On March 24th, 2017. “Speaker Paul Ryan (R-Wis.) on Friday
said his party “came up short” in a news conference minutes after pulling the
GOP healthcare bill off the House floor, acknowledging that ObamaCare will stay
in place “for the foreseeable future.””
Yet on December 20th, 2017 the INDIVIDUAL MANDARE was
repealed. ““When the individual mandate is being repealed that means ObamaCare
is being repealed,” Trump said…“We have essentially repealed ObamaCare, and we
will come up with something much better…”
“Andy Slavitt, who served as the acting administrator for
the Center for Medicare and Medicaid Services under President Barack Obama,
warned late Friday night that Republicans may try to repeal and replace
Obamacare once again before the 2018 midterm elections. “Republicans have been
meeting in secret to bring back ACA repeal,” he writes…
… Santorum and others may think that there will be a “blue
wave” in 2018 no matter what, so this may be the last time the GOP has the
opportunity to get rid of Obamacare. And that might make Republicans desperate
enough to try again.” (R)
At the end of this post there are links to a series of over
60 posts tracking the activity between March 24th and December 20th. Laws are
like sausages,” goes the famous quote often attributed to the Prussian
Chancellor Otto von Bismarck, “it is better not to see them being made.”
In 2018, mostly under-the-radar, efforts are continuously
underway to continue to undermine what’s left of ObamaCare.
“Republicans, having failed to repeal Obamacare, have
stumbled, almost accidentally, into replacing it. For better and for worse, and
with little coherent vision at work, they are making Obamacare their own. And
over time, they are likely to embrace it…,
Congress has already repealed several unpopular parts of the
law as part of last year’s tax legislation — most notably the individual
mandate, which now expires at the end of this year, but also the Medicare
cost-control board (known as the Independent Payment Advisor Board).
The executive branch has exerted its own influence on the
law. In October of last year, President Trump signed an executive order calling
for the expansion of association health plans and limited-duration insurance,
in hopes of creating a secondary market for health plans that are cheaper and
less regulated, and this year, the administration released extensive proposals
for each. The administration also stopped paying the law’s cost-sharing
reduction subsidies, which reimburse insurers for low-income beneficiaries. And
the Department of Health and Human Services has begun allowing states to attach
work requirements to Medicaid, making the program more bureaucratic, but
possibly enticing red states that have so far declined to expand the program to
Having failed in their repeal effort, Republicans are now in
something of an arranged marriage with the health care law. These alterations
are being made in a predictably haphazard fashion, with little in the way of
guiding theory, but the cumulative effect is to turn Obamacare into a law that
they can, if not love, at least learn to live with.”(A)
“Bigger changes are coming. The administration has proposed
regulations that would allow so-called short-term health plans to be offered
for nearly a year of coverage. Those plans aren’t subject to any Obamacare
rules in most states, and are likely to be marketed aggressively. They are
likely to cover fewer health services and be available only to the healthy —
but at a lower price. Another pending rule would expand the availability of
association health plans, a form of group insurance purchasing that may be
attractive to small businesses looking for cheaper, less comprehensive
People buying those plans may face some unpleasant
surprises. The plans are likely to require applicants to fill out detailed
health histories, and to exclude those with prior illnesses. They also are
likely to exclude or limit services — like addiction treatment, maternity care
or prescription drugs — that all Obamacare plans require. Association plan
buyers have tended to have problems with fraud. And some short-term plans have
a history of declining to pay for serious illnesses after the fact.
But even if the new plans serve their customers well, their
popularity could leave the remaining markets a bit shakier. Because the
short-term plans will be open only to the healthy, the remaining customers will
tend to be sicker, and more expensive to insure.” (B)
“It’s been well documented that the Trump White House has
filled federal agencies with bureaucrats whose life work is destroying the very
agencies they’ve been assigned to. But one is in a better position than her
fellows to threaten the health of millions of Americans—and she’s been working
at that assiduously.
We’re talking about Seema Verma, who as administrator of the
Centers for Medicare and Medicaid Services also is effectively the
administrator of the Affordable Care Act. In the Trump administration, that has
made her the point person for the Trump campaign to dismantle the act,
preferably behind the scenes…
Still, Verma had spent enough time in the healthcare field
that observers thought she might not be totally egregious as CMS administrator.
But then, during her confirmation hearing in February 2017, she let on that she
didn’t see why maternity coverage really needed to be mandated for all health
policies, since “some women might want maternity coverage, and some women might
not want it…
It wasn’t an auspicious start. But since then she has lived
down to our expectations. Verma never has concealed her hostility to Medicaid —
especially Medicaid expansion, a provision of the ACA. Her animosity is fueled
at least in part by ignorance (willful or otherwise) about the program. Back in
November, on the very day that voters in Maine and Virginia were demonstrating
full-throated support at the polls for expanding Medicaid in their states,
Verma was unspooling a string of misleading statistics and suspect assertions
about the program to support a policy of rolling back enrollment.” (C)
“Passing two measures aimed at stabilizing the Affordable
Care Act marketplaces by infusing insurers with more funds would lower monthly
premiums by 20 to 40 percent and prompt an additional 3.2 million people to get
covered, says an attention-grabbing independent analysis released yesterday by
the firm Oliver Wyman.
These measures – which would pay insurers for extra
cost-sharing discounts for the low-income and reimburse them for their most
expensive customers – are currently stuck in political limbo as leaders on
Capitol Hill consider whether to include them in a massive, must-pass spending
bill next week.
The bills have become emblematic of inter and intraparty
disputes over how to approach a world with most of the ACA still in place.
Democrats are bitter that Republicans are still chipping away at parts of the
law by repealing its individual mandate and changing other provisions through
the executive branch…
And Republicans can’t even agree among themselves how to
handle the law now that they’ve failed to entirely wipe it from the books. (D)
“Republicans campaigned for roughly a decade, promising
voters they would dismantle former President Barack Obama’s landmark health
care legislation; but one of their own senators is trying to keep it alive
through the 2018 election cycle…
Sen. Lamar Alexander, R-Tenn., along with Sen. Patty Murray,
D-Wash., is using the deadline to sway leadership to include a proposal that
would fund politically contentious Obamacare subsidies through 2019. The
proposal would provide $10 billion a year for three years for these subsidies…
Additionally, the proposal would give states greater
Obamacare waiver flexibility and would broaden consumer eligibility for “copper”
plans. Abortion-covering health insurance plans would not receive subsidies
under the proposal…
Republicans are either not thrilled about Alexander’s
proposal, calling it a bad idea and one that could hurt the party going into
2018, or they think it could be one way to provide taxpayers some relief from
the financial burdens Obamacare imposed.” (E)
“The House passed the $1.3-trillion omnibus spending package
meant to keep the government running until Sept. 30 in a vote of 256-167,
leaving the Senate barely 35 hours to get the same legislation approved by
Friday at midnight to avert a shutdown.
The bill boosts funding for the National Institutes of
Health, the CDC, and the Department of Veterans Affairs (VA) as well as other
key agencies, but keeps funding flat for the Centers for Medicare and Medicaid
The bill also does not include the health insurance
stabilization bill from Sen. Lamar Alexander (R-Tenn.) and Sen. Susan Collins
(R-Maine). They had wanted the omnibus package to include measures restoring
for 3 years the cost-sharing reduction subsidies (monies that help insurers
defray out-of-pocket costs for low-income enrollees), establishing 3 years of
reinsurance (monies that help pay for the sickest of patients and keep premiums
from spiking) at $10 billion per year, and streamlining the 1332 waiver process
to allow states more flexibility in health plan design.” (F)
“The Trump administration hopes to move forward with a rule
expanding alternatives to ObamaCare plans by this summer, Secretary of Labor
Alex Acosta said Monday. The rule allows small businesses and self-employed
individuals to band together to buy insurance as a group in what are known as
association health plans. “We hope to have that by this summer,” Acosta said
Monday during a tax reform event alongside President Trump in Florida.” (G)
“In 2012, the Supreme Court of the United States upheld
Obamacare in a 5-4 ruling, with Chief Justice John Roberts writing the majority
opinion. Many Obamacare opponents believe Roberts used contorted reasoning to
save the law by labeling Obamacare’s individual mandate penalty a tax.
Now, six years later, 20 states have seized on the Roberts
ruling to ask the courts again to undo Obamacare. These states filed a lawsuit
indicating that because the December 2017 tax reform bill repealed the
individual mandate penalty, there’s no longer any legal rationale for the
mandate. They also argue that because there’s no “severability clause” in
Obamacare, the entire law must be struck down.
If this sounds confusing, read on to unpack what’s going on
with this latest attempt to undo Obamacare through the courts.
The Obamacare mandate was ruled a tax…
Opponents of the law argued Congress didn’t have the power
to require individuals to purchase a product from private insurers, while the
Obama administration argued authority for the mandate came from the Commerce
Clause, which gives the federal government power to regulate commerce “among
the several states.”” (H)
“Gov. Scott Walker has asked for a federal waiver to operate
a state-based reinsurance plan designed to stabilize the state’s individual
health insurance market and hold down premiums under the Affordable Care Act.
Following a 44 percent average spike in Obamacare premiums
this year, Walker’s office estimates the $200 million program would lower
premiums by 11 percent from what they otherwise would have been, amounting to a
5 percent decrease in premiums compared to 2018.
Under the plan, the state would pay $34 million for
reinsurance in 2019, while $166 million would come from federal funds…
“We are taking action to address the challenges created by
Obamacare and bring stability to the individual market,” Walker said. “Our
Health Care Stability Plan provides a Wisconsin-based solution to help
stabilize rising premiums in order to make health care more affordable for
those purchasing in the individual market. With Washington D.C. failing to fix
our nation’s health care system, Wisconsin must lead.” (I)
“The American Academy of Family Physicians and other doctor
groups have unleashed detailed critiques of Trump’s effort to introduce cheaper
health insurance with skimpier benefits….
“Insurers could reduce or eliminate certain essential health
benefits to avoid vulnerable, expensive patients by excluding specific
services,” AAFP board chair Dr. John Meigs, Jr., a family physician from
Alabama wrote in a letter last week to U.S. Health and Human Services Secretary
“In doing so, insurers could potentially make plans more
expensive for people with long-term chronic conditions or with sudden medical
emergencies,” Meigs said. “Inadequate benefits could leave this population with
too little coverage to meet their health care needs.” (J)
“The Affordable Care Act (aka Obamacare) banned any
hospital, doctor, or insurance company who receives federal funding from
discriminating against or denying services based on sex; the Obama
administration made it clear in 2016 that provision included transgender and
These benefits and protections are heading for oblivion
though, according to the Times. The Trump administration is pointing to a
January 2017 ruling from a Texas federal judge who said the 2010 law did not
cover gender identity or presentation.
“Congress did not understand ‘sex’ to include ‘gender
identity,’” Judge Reed O’Connor ruled. In the Affordable Care Act, he said,
Congress “adopted the binary definition of sex.” (K)
“As Republicans careen toward the midterms with tax reform
under their belts and not much else, rumor has it that a small group of
Republican senators are working with the White House and former Sen. Rick
Santorum (R-Pa.) to revive the debate over ObamaCare repeal.
Their purpose is laudable. But, privately, conservatives
across Capitol Hill are expressing concern that the proposal may not do enough
to dismantle ObamaCare’s regulatory structure, reduce its colossal spending, or
allow freedom to innovate outside the law’s stifling framework…
The bill’s premise — to devolve much of the health-care
spending to the states — is a good starting point. But its implementing details
are still unknown, leaving conservatives to wonder if the new bill will
actually repeal ObamaCare and reform the health-care marketplace, or if it will
simply recast much of the law’s worst elements with a few minor tweaks…
Voters are still waiting for a full repeal effort. Anything
less will not suffice as a solution for candidates who will soon be elected on
a message of repeal. Nor will it suffice for a party who has spent years making
the same promise.” (L)
“Less than a year after the GOP gave up on its legislative
effort to repeal the law, Democrats are going on offense on this issue,
attacking Republicans for their votes as they hope to retake the House
ObamaCare’s favorability in polls has improved since the
repeal push last year, with more now favoring the law than not. A Kaiser Family
Foundation poll in March found that 50 percent of the public favors the law,
while 43 percent holds an unfavorable view.
GOP strategist Ford O’Connell said the political winds have
shifted on the issue, turning ObamaCare into a subject Democrats want to tout
and many Republicans want to duck.
“I don’t think it’s seen as a winning issue,” he said. “It’s
also an issue that tends to fire up the Democratic base more so than the
Republican base.”” (M)
“While Republican moves to overhaul Social Security,
Medicare or Medicaid appear unlikely — at least for this year — Democrats are
increasingly warning about the prospect because of the deficit concerns created
by the tax plan. The GOP argues Democrats want to distract from the fact that
they did not support the tax overhaul, the signature Republican achievement of
Trump’s first year in office.
Democrats’ ability to sell voters on their vision for health
care and warn about the possibility of cuts to Social Security and Medicare
could prove crucial for candidates, such as Manchin, who are trying to win in
Polling suggests Trump and the GOP’s efforts to reshape the
American health-care system have not resonated with voters. Thirty-six percent
of respondents to the Economist/YouGov poll said they strongly disapprove of
how the president has handled health care, compared with only 15 percent who
said they strongly approve.” (N)
“People have voted with their enrollment decisions: A
sizable number of Americans do not get insurance from their employers and value
the coverage on Obamacare’s markets. That refutes the GOP myth that the program
forces Americans to purchase junk insurance that they do not want. A recent
Kaiser Family Foundation poll found that these consumers seek to guard against
major medical costs, to gain the peace of mind that comes with insurance and to
obtain coverage for chronic medical care, suggesting that the law serves
important and durable needs.
Another fictional Republican claim is that Obamacare has
been collapsing. A Kaiser study this year found that insurance markets
stabilized in 2017, despite Mr. Trump’s best efforts to undermine the law. This
comports with findings from the Congressional Budget Office and a range of
other independent analysts…
Obamacare continues to serve an important need. What’s sad
to see is how easy it would be to make it even more useful, if Republicans
would focus on improvement instead of sabotage.” (O)
“What’s the secret of Obamacare’s stability? The answer,
although nobody will believe it, is that the people who designed the program
were extremely smart. Political reality forced them to build a Rube Goldberg
device, a complex scheme to achieve basically simple goals; every progressive
health expert I know would have been happy to extend Medicare to everyone, but
that just wasn’t going to happen. But they did manage to create a system that’s
pretty robust to shocks, including the shock of a White House that wants to
What this says to me is that if Republicans manage to hold
on to Congress, they will make another all-out push to destroy the act —
because they’ll know that it’s probably their last chance. Indeed, if they
don’t kill Obamacare soon, the next step will probably be an enhanced program
that lets Americans of all ages buy into Medicare.” (P)
“At the outset, Obamacare had three central features:
• Insurers could not charge higher prices to people with
• Those without coverage had to pay a penalty to the
government (the “mandate”).
• Low-income people would be eligible for subsidies.
The first two provisions were necessary to prevent the death
spiral, and government couldn’t mandate insurance purchases without adding
subsidies for the poor.
Despite a bumpy rollout and some frustrations over shrinking
choices and rising prices at health care exchanges, Obamacare was working
remarkably well by most important metrics. Program costs were much lower than
expected, and the uninsured rate among nonelderly Americans fell sharply — from
18.2 percent in 2010 to only 10.3 percent in 2018.
This progress is now imperiled.
The mandate — by far the program’s least popular provision —
was repealed as part of tax legislation passed in December 2017. And because
economists predict that its absence will slowly rekindle the insurance death
spiral, we’re forced back to the policy drawing board… (Q)
SEE OBAMACARE/ TRUMPCARE CHRONOLOGY AFTER THE FOOTNOTES
(A) The G.O.P. Accidentally Replaced Obamacare Without
Repealing It, by Peter Suderman
(B) Republicans Couldn’t Knock Down Obamacare. So They’re
Finding Ways Around It., by Margot Sanger-Katz, https://www.nytimes.com/2018/04/11/upshot/republicans-couldnt-knock-down-obamacare-so-theyre-finding-ways-around-it.html
(C) How Trump’s Obamacare administrator is taking a hatchet
to Obamacare, by Michael Hiltzik,
(D) The Health 202: Republicans could lower Obamacare
premiums. But will they?, by Paige Winfield Cunningham,
(E) Senate May Fund Obamacare Subsidies With This Sneaky
Move, by Robert Donachie,
(F) House Passes Spending Bill Without Obamacare Fix, by
(G) Trump Official: Alternative to ObamaCare Plans Likely
This Summer, by Peter Sullivan, http://galen.org/2018/obamacare-watch-newsletter-4-20-18/
(H) States Take Another Run at Undoing Obamacare Through the
Courts, by Christy Bieber,
(I) Amid rising Obamacare premiums, Walker seeks federal
waiver for reinsurance program, by op 5 percent, by Lauren Anderson,
(J) Doctors Attack Trump’s Short-Term Health Plans Ahead Of
Comment Deadline, by Bruce Japsen,
(K) Trump to Allow Anti-Trans Discrimination in Health Care,
by BY NEAL BROVERMAN,
(L) Republicans have a long way to go toward fully repealing
ObamaCare, by Rachel Bovard, http://thehill.com/opinion/healthcare/383722-republicans-have-a-long-way-to-go-toward-fully-repealing-obamacare
(M) GOP in retreat on ObamaCare, by BY PETER SULLIVAN,
(N) It’s not all about Trump: Democrats’ midterm chances
ride on health care and Social Security, too, by Jacob Pramuk,
(O) Americans are sticking by Obamacare. If only the GOP
would stop trying to kill it.,
(P) Obamacare’s Very Stable Genius, by Paul Krugman,
(Q) Back to the Health Policy Drawing Board, by ROBERT H.
Assignment: Learn everything you can about sepsis than make sure your local hospital uses Artificial Intelligence to diagnose (and even recommend treatment for) sepsis?
Less than one day after burying his beloved wife Barbara, former President George H.W. Bush was hospitalized in the intensive care unit with sepsis.
He recovered and left the hospital, but too often this
potentially deadly condition takes lives.
In 2017 alone, 1 in 3 people who died in a hospital had sepsis.
The Centers for Disease Control tracks the disease and its
complications. Last year, it found at
least 1.7 million cases diagnosed in the United States.
What is sepsis?
Sepsis is the body’s extreme response to common bacterial
infections. Things as simple as an
infected skin cut, a urinary tract infection or illness affecting your lungs
can trigger it. If you don’t get proper medical attention quickly, it can lead
to tissue damage, organ failure and death.
It can strike anyone, but children, the elderly and those
with chronic health problems are most at risk.
To help you know your risk and to avoid putting yourself or
your family at risk, check out the CDC’s fact sheets on how to protect
“Do not take that slight cut on your knee or a bruise on
your elbow lightly for they can land your health in a complicated state called
sepsis. Sepsis occurs when an existing infection causes the immune system to
flare up intensely. As a result, your body swells up severely blocking the
blood flow to your organs. While the symptoms take 24 -48 hours to manifest, do
watch out for signs of fever, shortness of breath, unbearable pain, and a racy
heart. Although bacterial infections are said to be the major cause of the
disease, there are other culprits to watch out for.” (A)
Physicians will accept pathogen coverage of 80% to 90% from
their preferred empiric antibiotic regimen when managing patients with mild and
severe sepsis, respectively, from bacterial infections, survey results showed.
The survey of internal medicine physicians in Canada also
showed that physicians perceived that their preferred empiric antibiotic
regimen would cover 90% of the offending pathogens in each clinical scenario of
Researchers said the findings could be used to inform
clinical guidelines and improve prescribing practices.
According to Alex M. Cressman, MD, MSc, from the University
of Toronto and Sunnybrook Health Sciences Center, and colleagues, prescribers
must balance “early empiric antibiotic coverage and the antimicrobial
stewardship goal of minimizing unnecessary broad-spectrum treatment” when
choosing an antibiotic regimen. They suggested a need for treatment thresholds
to aid physicians in choosing empiric antibiotic regimens for patients with
serious bacterial infections.
scenario-based survey of general internists and infectious disease specialists
across Canada, we characterized physicians’ perceived likelihood of adequate
coverage achieved by their preferred empiric antibiotic regimens for patients
with mild and severe sepsis,” Cressman and colleagues wrote. “We also
identified physicians’ minimum acceptable thresholds of adequate coverage for
According to Kollef and Burnham, treatment bundles can
overlook important factors. Specifically, treatment bundles for sepsis tend not
to assess antibiotic necessity, dosing strategies and antibiotic duration, and
the in vitro activity of the antibiotic regimen. They highlighted the success
that rapid molecular diagnostics has had in expediting patient evaluation for
sepsis, ensuring effective, early antibiotic therapy and reducing the
unnecessary use of broad-spectrum agents.
“Further work is needed to understand their work in a
broader context that includes other front-line antibiotic prescribers,” Burnham
and Kollef wrote. “Empiric antibiotic prescribing will continue to be a moving
target, but with advances in [rapid molecular diagnostics], the ideal scenario
of minimizing antibiotic use while maximizing excellent patient outcomes moves
closer to realization, including in critically ill patients.” (B)
Hospitals have a hard time meeting the CMS’ sepsis treatment
The national average compliance rate for the Severe Sepsis
and Septic Shock Early Management Bundle is barely 50%, according to the most
recent data on Hospital Compare. The measure was adopted in July 2015 to
improve hospitals’ identification and treatment of the life-threatening
condition. More than 200,000 people die each year from sepsis.
WellSpan Health, an integrated delivery system based in
York, Pa., has blown past that average, recently boasting an 85% compliance
rate for the bundle. WellSpan executives credit a year-old quality improvement
initiative that involves leveraging the electronic health record and a remote
patient monitoring team to identify and treat patients with sepsis early…
To address alert fatigue, WellSpan established a remote
surveillance team to monitor sepsis alerts and patients’ vital signs 24/7. The
Central Alert Team operates much like air traffic controllers do, with the
nurses monitoring patients at five hospitals, allowing them to review and
intervene when necessary.
“The idea of the alert team is to facilitate early recognition
and communication with the care team at the bedside, so they launch appropriate
interventions,” Delaveris said.
Alerts go to the Clinical Alert Team rather than nurses at
the bedside. Using patient record data on hand, nurses on the alert team will
determine if an alert should be elevated to the next level. If so, they contact
the patient’s physician or nurse directly to let them know the sepsis bundle
should be activated.
Because the nurses only reach out to the bedside team when
they see something amiss, the clinicians take their alerts seriously, Delaveris
said. WellSpan also introduced the nurses to the clinicians they’d be working
with so “it’s not just someone calling from the sky. We wanted to build a
relationship and trust,” he added.
At least one registered nurse with intensive-care and
emergency department experience is on duty at any given time monitoring
patients for sepsis.
The nurses also continuously monitor the patients they see
as at risk for sepsis to ensure the clinical team is following all of the
bundle’s steps. WellSpan opted to use the bundle from the Surviving Sepsis
Campaign, which is closely aligned with the CMS requirements. The bundle has
multiple steps that need to be accomplished within designated time periods.”
“Know the risks. Spot the signs. Act fast. Merit Health
Wesley has worked for the past few years to integrate evidence-based clinical
practices into the medical management of sepsis and reduce risk in the
community by educating the public about the illness.
Merit Health Wesley is the first in Mississippi to achieve
The Joint Commission’s Gold Seal of Approval for Sepsis Care.
“This achievement is a symbol of quality that reflects our
hospital’s ongoing commitment to providing safe and effective patient care,”
said Debbie Johnson, vice president of quality and clinical transformation and
patient safety officer. “We endeavor to provide the highest quality of sepsis
care through a comprehensive, multi-disciplinary approach to sepsis management
and long term recovery.”
The sepsis management team at Merit Health Wesley has
reduced the risk of sepsis by limiting the progression of sepsis. They are
focusing on early diagnosis and rapid, efficient and effective treatment. Key
elements of the hospital’s process are medical staff-approved sepsis protocols,
a team approach with focused patient handoffs, regular reviews of designed
process compliance, and accountability meetings to review outcomes. Merit
Health Wesley chose to authenticate their best practices and process
improvements by pursuing certification.
Since as many as 87 percent of sepsis cases start in the
community, Merit Health Wesley has also implemented a community outreach and
education plan. Patients and their families, nursing homes, emergency management
staff and other care providers are educated to increase their awareness of
sepsis and common early warning signs, as well as, evidenced based standards of
care for rapid treatment, all key to improved outcomes and survival.” (D)
“Massachusetts Institute of Technology researchers have
developed a machine-learning system that could help clinicians decide when to
treat patients for sepsis in the emergency room.
Sepsis is one of the most common reasons for readmission to
the hospital and one of the most common causes of death in the ICU. The
researchers suggest that most of the ICU patients are admitted through the
Treatment typically begins with antibiotics and IV fluids at
a couple liters at a time, according to the researchers. Sepsis shock can
happen if a patient’s body doesn’t respond well to treatment, which results in
blood pressure dropping dangerously low with organ failure. Once that happens,
the patient goes to ICU where clinicians can reduce and stop fluids to start
vasopressor medications to raise and maintain blood pressure.
However, giving a patient fluids for too long could cause
more organ damage. The researchers say that vasopressor intervention could be
helpful and has previously been linked to improved mortality in septic shock.
But administering vasopressors too early can cause heart arrhythmias and cell
damage, leaving clinicians with an unclear answer on when to administer
MIT researchers have developed a model to alleviate that
problem. The model learns from health data on emergency-care sepsis patients
and can predict if a patient will need vasopressors within the next few hours.
In a study, the researchers compiled a dataset for ER sepsis
patients. When they tested the algorithm, the model was able to predict the
need for a vasopressor more than 80% of the time…
The machine-learning system could be used in a bedside
monitor to track patients and send alerts to clinicians in the ER about when to
start vasopressors and reduce fluids.
“This model would be a vigilance or surveillance system
working in the background,” Thomas Heldt, the study’s co-author, said. “There
are many cases of sepsis that [clinicians] clearly understand, or don’t need
any support with. The patients might be so sick at initial presentation that
the physicians know exactly what to do. But there’s also a ‘gray zone,’ where
these kinds of tools become very important.”
Other models have been built to predict who is at risk of
developing sepsis or when to administer vasopressors in the ICU. The
MIT-developed model is the first one to be trained on data from the ER.
“[The ICU] is a later stage for most sepsis patients. The ER
is the first point of patient contact, where you can make important decisions
that can make a difference in outcome,” Heldt said…
“The model basically
takes a set of current vital signs, and a little bit of what the trajectory
looks like, and determines that this current observation suggests this patient
might need vasopressors, or this set of variables suggests this patient would
not need them,” Prasad said.
The researchers hope to expand their work to make more tools
that can predict in real-time if patients in the ER would initially be at risk
for sepsis or septic shock.
“The idea is to integrate all these tools into one pipeline
that will help manage care from when they first come into the ER,” said Prasad.
The researchers also say that the system could help
clinicians in emergency room departments in major hospitals focus on patients
who are most at-risk of developing sepsis.
“The problem with sepsis is the presentation of the patient
often belies the seriousness of the underlying disease process,” Heldt said.
“If someone comes in with weakness and doesn’t feel right, a little bit of
fluids may often do the trick. But, in some cases, they have underlying sepsis
and can deteriorate very quickly. We want to be able to tell which patients
have become better and which are on a critical path if left untreated.” (E)
Jonathan Perlin, MD, president of clinical services and
chief medical officer at HCA Healthcare, calls sepsis an “overwhelming
infection” that can lead to severe organ failure and even death. He says the
key to survival is early recognition and aggressive treatment.
“It’s a medical emergency that should be treated as
aggressively as a heart attack or stroke,” Dr. Perlin said. “At HCA, we’re
pleased to be able to rally the data of more than 28 million patients every
year to help control sepsis, one of the most challenging diagnoses inflicted on
patients, and ultimately, better inform patient improvements and outcomes.”..
For every hour of a delayed sepsis diagnosis, it increases
the chance of death between 4 and 7 percent…
How does SPOT work?
Hospital computers, through “machine learning”, are trained
by ingesting millions of data points on which patients do and do not develop
sepsis. Those computers monitor clinical data every second of a patient’s
hospitalization. When a pattern of data
consistent with sepsis risk occurs, it will signal with an alert to trained
technicians who call a “code sepsis.”
The bedside nurse responds, begins evaluating the patient,
and if sepsis is not “ruled out,” treatment begins immediately.
“SPOT is operating with 100 percent sensitivity, that is,
all true sepsis positives have been identified,” he said, “allowing caregivers
to fully focus on those patients who need intensive monitoring and support.”
More than 5,500 lives have been saved over the last three
years as a result of the stop severe sepsis program, the national standard that
relies on detecting sepsis at the cusp of deterioration, and HCA’s new
“The doctors and nurses tell us there were some patients
SPOT detected that we would’ve known about,” Perlin said. “More importantly, it
told us time and again those patients we didn’t appreciate that were headed
HCA celebrated in August 1 million patients followed by
“Durham, N.C.-based Duke University Hospital in November
will launch Sepsis Watch, a system that uses artificial intelligence to help
identify patients in the early stages of sepsis, according to IEEE Spectrum.
Duke University Hospital will deploy the system in its
emergency department before extending it to the general hospital floor and
intensive care unit.
“The most important thing is to catch cases early,
before they get to the ICU,” Suresh Balu, project lead and director of the
Duke Institute for Health Innovation, told IEEE Spectrum.
The Sepsis Watch system can identify cases based on numerous
variables, including vital signs, lab test results and medical histories. The
AI’s training data consists of 50,000 patient records and more than 32 million
data points. While operating, the system pulls information from medical records
every five minutes to evaluate patients’ conditions, which offers real-time
analytics physicians can’t provide.
When the AI system detects a patient who may be in the early
stages of sepsis, it alerts a nurse on the hospital’s rapid-response team who
will either dismiss the alert, place the patient on a watch list or contact a
physician about starting treatment. The system will also walk staff through a
sepsis treatment checklist using protocols outlined by the Surviving Sepsis
“The model detects sepsis,” Mark Sendak, MD, physician
and data scientist, told IEEE Spectrum. “But most of the application is
focused on completing treatment.”
Electronic health records can help identify hospitalized
patients at risk of death, according to a new study in The American Journal of
Inpatients’ conditions can deteriorate quickly; the faster
the intervention, the better the patient’s chances of survival. The
researchers, from Arizona based Banner Health, created an algorithm that looked
for at least two out of four systemic inflammatory response syndrome (SIRS)
criteria, plus at least one of 14 acute organ dysfunction parameters. The
algorithm continually sampled the EHR data in real time of 312,214 patients in
24 Banner Health hospitals, and contained an alert to notify the physician of
the risk of death when a patient triggered it.
The alert identified a majority of the high risk patients
within 48 hours of admission and enabled early and targeted medical
intervention. The patients who triggered the alert had a “significantly
high” chance of dying in that hospital stay compared to patients who
didn’t trigger the alarm.” (G)
“.. the technology that goes by the name AI Clinician,
described today in a paper in Nature Medicine, doesn’t diagnose—it makes
decisions. It takes all the information about a patient with sepsis and
recommends a course of treatment.
“It’s not mimicking the perceptual ability of the doctor,
where the doctor sees certain symptoms and says the patient is going into
septic shock,” says Aldo Faisal, an associate professor of bioengineering and
computing at Imperial College London and one of the paper’s authors. “It’s
really cognition that is captured here. We’re not just making the AI see like a
doctor, we’re making it act like a doctor.”
The researchers didn’t try out their system on real
patients; the technology isn’t ready for the clinic yet. Instead, they trained
and tested AI Clinician on medical record databases from intensive care units
(ICUs) in the United States. They first used 17,000 cases to teach the model
about sepsis treatment, and then had it issue recommendations for 79,000 cases.
Overall, the treatments that the AI recommended were more
likely to keep patients alive than those administered by the human doctors…
Part of the treatment is to give patients intravenous fluids
and drugs called vasopressors that constrict the blood vessels and increase
blood pressure: These actions ensure that blood is reaching the organs.
However, there’s considerable debate about how much to give, and when.
The researchers trained AI Clinician to issue
recommendations on fluids and vasopressors. Gordon says these basic
recommendations are just a start, and that the team has already been working on
a model that includes more treatment factors…
Theoretically, an AI could control electronic pumps that
deliver IV fluids and medications. “It would be the most personal doctor you
can imagine, relentlessly watching over you,” Faisal says…
Essentially, reinforcement learning comes down to trial and
error. The trainers establish a goal—such as winning a game, achieving a high
score, or keeping a sepsis patient alive—and link it to a reward. (In this
case, the AI was programmed to maximize credits, and it earned credits for each
patient that stayed alive and lost credits for those that died.) The AI tries
out a sequence of actions at random, and if it achieves its goal, it gets the
payoff. Over many repetitions, it learns which combinations of actions are most
likely to result in the reward.” (H)
“After finding inefficiencies and a high potential for error
in their sepsis treatment process, University of Utah Health, a four-hospital
system based in Salt Lake City, partnered with clinical communication solutions
provider Spok to help improve sepsis response…
Dr. Horton began to identify problems in sepsis response
while evaluating patients with fevers. “When I was consulting for a fever,
I’d go see a patient, get into their chart and find they had abnormal vital
signs that had been there for several days,” he said. “Our EHR imports
those notes every day, but there were no discussions about those vital
At patient bedsides, nurses would take vital signs and
continue this process for four or five other patients, making the first vital
signs up to an hour old by the time they were entered into the computer.
“If this was an emergent case, we’d already lost an hour,” Dr. Horton
said. “There may not be communication about those vital signs, they may
just sit in the computer waiting for the nurse to see them and a provider may
not get back to them quickly.”
Some of the health system’s providers couldn’t put the
pieces together to say it was sepsis, Dr. Horton said. “And as we started
looking into it, we realized we had no real process in place at our institution
to address sepsis as a leading cause of death.”
If there was a way to get the vital signs in the notes sent
to a provider who knows what to do with them, the hospital could ensure
patients aren’t slipping through the cracks, Dr. Horton said.
To address this issue, University of Utah Health leveraged
their EHR system with Spok Care Connect, which takes the EHR’s sepsis alert or
a critical test result and sends it to the right clinicians’ mobile device
The alert contains the information clinicians need to act
right away, including who the patient is, their room number and their modified
early warning score, or MEWS. MEWS is a physiological test that prevents delays
in the intervention or transfer of critically ill patients. The alert is sent
in seconds, allowing the care team to respond faster.
University of Utah Health’s EHR automatically uses vital
signs entered to calculate the MEWS score. If the MEWS is sufficiently high,
Spok sends that MEWS alert as a message to either the charge nurse or the rapid
response team. When vitals are outside normal range, the recipients get a
notification to begin intervention on that patient right away.
“What was helpful for us was having all our sepsis data
in one place — we can look at the data and take it back to our providers to
tell them what we’re seeing,” Dr. Horton said. “If you have an
EHR-based algorithm, patients’ illness can be detected earlier on and
resuscitated earlier on.”
The data University of Utah Health collected also allowed
them to look at the odds of septic patients getting antibiotics within the
first 24 hours, Dr. Horton said.
“For all sepsis patients, we saw a length of stay that
was decreased by 10 percent and because of that our total direct cost decreased
by 10 percent.”
“We can have the best hospital in the world, but if you
don’t know what vital signs are, and if the vital signs aren’t entered into the
computer in real time, then that patient is losing, and the institution is
losing,” Dr. Horton said.” (I)
“.. a new alert system, pioneered by doctors at Cambridge
University Hospitals and part of a two-year pilot, has led to a seven-fold
increase in the number of patients getting life-saving drugs.
The alert system works by constantly analysing patients’
observations, as recorded by staff on handheld devices.
This includes temperature, pulse, blood pressure and level
of consciousness taken at various stages as patients are assessed in A&E.
If the observations suggest a patient might have sepsis, a
text message appears on the hand-held device and doctors can treat the patient.
The alert system was introduced at Addenbrookes Hospital in
2016. In July 2015, only 11 per cent of patients with possible sepsis were
given antibiotics within an hour of arriving at A&E. This increased to 76
per cent by August 2016.” (J)
“New York state hospitals’ adherence to sepsis protocols
increased and sepsis mortality declined after reporting became mandatory,
The analysis of sepsis reporting data from 185 New York
hospitals from April 2014 through June 2016 found that sepsis protocols were
initiated in 81.3% of eligible patients, most often in emergency care settings.
Risk-adjusted deaths declined from 28.8% to 24.4%
(P<0.001) among patients for whom a sepsis protocol was initiated, reported
Mitchel M. Levy, MD, of Brown University/Rhode Island Hospital in Providence,
and colleagues in the American Journal of Respiratory and Critical Care
While hospitals have some flexibility in developing their
sepsis protocols, the law requires:
cultures followed by antibiotics and measurement of blood lactate levels within
3 hours of presentation in patients with severe sepsis (“3-hour
of intravenous fluids (30 cc/kg), vasopressors and re-measurement of lactate
within 6 hours in patients with septic shock, defined as systolic pressure
<90 mm Hg or lactate level ≥4 mmol/L (“6-hour bundle”)..
Greater hospital compliance with 3-hour and 6-hour bundles
was associated with shorter length of hospital stay as well as with increased
“Despite the controversy, the proof in the literature
is overwhelming,” he said. “The question I have when I debate this
is, ‘Where would you want your loved one to be treated — at a hospital that is
known to be continuously working toward meeting these measures or at a hospital
that doesn’t agree with them?'”
Twenty-seven states fall below the national average for
appropriate sepsis care, according to sepsis performance data added to CMS’
Hospital Compare website in July.
Nationally, the average percentage of patients who received
appropriate care for severe sepsis and septic shock is 49 percent, according to
The sepsis performance measure is based on data from the
first quarter of 2017 through the third quarter of 2017. The preview period for
this change spanned from May 4 to June 2. The first full year of sepsis data
will be available by October.
Here are the states ranked by the percentage of patients who
received appropriate care for severe sepsis and septic shock, ordered from
highest to lowest: • New York: 45 (L)
“Sepsis is a major cause of death in U.S. hospitals, yet
timely and effective sepsis care can reduce the risk of death,” Chanu Rhee, MD,
MPH, assistant professor of population medicine at Harvard Medical School and
Harvard Pilgrim Health Care Institute, said during a presentation.
Previously, Infectious Disease News spoke with Konrad
Reinhart, MD, chair of the Global Sepsis Alliance, about the global rise of
sepsis. Although he said there have been improvements in coding standards in
the last 5 years, before that “the medical system was not doing a good job of
accounting for cases of sepsis.”
Rhee and colleagues found that the reliance on claims data
may be hindering sepsis surveillance, research and quality improvement.
Likewise, Rhee said variations in hospital diagnosis, documentation and coding
practices may make it difficult to benchmark hospital sepsis outcomes using
“Administrative claims data have important limitations,”
Rhee said. “We know they have low-to-moderate sensitivity when identifying
sepsis and, more importantly, recent analyses have suggested that claims-based
trends are biased by changing diagnosis and coding practices over time.”..
Rhee explained that varying claims data between hospitals
limits its use when comparing sepsis rates and outcomes.
“I would be the first to acknowledge that there is no true
gold standard for sepsis,” Rhee said. “However, the EHR clinical criteria, I
believe, are more objective and consistent.” (M)
“The Sepsis Alliance is using the month of September to
educate the public and care providers about the dangers of sepsis and the need
to take quick action. By using the TIME acronym, it serves as a reminder to
seek medical attention as soon as symptoms are present.
Temperature – Higher or lower than normal.
Infection – May have signs and symptoms of an infection.
Mental decline – Confused, sleepy, difficult to rouse.
Extremely ill – “I feel like I might die,” severe
pain or discomfort.
If you have a combination of any of these symptoms, see your
medical professional immediately, call 911, or go to a hospital with an
advocate and mention concerns about sepsis.” (N)
“A local hospital is using a lighter approach to educate
staff on a critical problem.
Nurses and doctors at Penn Presbyterian had to solve clues,
just like an escape room game, to properly diagnose and treat a mock patient
with sepsis – a life-threatening response to an infection. And to save him,
they had an hour to complete all the tasks.
A nurse developed the exercise to make colleagues more aware
of how to detect and treat sepsis.
And some of the equipment in the room was just used as a
decoy – trying to make staffers more attentive and think as they would have to
in a real-life situation. No doubt this will help them and their patients in
the future. (O)
“I have been on active surveillance (AS) for prostate cancer
since December 2010. But though I generally am a compliant patient, I increasingly
have become resistant to MRIs and biopsies.
I have had five biopsies since 2010. Only a single core out
of 60 has revealed any cancer — less than one millimeter back in 2010. It was
never seen again.
In the beginning, I had annual biopsies; lately, I have been
on a biopsy vacation.
When I heard about potential sepsis, I became uncertain
about being needled.
I worry about the potential, though rare, for deadly
infections. My hospital takes steps to prevent infections (they have a low rate
in prostate biopsies, one infection in 6,000 patients vs one in 1,500
nationally), but sepsis is a killer.” (P)
“When someone is admitted to the hospital, they expect to
get better. Instead, nearly 100,000 people in the United States are dying each
year because of healthcare-associated infections (HAI), which is more than
breast and prostate cancer fatalities combined.
Those who acquire HAIs but survive are forced to stay in the
hospital for significantly longer than those who do not receive an infection,
racking up medical bills that likely could have been avoided.
According to the Center for Disease Control (CDC), there are
four common types of HACs:
Catheter-associated urinary tract infection (CAUTI): This is
a type of infection that can occur in any part of the urinary system. The
biggest risk factor for a CAUTI is using a catheter for too long. Doctors
should remove them as soon as they are no longer needed to minimize this risk.
Central line-associated bloodstream infection (CLABSI):
CLABSI is a serious infection that occurs when germs enter the bloodstream
through a central line, which is a tube that doctors place near large veins to
give medications or fluids or collect blood for testing.
Surgical site infection (SSI): An SSI is an infection that
occurs after a surgical procedure at the part of the body where the surgery
Ventilator-associated pneumonia (VAP): VAP is lung infection
that develops in individuals while they are on ventilators to help them
Many HAIs are a result of a doctor failing to follow proper
medical procedures. Making errors during surgery, using poor hand hygiene,
using materials that are not sterile, improper insertion of a catheter or
central line, and failure to remove devices in a timely manner are just some of
the ways medical providers can cause HAIs.” (Q)
“Early Recognition of Sepsis across the Continuum. “To
facilitate timely diagnosis and management, healthcare organizations across the
continuum should have protocols for response when sepsis is suspected, much as
they do for chest pain.”” (R)
“In a recent national survey of more than 1,300 EMS
providers, the National Association of Emergency Medical Technicians (NAEMT) in
association with the Sepsis Alliance found that although nearly all respondents
(98%) consider sepsis a medical emergency, only about half (51%) feel very
confident in their ability to recognize symptoms of sepsis—the body’s
life-threatening response to an infection…
Unfortunately, more than one third of EMS providers surveyed
say that sepsis isn’t a key priority within their organization, and 33% say
their organization isn’t well prepared for patients with sepsis. Furthermore,
25% state that while they know patients have sepsis, physicians don’t like to
diagnose them with it, and 58% say when patients are showing signs of sepsis,
not all hospitals initiate a sepsis protocol.” (S)
“UK researchers have developed a test they say might quickly
identify sepsis, a potentially fatal complication from an infection.
Scientists at Scotland’s University of Strathclyde developed
an experimental microelectrode device that analyzes a patient’s blood and
provides results as quickly as 2.5 minutes. Current testing methods for sepsis
can take up to 72 hours.
This is important given that every hour without diagnosis
and treatment increases the chance of dying.” (T)
Can You Really Get Sepsis from Trying on Shoes Without
Famed Renaissance painter Caravaggio didn’t die of syphilis,
as some historians long thought.
Instead, it appears that the talented Italian artist — who
had a reputation for gambling, drinking, sleeping with prostitutes and even
murder — died of a sword wound that developed a nasty infection, leading to
deadly condition called sepsis, a new study finds. Sepsis is the body’s
overwhelming and life-threatening response to an infection.
A team of French and Italian scientists made the discovery
by digging up and analyzing what they believe are the skeletal remains of the
revolutionary painter, who died at age 39 in 1610. [Photos: Renaissance
Husband’s Heart Buried with Wife]..
Over the years, historians have speculated how the artist
died. Caravaggio had a fever at the time his death, prompting some to guess
that he had malaria or even brucellosis, an infection that people can get from
eating unpasteurized dairy products.
To investigate, the researchers searched the cemetery
reported to hold Caravaggio’s remains. They looked for a skeleton that was
about 5 feet, 4 inches (1.65 meters) tall and between 35 and 40 years of age.
Nine skeletons in the cemetery met these criteria, but only
one dated to the beginning of the 17th century, according to radiocarbon
dating, the researchers said. Even more revealing were the high levels of lead
in the bones, “which was a discovery of great importance since Caravaggio
was known to be careless when using lead for painting,” the researchers
wrote in the study, published online Sept. 17 in the journal The Lancet.
The research team also analyzed the individual’s DNA and
found that it matched the genetic profile of other men with the name Merisi or
Merisio, who are believed to be Caravaggio’s relatives.
Satisfied they had Caravaggio’s remains, the researchers
next analyzed his teeth and found the bacteria Staphylococcus aureus hiding
within the remaining blood vessels of the artist’s teeth. This bacterial
infection likely led to Caravaggio’s sepsis, the researchers said.
“[The cause of death] resulted from sepsis secondary to
superinfection of wounds after a fight in Naples, a few days before the onset
of symptoms,” they wrote in the study.” (V)
“The cost of treating patients who develop sepsis in the
hospital rose by 20% in just three years, with hospitals spending $1.5 billion
more last year than in 2015, according to a new analysis.” (X)
“…of the 1.5 million Americans who develop sepsis each year,
nearly 260,000 die from it.”
Doctor, Did You Wash Your Hands?™ http://doctordidyouwashyourhands.com/
When I was appointed President and CEO of LibertyHealth/
Jersey City Medical Center in 1989 one of our goals was to become a top tier
New Jersey teaching hospital.
If Columbus had an advisory committee he would probably
still be at the dock. (A)
The Mystery of the Hospital CLAUSTROPHOBIA CLUSTER
We don’t know what we don’t know” (1) The challenge to
Two years ago, while on vacation, my wife punctured her hand
with a BBQ skewer. So she went to the nearest ER.
Confidential September 11, 2001 LESSONS LEARNED memorandum
by hospital CEO Jonathan Metsch goes “viral” and becomes a New Jersey
gubernatorial campaign issue
Trust but Verify” (Ronald Reagan) – Four Lessons Learned as
a junior CEO back in the day..
DON’T DEPEND ON ANYONE ELSE TO BRING THE COFFEE! & other
Lessons Learned as a junior hospital CEO back in the day….
Tomorrow morning’s Emergency Preparedness meeting (just
scheduled for 8AM)
“If you don’t have a seat at the table, you’re probably on
OBAMACARE/ TRUMPCARE/ GAWANDECARE
From REPEAL & REPLACE to WRECK & REJOICE (from
Obamacare to Trumpcare)
“It leaves us with two laws… Call the first one Obamacare…
Call the second one Trumpcare”
The new health care Gold Standard” GawandeCare”
“…what would it look like if Amazon CEO Jeff Bezos took the
helm of a major integrated (health care) delivery system?”
Case Study on Disruption/Disintermediation in health care
When physicians opt out of Medicare they should reimburse
Medicare for paying for their training
The Mayo Clinic is discriminating against Medicare Patients.
A Medicare Conundrum: Observation status – Readmission
penalties – Hospitalist handoff to primary care physician.
Should physicians be afforded Mulligans for non-reimbursable
“…really targeting the depth of the opioid epidemic would
require an infusion of federal dollars on par with the more than $20 billion a
year spent on HIV/AIDs.”
PUBLIC HEALTH administrators can transform monumental unique
challenges to “rapid response” opportunities. Think: Hurricanes Florence and
Michael, the California wildfires, the mysterious polio-like illness, the
opioid epidemic, mass shootings, and immigrant family separation.
President signs “Right to Try Act” – “Despite good
intentions – right to try legislation grants no rights.”
“Right-to-try should not be right-to-die-poorer”
HOSPITAL/ HEALTH SYSTEM QUALITY
Stop the name games! University hospitals and regional
medical centers should live up to their billing *
Are hospital quality/safety metrics used by payers &
accrediting organizations getting ahead of the science of q/s measurement? (I)
HOSPITAL WEB SITE ARCHEOLOGY
Johns Hopkins All Children’s Hospital (St Petersburg,
Florida) – problems in the hospital’s heart surgery unit
San Francisco General, a public hospital with San
Francisco’s only trauma center, all commercial insurance is “out-of-network.”
HOW ACADEMIC MEDICAL CENTERS ADDRESS CONFLICTS-OF-INTEREST
You are a new member of the Board of University Medical
Center and have been appointed chairperson of the Board’s Compliance Committee.
“…of the 1.5 million Americans who develop sepsis each year,
nearly 260,000 die from it.” (A)
Have you met your interventional pathologist or
interventional neurologist or interventional oncologist?
Can/should health care workers be fired for using
appropriately prescribed medical or legally purchased recreational marijuana?
“Concurrent” Surgeries – Is it OK for a surgeon to operate
in different ORs at the same time?
There’s a growing movement in the United States to install
video cameras in operating rooms…
Concierge medicine is the all the rage but rather should we
be enraged about it?
Do you want to be treated by a stranger when you are
admitted to the hospital? Every practicing physician should have hospital
It’s like the Wild, Wild West, the (physician specialty)
turf wars…. (A)
“Two-thirds of beneficiary communication is more complex to
read than Moby Dick…” Let’s start with EOBs!
“…SEXUAL HARASSMENT IN HEALTHCARE CAN ADVERSELY AFFECT
EMPLOYEE HEALTH AND, BY EXTENTION, PATIENT SAFETY…”
On July 4th as we respect and admire hospital staff members
who are working 24/7, it is interesting to look at hospital care during the
posts related to these posts can be found throughout
E. Then every day from your News Feeds select articles on
your topics and move them to the appropriate folder.
F. When you are inspired to write a “case” start a
Word document, then go to the case folder and select key points from the
articles, and cut and paste them to the Word document. As well capture article
title, author and hyperlink.
G. Move the key points around until you have created a
H. Then label each point A,B.C…and move article title,
author and hyperlink to footnotes at the end of the case.
I am retired from teaching so I asked Professor “GOOGLE”
about getting up-to-date on Case Study teaching. Here’s what I found.
The Case Method
Cases are narratives, situations, select data samplings, or
statements that present unresolved and provocative issues, situations, or
questions (Indiana University Teaching Handbook, 2005). The case method is a
participatory, discussion-based way of learning where students gain skills in
critical thinking, communication, and group dynamics. It is a type of
What is the Case Study Method?
How the Case Method Creates Value
Often, executives are surprised to discover that the
objective of the case study is not to reach consensus, but to understand how
different people use the same information to arrive at diverse conclusions.
When you begin to understand the context, you can appreciate the reasons why
those decisions were made. You can prepare for case discussions in several
Using Case Studies to Teach
Advantages to the use of case studies in class
A major advantage of teaching with case studies is that the
students are actively engaged in figuring out the principles by abstracting
from the examples. This develops their skills in: Problem solving; Analytical
tools, quantitative and/or qualitative, depending on the case; Decision making
in complex situations; Coping with ambiguities
Teaching Case Studies Online: A Resource List
It’s difficult to find a good set of resources for teaching
online case studies. While researching how to structure and moderate online
case studies for one of our faculty members, I put together a list of several
resources. Hopefully, you’ll find these a helpful place to start as you are
learning to teach using case studies online.
Top 10 Free Training Courses for Online Teachers
Whether you’re new to distance learning or an experienced
online teacher, you can find free online training resources to fit your needs.
Are you a “face to face” classroom teacher
considering shifting to online education?
Or are you an online teacher interested in the latest
technology to make your online courses more effective?
For example, some online schools offer free training modules
to help campus-based teachers learn how to transition to cyber-classrooms.
Other organizations offer tips on designing online classes and teaching with
Recently after a doctor’s appointment I went to a nearby lab to have blood drawn for routine tests. I asked the phlebotomist to wash her hands to which she replied she already had. She had washed her hands in another room after the last patient, done some other work, come into the room, put gloves on, then went and used a shared computer, before finally drawing blood. When I asked, she refused to wash her hands in front of me. So I refused to let her proceed. The same with the second tech. Finally the third washed her hands correctly in front of me. But not again before she left the room! I reported this to the absentee owner!
Do you ask “Doctor, Did You Wash your Hands?” If not, why not? Everyone knows, including our physicians, that proper hand washing is the most effective patient safety measure right? Your physician and other clinicians (e.g. nurses, PTs, lab techs drawing blood) should wash their hands before and after each patient, both times in front of you.
First some history. “Ignaz Semmelweis, a young Hungarian doctor working in the obstetrical ward of Vienna General Hospital in the late 1840s, was dismayed at the high death rate among his patients. He had noticed that nearly 20% of the women under his and his colleagues’ care in “Division I” (physicians and male medical students) of the ward died shortly after childbirth. This phenomenon had come to be known as “childbed fever.” Alarmingly, Semmelweis noted that this death rate was four to five times greater than that in “Division II” (female midwifery students) of the ward. One day, Semmelweis and some of his colleagues were in the autopsy room performing autopsies as they often did between deliveries. They were discussing their concerns about death rates from childbed fever. One of Semmelweis’ friends was distracted by the conversation, and he punctured his finger with the scalpel. Days later, Semmelweis’ friend became quite sick, showing symptoms not unlike those of childbed fever. His friend’s ultimate death strengthened Semmelweis’ resolve to understand and prevent childbed fever. In an effort to curtail the deaths in his ward due to childbed fever, Semmelweis instituted a strict hand washing policy amongst his colleagues in “Division I” of the ward. Everyone was required to wash their hands with chlorinated lime water prior to attending patients. Mortality rates immediately dropped from 18.3% to 1.3% in 1848 in Semmelweis’ division. (A)”
(1861) “…. Louis Pasteur was showing the world that microorganisms did indeed exist, that they acted on our world in myriad ways and that the ancient wisdom about “bad vapors” and spontaneous generation were wrong. Dead wrong. Prior to Pasteur and what would become known as “germ theory,” the prevailing theories held that organisms, like maggots and fleas, were spontaneously originated from other matter, like raw meat or diseased flesh….. Pasteur is credited with opening the world’s eyes to the new science of microbiology and ushering in a brand new form of preventive medicine: immunization. …Building on what Pasteur was discovering, British surgeon Lister began to use this new germ theory to demonstrate the lifesaving value of disinfectant. Despite his skill at surgery, Lister knew that half his amputee patients would die of infection after the procedure….. He began to treat his surgery equipment, before and after use, with carbolic acid. He also treated his patients’ wounds with it…..within two years, operative mortality decreased from nearly 50 percent to just 15 percent.” “Much of the greatness of Pasteur and Lister lies in their dogged persistence to spend 20 years convincing the rest of the medical world of the truth of their investigations,” ….. (B)
(1881) “What Dr. Towsend did next was something that Joseph Lister, despite years spent traveling the world, proving the source of infection and pleading with physicians to sterilize their hands and instruments, had been unable to prevent. As the president (Garfield) lay on the train station floor, one of the most germ-infested environments imaginable, Towsend inserted an unsterilized finger into the wound in his back, causing a small hemorrhage, and almost certainly introducing an infection that was far more lethal than Guiteau’s bullet.” (C)
“The shot in the back was not fatal, not hitting any vital organs. The bullet lodged behind the pancreas. “If they had just left him alone he almost certainly would have survived,” Millard said. Within minutes, doctors converged on the fallen president, using their fingers to poke and prod his open wounds. “Twelve different doctors inserted unsterilized fingers and instruments in Garfield’s back probing for this bullet,” Millard recounted, “and the first examination took place on the train station floor. I mean, you can’t imagine a more germ-infested environment.” American doctors at the time didn’t believe germs existed at all. And according to Dr. Jeffrey Reznick of the National Library of Medicine, they rejected the use of antiseptics pioneered by British surgeon Joseph Lister, for whom Listerine would later be named” (D)
FAST FORWARD 150 YEARS
“Hospital infections affect almost two million people in the United States every year, 100,000 of whom die. Up to 70 percent of these infections could be prevented if health care workers follow recommended protocols, which include hand hygiene…. “Why is it still so hard to get health care workers to wash their hands? Active resisters are people who like doing things a certain way for the simple reason that things have always been done that way. During one site visit, an infectious diseases doctor involved in preventing infections told us: Getting the surgeons to adopt things in general is problematic … they’re like baseball players, they’ve got superstitions…in their minds if it’s working, why should we change it. But at least you know who these people are since they speak up at meetings and actively resist changing behavior. The second type are what we termed organizational constipators. These individuals often have nothing against an initiative per se but simply enjoy exercising their power by refusing to change, albeit below the radar. The challenging aspect about organizational constipators is that the people above them think they are doing a good job, while those below them cannot believe they still have a job. Yet another barrier we found in our research is that many hospitals have a culture of mediocrity rather than a culture of excellence. These hospitals are content to be just good enough. Leadership is generally ineffective. Overperformers are rewarded with more work.” (E)
“…this sobering truth. When bacteria lurking on, for instance, a medical device, a bed rail, a bandage or a caregiver’s hands find their way into a patient’s body via a surgical wound, a catheter, a ventilator, or some invasive procedure, the disturbingly frequent result is a serious, sometimes devastating, infection.” (F)
“Hospital-acquired infections (HAI) cost $9.8 billion per year, with surgical site infections alone accounting for one-third of those costs, followed closely by ventilator-associated pneumonia at 31.6 percent….” (G)
“Hands are the most common vehicle for transmission of organisms and “hand hygiene” is the single most effective means of preventing the horizontal transmission of infections among hospital patients and health care personnel. ” (H) (I)
“How dirty is your Qwerty? It turns out that your computer keyboard could put a host of potentially harmful bacteria — including E. coli and staph — quite literally at your fingertips. Sure, it may sound like a hypochondriac’s excuse to stay away from the office. But a growing body of research suggests that computer mice and keyboards are, in fact, prime real estate for germs. It’s a phenomenon most recently illustrated by tests at a typical office environment in the United Kingdom. A consumer advocacy group commissioned the tests in which British microbiologist James Francis took a swab to 33 keyboards, a toilet seat and a toilet door handle at the publication’s London office in January. Francis then tested the swabs to see what nasty germs he managed to pick up. He found that four of the keyboards tested were potential health hazards — and one had levels of germs five times higher than that found on the toilet seat.” (J)
“Question: I recently had an appointment with a medical specialist. I got called into the clinic room where I waited for the doctor; and I noticed a few “wash your hands” posters. When he came in, I swear he didn’t use the hand sanitizer. I couldn’t be sure. And I didn’t want to ask – but I was kind of grossed out. What should I have done? Is it okay to question the doctor about hand washing? Answer: Your concerns about hand washing are certainly justified. Poor hand hygiene practices are largely to blame for the spread of germs within health care settings… If you ever suspect that your doctor, nurse or other health care provider forgot to use the hand sanitizer, by all means raise the question. But, in reality, most patients in your situation are reluctant to do so. “Very few people would ever be comfortable asking their health-care providers if they’ve cleaned their hands,” acknowledges Dr. Vearncombe. “Our patients feel very vulnerable,” she explains. “They are in an imbalanced power relationship with us, so it is really hard for them to ask.” Indeed, some patients fear that their treatment could be jeopardized if they challenge the doctors and nurses on even routine matters such as hand hygiene. Their care will certainly not be affected, but it’s a worry for them nonetheless. Surveys going back almost a decade found that Ontario patients didn’t want to be placed in the role of a police officer to ensure that doctors and nurses wash their hands. As a result of these surveys, most of the hand-hygiene education in Ontario has focused on the health care providers themselves. Since 2007-2008, Ontario hospitals have been required by provincial law to report their hand-hygiene rates. In some hospitals, such as Sunnybrook, designated staff members routinely observe interactions of health care providers with patients to track if they are actually washing their hands at the appropriate times.” Before mandatory reporting took effect, a study carried out at a few hospitals had revealed that hand-hygiene compliance rates were “abysmally low,” notes Dr. Vearncombe. The rate at Sunnybrook, for instance, was originally less than 40% – similar to many other hospitals. “We have made great increases in our hand-hygiene compliance, and the most recent results show our overall rate is now 87%.”.. A pilot study at Sunnybrook has been exploring what role patients could play. Three of the hospital’s inpatient wards were selected for the pilot. As part of the study, an information card was placed on the bedside table whenever a room was cleaned and prepared for a new patient. “This little card explained in lay language what to expect” when a health-care provider entered the patient’s room, says Dr. Vearncombe. The cards stated that “Your care provider should clean their hands: 1) Before contact with you; 2) Before a procedure; 3) After a procedure; and 4) After contact with you.” The cards also included the catchphrases: It’s okay to ask staff, ‘Did You Clean Your Hands?’ and Reminders help everyone! So, the next time you suspect a health-care worker may have skipped the hand sanitizer, don’t hold back. Everyone benefits when fewer germs are spread around.” (K)
“At Denver Health Medical Center, the CenTrak monitoring system is used on two of the medical-surgical wards, the medical intensive care unit, and the step-down care unit. On these particular units, all rooms are single occupancy. All nurses and healthcare technicians on these floors, as well as those on the float team, have badges. Additionally, select hospitalists, intensivists and residents also have badges to track their personal electronic hand hygiene adherence. “We monitor both waterless hand sanitizer and soap dispensers,” Young explained. “We have defined adherence with the technology to be performing hand hygiene within 60 seconds before or after entering the room and within 60 seconds before or after leaving the room.” Denver Health has used the electronic hand hygiene monitoring system as a means to both effect and measure change in hand hygiene. For example, it has used electronic hand hygiene to study the effect of poster placement on hand hygiene habits. It also has provided individual feedback to staff members on their hand hygiene rates and studied the change in electronic hand hygiene over time. The hospital has achieved quite a success with baseline hand hygiene adherence rates nearly doubling. While Denver Health measures multiple hand hygiene workflows, this particular example of improved compliance was in regard to its wash-in/wash-out protocol – the requirement for staff to wash their hands upon entering a room and again after their interaction with a patient. “Using data from the electronic hand hygiene compliance system, Denver Health was able to properly audit hand hygiene processes and provide additional training and education to staff where needed most,” said Young.” (L) “The 70-page report, “Guide to Hand Hygiene Programs for Infection Prevention,” outlines an eight-step multimodal program that hospitals can follow to ensure hand-hygiene program success. “It’s when all those components of hand-hygiene programs are working together effectively that we see the biggest change,” Timothy Landers, R.N., lead editor of the guide, said in a report announcement. However, the report makes it clear that without one component–the full support of hospital leadership–programs will continue to fail. “Leadership’s commitment to hand hygiene must be visible and engaging–to the organization and the public through formal communication, hand-hygiene education, promotions, and event sponsorship,” the report said. In addition to leadership support, the guide also recommends that hospitals follow these steps: Establish ongoing monitoring and feedback on infection rates, such as tracking endemic and emerging drug resistant pathogens. Create a multidisciplinary design and response team led by a senior administrator to emphasize that the organization is committed to hand-hygiene compliance. Provide ongoing education and training for staff, patients, families and visitors. The report suggests the use of instructive posters, pocket cards and brochures for training. Ensure hand-hygiene resources are accessible throughout the organization, including patient care corridors and at the entrance and exit of patient rooms. Reinforce hand-hygiene behavior and accountability. Some organizations have success conducting contests and recognizing healthcare workers who comply with the guidelines. Provide reminders throughout the healthcare setting. For example, the report suggests organizations provide real-time feedback from observers, coworkers, patients and visitors. Develop an ongoing monitoring program that includes feedback. Some organizations, the report said, post monthly compliance data on hospital units or their hospitals’ Web sites and discuss the findings with staff during meetings.” (M)
“Most evaluation reviews are generated after a major, life-threatening error occurs, which usually happens infrequently. Historically, when an evaluation determined that a process completed by personnel was deficient, problem-solving efforts focused on the identification of the specific individual(s) who “caused” the problem. Later, quality improvement efforts focused on developing a culture of safety and recognized that additional contributions to errors were due to complex, poorly designed systems. The advantage of an evaluation that reviews system problems is that it encourages health care professionals to report adverse events and near misses that might be preventable in the future, while balancing the identification of system problems with holding individual providers responsible for their everyday practices. Improvement is impossible without evaluation reports to provide data on the factors that contribute to mistakes and lead to subsequent individual and system changes that support safer practices. An evaluation strategy examining process measures include the following examples: Document staff use of maximum sterile barriers (cap, mask, sterile gown, sterile gloves, large sterile sheet) and aseptic technique for the insertion of central intravenous catheters or guidewire exchange. Document timing of antibiotic prophylaxis when used in surgical patients (e.g., within 1 hour of incision). Document if hand hygiene is performed and clean or sterile gloves are worn before assessing a catheter insertion site or changing a dressing on intravascular catheters. Document time elapsed from when patient culture (microbiology and susceptibility) results are reported and when the appropriate isolation precautions are instituted (patient room placement, signs, PPE used, disposable equipment used, medical record documentation, etc.). Ensure that staff (nurses, doctors, and housekeeping) enter a contact isolation room using the specified personal protective barriers (e.g., gloves, gown) on each entry. Ensure that staff properly remove PPE after leaving a patient’s room. Assess the annual rates of influenza vaccination for health care workers and other personnel eligible to receive vaccination; assess the rates of influenza vaccination for patients. Ensure that needle disposal containers are no more than three-quarters full at time of disposal. Periodically monitor and record adherence with the hand hygiene guidelines: the number of times personnel washed their hands divided by the number of hand-hygiene opportunities, computed by ward or by service. Provide feedback to personnel regarding their performance. Monitor the volume of alcohol-based hand rub (or detergent used for handwashing or hand antisepsis) used per 1,000 patient days. When outbreaks of infection occur, assess the adequacy of health care worker hand hygiene. When a patient with a known colonization or infection with a multidrug-resistant organism (e.g., MRSA, VRE) is transferred to your facility, evaluate effectiveness of system notification to health care personnel in the receiving facility. Record compliance with hospital policy for catheter-site dressing changes.” (N)
“Hospitals have several different options to consider when monitoring compliance. • Direct observation: This method involves monitoring the actual hand hygiene actions of staff. It can be done manually – with an actual person doing the monitoring – or it can be done with the assistance of technology such as smartphone apps. The smartphone apps can improve the likelihood of making covert observations and reduce the instances of Hawthorne effect, which is a social occurrence in which individuals alter or improve their behavior in response to their awareness of being observed. • Measuring product use: This is an indirect way of conducting observations by quantifying the amount of soap and sanitizer used. Mathematical models can be used to determine how many hand hygiene opportunities there were versus how often staff actually took advantage of these opportunities. • Electronic monitoring: Several different types of sensors are now available to measure handwashing compliance. While they can be expensive, a major benefit of electronic monitoring is it can provide administrators with real-time feedback on compliance prior to a healthcare worker’s interaction with patients.” (O)
“More than 5,200 nurses and other caregivers in 71 units at 42 hospitals across multiple states were given a radio frequency identification (RFID) badge that recorded when they triggered the ubiquitous sanitizer dispensers typically placed near the entrance to a room. Researchers monitored the tracking for as long as three and half years, ending in August 2013. There were an estimated 20 million hand-washing opportunities to study. The researchers focused on “total daily usage per unit bed,” a calculation in which the number of times total dispensers in a given hospital unit were used each day was divided by the number of beds in that unit. Nice Start… Personal tracking did indeed trigger an initial improvement. The daily usage of dispensers jumped from an average of 28.4 times per day in the 17 days before the tracking commenced, to 46 times a day at launch. Workers who did not receive a badge did not show any change in hand-washing habits. …But No Sustained Momentum Hand-washing continued to improve for more than a year and a half, but then peaked at month 20. As the graph above shows, three years into the project, usage had backslid to where it was in the first month. That said, the researchers calculate that it would be a full 10 years of waning compliance before hand hygiene habits fell to where they were before the monitoring program was introduced – though a sub-50 compliance rate is no one’s idea of optimal. Clearly, technology in a vacuum is not the solution. “Managers cannot simply ‘monitor and forget,'” the researchers wrote. “There is a need for ongoing managerial interventions to sustain the benefits of monitoring.” (P)
“HyGreen Inc., Gainesville, Fla., provides just-in-time coaching to health care workers when they forget to wash, and records the information in real time, says Elena Fraser, vice president of sales and marketing. “The instant the health care worker dispenses the hand wash, both the light-emitting diode on the top of the HHCM sensor and the badge turn green. At the same time, a wireless signal documents the worker identification, time and location and sends that information to the database,” she explains. When the health care worker steps into a zone that is created by a monitor over the patient bed, the monitor recognizes that the badge is green. Again, time, location and worker ID are transmitted to the database. If the health care worker forgets to wash his or her hands, the bed monitor will cause the badge to vibrate, which serves as a subtle reminder.” (Q)
“Vanderbilt already had a traditional hand-hygiene program in place, but it was doing little to improve hand-washing rates. So the doctors took a different approach, focusing on three important areas: Training. Every single hospital employee received training on correct hand-washing protocol, from clerical workers to chief surgeons. The training program placed much of its focus on the direct link between hand-washing and hospital-acquired infections. Communication. Peer-to-peer communication was key to making the program work. Staff members were encouraged to speak up and remind each other of correct hand-washing practices if they noticed lapses. If someone received a reminder, the only correct response was “Thank you.” Shared accountability. All staffers were held equally accountable for their unit’s success with achieving high hand-washing rates, even if they were visiting surgeons. Designated employees were tasked with monitoring how closely everyone followed established protocols, and units that didn’t meet established targets were encouraged to boost their performance as a whole. Staffers were also rewarded based on their collective performance in improving hand-washing rates.” (R)
“The My 5 Moments for Hand Hygiene approach defines the key moments when health-care workers should perform hand hygiene.This evidence-based, field-tested, user-centred approach is designed to be easy to learn, logical and applicable in a wide range of settings. This approach recommends health-care workers to clean their hands; before touching a patient; before clean/aseptic procedures; after body fluid exposure/risk; after touching a patient, and; after touching patient surroundings.” (S)
Few scientific studies have evaluated measurement techniques; a recent review of the reliability and validity of hand hygiene measures found that only 28% of research articles and guidelines related to hand hygiene measurement included any mention of reliability or validity. Methodology between studies varies a great deal, including how adherence or non-adherence is defined and how observations are carried out; in addition, sufficient details concerning the methods and criteria used are often lacking. The following are some of the specific challenges to measuring hand hygiene adherence: • Contact with patients and their environment takes place in many locations within organizations. • Opportunities for hand hygiene occur 24 hours a day, 7 days a week, 365 days a year and involve both clinical and nonclinical staff. • The frequency of hand hygiene opportunities varies by type of care provided, unit, and patient factors. • Monitoring is often resource intensive; infection preventionists, quality improvement staff, and other health care workers (for example, nursing, respiratory therapy) face numerous competing demands for their time and expertise. • Observer bias (such as the Hawthorne effect) is difficult to eliminate.” (T)
It’s a simple enough request, but for patients and families who feel vulnerable, scared or uncomfortable in a hospital room, the subject can be too intimidating to even bring up with a doctor or nurse: Have you washed your hands? Hospitals are encouraging patients to be more assertive, amid growing concern about infections that are resistant to antibiotics. Strict hand hygiene measures are the gold standard for reducing infections associated with health care. Acquired primarily in hospitals but also in nursing homes, outpatient surgery centers and even doctor’s offices, they affect more than one million patients and are linked to nearly 100,000 deaths a year, according to the Centers for Disease Control and Prevention. The CDC aims to engage both patients and caregivers in preventing dangerous hospital infections. Centers for Disease Control. Yet despite years of efforts to educate both clinicians and patients, studies show hospital staff on average comply with hand-washing protocols, including cleansing with soap and water or alcohol-based gels, only about 50% of the time. (U)
(2013) “At North Shore University Hospital on Long Island, motion sensors, like those used for burglar alarms, go off every time someone enters an intensive care room. The sensor triggers a video camera, which transmits its images halfway around the world to India, where workers are checking to see if doctors and nurses are performing a critical procedure: washing their hands.” (V)
(2012) “But there are skeptics. “Another potential issue with the video observation is a false accusation of failure to wash. Patient rooms and patients themselves are not being watched. Let’s say a nurse went into a patient’s room to tell him something and didn’t touch anything. A person in India watching a video from a camera focused on a door or sink would not be able to tell that. If the nurse doesn’t wash her hands when she leaves the room, is she going to be cross-examined? (W)
“Healthcare can benefit from the power of cameras to improve accountability,” Makary, Pawlik and Xu conclude. “In an era where 86% of nurses report having recently witnessed disruptive behavior at work, hand washing compliance remains highly variable, and many physicians do not use evidence based medicine, recorded video can be an invaluable quality improvement tool. If concerns about consent, privacy, and data security are dealt with carefully, video data can tell a story that simply cannot be matched by written documentation.” (X)