The Joint Commission Journal on Quality and Patient Safety, vol. 33, no. 7:367-375 (July 2007).

Patient Safety--Infections 2

“Jaded Julie, back in my professorial days I was advised never to teach everything I know about a topic.”

“But you’ve been violating that rule almost weekly for the past year-and-a-half, Curmudge. And now you are going to teach health care professionals how to minimize nosocomial infections? Isn’t that rather presumptuous for someone whose current intellectual occupation is lawn mowing and snow blowing?”

“Wrong, Julie. As I’ve said before, a blog doesn’t teach. A blog inspires, reminds, refreshes, and sometimes incites; but it’s too short to teach.”

“Okay, have at it. But be sure to cite references so our readers will realize that the info we are passing along is from people who know what they are talking about.”

“To begin, I think health care workers should read last week’s blog to get a ‘heads up’ on what patients are expecting. Then you won’t be surprised when a patient asks you to swab your stethoscope with alcohol (1). And a male physician should be careful not to drag his never-cleaned necktie across a patient’s tummy during an examination (2). In addition, they should jog their memory by skimming Wikipedia’s overview on nosocomial infection (3); there are topics there that we won’t have space to cover.”

“Golly, Curmudge, after reading some of the papers you found I’ve become convinced that many surfaces in patient rooms are coated with invisible creepy-crawly drug-resistant bugs like MRSA and Clostridium difficile (4, 5). Control of C. diff. requires cleaning surfaces with bleach, and hands must be washed with soap and water; alcohol-based hand sanitizers are not sufficient (5). When using soap and water, you know you’ve scrubbed long enough when you have sung ‘Happy Birthday’ twice.”

“Hospital patients are usually in poor health and have impaired resistance to bacterial infections. Because that is likely with patients with central lines or on respirators, IHI has published ‘bundles’ of evidence-based practices to minimize central line blood stream infections and ventilator-associated pneumonia (6). We talked about these back on October 23, 2008.”

“Okay, Curmudge, suppose your are a bacterium living in a hospital and want to impress your friends by infecting someone. How would you do it?”

“I’d head for the OR. It’s a really big score for a bug if he can cause a surgical site infection. Hopefully, I would get a ride into the OR on equipment, clothing, or the patient himself. Once there, I would try to find a way into the sterile field, possibly by someone’s lapse in gowning, gloving, or aseptic technique (7). The likelihood of my succeeding is increased if there are several trainees in the OR (in a teaching hospital), if the operation is of long duration, and if the patient requires a blood transfusion or is not kept warm (8, 9).”

“But what would happen if the patient received a prophylactic antibiotic within one hour prior to surgery?”

“If it were not an antibiotic to which I am resistant, my career would go south in a hurry. The life of a bacterium is not without risk, y’know.”

“Well, Curmudge, since your microbial existence just got zapped, please return to your human curmudgeon role and tell me what you see as the bottom line.”

“I’d be delighted, Julie. Everyone from surgeon to housekeeper must learn, believe in, and practice a culture of protecting our patients from infections. It’s got to become ‘the way we do things around here.’ LEARN IT, BELIEVE IN IT, and DO IT.”

“(Hmm…sounds a lot like a religion.) I presume, Curmudge, that typing in all capitals means that you are shouting. If you continue to behave that way, we’ll have to find you a private office.”

Affinity’s Kaizen Curmudgeon

(1) http://www.hospitalinfection.org/protectyourself.shtml
(2) Garavaglia, Jan How Not to Die: Surprising Lessons on Living Longer, Safer, and Healthier. (Crown Pub., 2008)
(3) http://en.wikipedia.org/wiki/Nosocomial_infection
(4) http://articles.latimes.com/2007/feb/03/opinion/oe-mccaughey3
(5) http://www.hospitalinfection.org/cdiff.shtml
(6) http://ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/WhatIsaBundle.htm
(7) Affinity Policies 01689 and 01704
(8) http://www.medscape.com/viewarticle/585849_print
(9) Karl, R.C., Staying Safe: Simple tools for safe surgery. Bulletin of the American College of Surgeons 92 (4):16-22 (April, 2007).