Iatrogenic disorders. Never events. Incidentalomas

“Jon, I recall learning about iatrogenic medicine in grad school; an under-the radar sub-specialty.” (email from Leon Silverberg, a health care MBA student in my  class 45 years ago)

Have you ever coerced your physician to prescribe an antibiotic (think sinus “infection”) or gone to a physician who prescribes antibiotics too automatically? (A) I used to demand and hoard antibiotics. I have stopped and now ask my physicians to explain why they are prescribing an antibiotic.

Overprescribing of antibiotics and other medical care decisions can have adverse consequences often referred to as “iatrogenic.”

“An iatrogenic disorder occurs when the deleterious effects of the therapeutic or diagnostic regimen causes pathology independent of the condition for which the regimen is advised….. Diagnostic procedures (mechanical and radiological), therapeutic regimen (drugs, surgery, other invasive procedures), hospitalization and treating doctor himself can bring about iatrogenic disorders. (B)

Another important term is “Never Events”……”in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.” (C)

So…. here are some examples of medical care to monitor.

 

Wrong Site Surgery.

“Of great concern is wrong-site surgery (WSS), which encompasses surgery performed on the wrong side or site of the body, wrong surgical procedure performed, and surgery performed on the wrong patient. This definition also includes “any invasive procedure that exposes patients to more than minimal risk, including procedures performed in settings other than the OR [operating room], such as a special procedures unit, an endoscopy unit, and an interventional radiology suite.”

Solutions: “to improve the accuracy of patient identification by using two patient identifiers and a “time-out” procedure before invasive procedures.” … “to eliminate wrong-site, wrong-patient, and wrong-procedure surgery using a preoperative verification process to confirm documents, and to implement a process to mark the surgical site and involve the patient/family.” (D)

 

Over Use of Antibiotics.

“’Nightmare bacteria,’ strains of superbugs resistant to even the most powerful antibiotics, have quadrupled in number in the last decade—and have been found lurking in hospitals in 42 states.” “(E)

“Antibiotics are considered the keystone of modern medicine, but their excessive use continues to generate unwanted side effects.

While specialists are making strides to preserve the effectiveness of antibiotics and to slow potential infections through better policy, the overuse of antibiotics continues to have severe health consequences for the U.S. and around the world. (F)

 

Medication Errors

“… any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use”.  (G)

 

Incidentalomas

….are “incidentally discovered masses or lesions, detected by computed tomography (CT), magnetic resonance imaging (MRI), or other imaging examinations performed for an unrelated reason. (H)

Incidentalomas are increasingly common findings on radiologic studies, causing worry for physicians and patients. Physicians should consider the risk of discovering incidentalomas when contemplating imaging. Patients may assume that incidentalomas are cancer, and may not be aware of the radiation risks associated with repeat imaging. (I)

“Many radiologists and nonradiologic physicians believe we should not report incidentalomas if they appear benign. As pointed out by 2 medical researchers, “Tests that provide information about unrelated conditions leave the physician and patient to contend with information they had not sought but which they find impossible to ignore; patients would be better served if physicians limited their access to unsolicited diagnostic information.”” (H)

 

 Having said that, your best resource in avoiding an iatrogenic  emergency is a great primary care physician.

 

(A)          http://www.medscape.com/viewarticle/827888

(B)          http://medind.nic.in/maa/t05/i1/maat05i1p2.pdf

(C)          https://psnet.ahrq.gov/primers/primer/3/never-events

(D)          http://www.ncbi.nlm.nih.gov/books/NBK2678/

(E)           http://www.npr.org/2013/03/08/173821490/nightmare-bacteria-defy-even-last-ditch-drugs

(F)           http://www.healthline.com/health-news/five-unintended-consequences-antibiotic-overuse-031114#1

(G)          http://www.amcp.org/WorkArea/DownloadAsset.aspx?id=9300

(H)          http://www.medscape.com/viewarticle/779377

(I)            http://www.ncbi.nlm.nih.gov/pubmed/25611713

 Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

 

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How Doctors Think

As you may have figured out by now I follow information about the health care industry pretty closely. As a hospital CEO for seventeen years, the New York Times, Newark Star Ledger and Jersey Journal were on my desk every morning when I walked in the door. Then as an adjunct professor in two graduate programs, and with the instantaneity of the internet, I got about a half a dozen news updates and summaries immediately, daily and weekly. But even with this constant immersion, sometimes articles are so compelling that I have to stop and think about the implications. This happened recently.

I was startled (and reminded) by a recent New York Times article (A), “Medical Errors May Cause Over 250,000 Deaths a Year” which noted: “If medical error were considered a disease, a new study has found, it would be the third leading cause of death in the United States, behind only heart disease and cancer.

Medical error is not reported as a cause of death on death certificates, and the Centers for Disease Control and Prevention has no “medical error” category in its annual report on deaths and mortality. But in this study, researchers defined medical error as any health care intervention that causes a preventable death.

For example, in one case a poorly performed diagnostic test caused a liver injury that led to cardiac arrest, but the cause of death was listed as cardiovascular. In fact, the cause was a medical error. Diagnostic errors, communication breakdowns, the failure to do necessary tests, medication dosage errors and other improper procedures were all considered medical errors in the study.”

Soon after a Washington Post article (B), “Exclusive: Patient safety issues prompt leadership shake-up at NIH hospital,” noted: “The National Institutes of Health is overhauling the leadership of its flagship hospital after an independent review concluded that patient safety had become “subservient to research demands” on the agency’s sprawling Bethesda campus.

The shake-up at the NIH Clinical Center, which was announced to staff Tuesday, represents the most significant restructuring at the nation’s premier biomedical research institution in more than half a century.

NIH Director Francis Collins said he will replace the hospital’s longtime leadership with a new management team with experience in oversight and patient safety, similar to the top structure of most hospitals….”

These articles sent me looking for a 2007 classic book – “How Doctors Think” (C) by Dr. Jerome Groopman, Chairman of Medicine at Harvard Medical School.

Discussing actual cases from his own clinical practice, Dr. Groopman developed a classification system for medical mistakes, observing a tendency to treat a case based on past experience rather than looking at it based solely on the evidence.

“Vertical Line Failure – thinking inside the box

Confirmation Bias – confirming what you expect to find by selectively accepting or ignoring information

Anchoring –the failure to consider multiple possibilities but quickly and firmly latching on a single one

Availability –an unusual event that recently occurred which has similarities to the current case causing MD to ignore important differences

Commission Bias – tendency toward action rather than inaction due to “bravado”, desperation, or patient pressure

Relying on “Strict Logic” – answering a clinical question in the absence of empirical data

Over-reliance on Clinical Algorithms – simply filling in the blanks on the template

Haste – complicated problems cannot be solved quickly

Outcome Bias – thinking that the diagnosis that is wished for has occurred• Limited Searching –stop searching for a diagnosis once “

 

This is not to criticize physicians who get most things right and in a very challenging, fast-moving environment occasionally make mistakes.

The point is we all fall into comfortable patterns of thinking – our own default classification systems.

As always Groopman is a wake-up call for me.

 

(A) http://well.blogs.nytimes.com/2016/05/03/medical-errors-may-cause-over-250000-deaths-a-year/?_r=0

(B) https://www.washingtonpost.com/national/health-science/exclusive-patient-safety-issues-prompt-leadership-shake-up-at-nih-hospital/2016/05/10/ad1f71f6-0ffb-11e6-8967-7ac733c56f12_story.html?wpmm=1&wpisrc=nl_evening

(C) http://www.jeromegroopman.com/how-doctors-think.html

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Former hospital prez says: Designate local Zika centers now. Medical experts do not know if, or where, or how much, or on what trajectory the Zika virus may spread across the United States.

Former hospital prez says: Designate local Zika centers now
Hudson Reporter
http://www.hudsonreporter.com/view/full_story/27199087/article-Former-hospital-prez-says–Designate-local-Zika-centers-now-?instance=top_story
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The following is an editorial submitted by Dr. Jonathan M. Metsch, a health educator and the former CEO of Jersey City Medical Center who is also a Hoboken resident

Medical experts do not know if, or where, or how much, or on what trajectory the Zika virus may spread across the United States. Nor do they know how else Zika might spread besides by certain types of mosquitos and by some types of sexual activity. However, the risks to pregnant women are well documented.

In fact, on Tuesday, a Honduran woman with the Zika virus gave birth at Hackensack University Medical Center to a baby girl with birth defects, and one of her doctors said they appear to be caused by the mosquito-borne virus, according to a story in the New York Times.

Of the more than 500 Zika cases so far in the U.S., all involved people infected in outbreak areas in South America, Central America, or the Caribbean, or people who had sex with infected travelers, the Times reported. The story noted that mosquitoes aren’t yet spreading Zika in the continental U.S., but experts predict small outbreaks are possible as mosquito season heats up.

Yes, it’s true that Zika is different from Ebola. But there are lessons to be learned from the 2014 Ebola scare relevant to planning for Zika. For example, Zika should not be considered treatable at any or every hospital.

According to the federal Center for Disease Control (CDC), “There is no vaccine to prevent or medicine to treat (the) Zika virus.”

One might argue that any hospital can take care of a Zika patient. But since there is no treatment, there’s an elevated risk for microcephaly – a birth defect that leaves babies with malformed heads and brains – and serious possible sequela such as Guillain–Barré syndrome, and since we cannot predict the trajectory or volume of a Zika surge, patients should initially be aggregated to develop evidenced-based care protocols.

The federal government should immediately develop guidelines for Zika regional referral centers (ZRRC)s, followed quickly by the designation of ZRRCs.

If there is no surge as mosquito season spreads across the county and if the severity of index cases is minimal, where to admit Zika patients can be reconsidered. But it would be better to start with robust, focused preparation and adapt to the situation as it actually emerges.

Meeting the virus head-on

In 2014, I suggested several anchor principles for Ebola preparedness in New Jersey, as hospitals of all sizes and scope “marketed” their Ebola readiness, only to learn that it took well over 20/ 25 full time staff to care for one Ebola patient (and 50 in Dallas!).

These recommendations included that every hospital that certified its Emergency Room as ready for Ebola be subject to at least three separate drills using a standardized form, and then be subject to random “secret shopper” inspections; that anyone with a confirmed or suspected Ebola diagnosis be immediately transferred to a regional center hospital designated by national standardized criteria which could demonstrate that it has sufficient nursing staff “volunteers” to care for a least five patients round the clock; and that isolation hospitals be readied for instant activation, whether a closed hospital prepared for Ebola now and standing by, or a “virtual” hospital ready-to-go in military fashion.

Also there was a need to minimize Ebola patients walking into an ER unannounced, and suggested a statewide 800 number be established so patients can call ahead and be transported by a prepared ambulance team and taken to a regional center.

Similar organizing principles are urgently need to be established for tiered Zika hospital preparedness. Here are some thoughts.

1. There should not be an automatic default to just designating Ebola Centers as ZRRCs, although there is likely to be significant overlap.

2. Zika Centers should be academic medical centers with respected, comprehensive infectious disease diagnostic/ treatment and research capabilities, and rigorous infection control programs. They should also offer robust, comprehensive perinatology, neonatology, and pediatric neurology services, with the most sophisticated imaging capabilities (and Zika-related “reading” expertise).

3. National leadership in clinical trials.

4. A track record of successful, large scale clinical Rapid Response.

5. Organizational wherewithal to address intensive resource absorption.

6. Start preliminary planning for Zika care out of the initial designated ZRRCs.

Zika protocols will be templates for are other mosquito borne diseases lurking on the horizon, such as Chikungunya, MERS, and Dengue.

– Jonathan M. Metsch, Dr.P.H.

Clinical Professor, Preventive Medicine, Icahn School of Medicine at Mount Sinai

Adjunct Professor, Management, Zicklin School of Business, Baruch College, C.U.N.Y.
Adjunct Professor, Rutgers School of Public Affairs and Administration & Rutgers School of Public Health
President & CEO, LibertyHealth/ Jersey City Medical Center (1989-2006)

 

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Unlike Joan Rivers who died in a surgi-center during a routine procedure, I would only be given general anesthesia on a hospital campus.

My first experience in taking anesthesia seriously was in 1970 as the Administrative Officer (with the rank of second lieutenant) of the Department of Surgery at Wilford Hall USAF Medical Center. I met an oral maxillofacial surgery resident (a dentist) who was doing a rotation in anesthesiology. Did the patients know who was putting them to sleep?

Around the year 2000 when I had Achilles tendon surgery (It would great if I could tell you the injury was caused by some outrageous athletic adventure, but it just happened….zip, zip, zip, pow!). A doctor walked in the pre-op room, said he was going to do the nerve block, sign here. When I asked his status, I had to ask, he said he was a chief resident. I told him I wanted to see the attending who came in and insisted the resident was better than he was at this. The attending did the nerve block when I insisted he do it.

In 2002 the New York Times reported: “Massachusetts has indefinitely suspended a surgeon’s medical license because he left a patient anesthetized on an operating table with an open incision in his back while he went to a bank several blocks away.” (1)

(Settlement Reached in Joan Rivers Malpractice Case. “In 2015, Ms. Rivers’s daughter, Melissa, filed a lawsuit in State Supreme Court in Manhattan against Yorkville Endoscopy, a for-profit outpatient surgery center where Ms. Rivers, 81, was undergoing a relatively routine procedure when she died in 2014. The suit also named Dr. Gwen Korovin, an ear, nose and throat specialist; Dr. Renuka Bankulla, the main anesthesiologist, and two other anesthesiologists; and Dr. Lawrence Cohen, who stepped down as the clinic’s medical director.”) (2)

Over the years many family members and friends have called me about their research on getting the most appropriate and best surgeon for a serious problem. When I asked them about anesthesia I cannot recall one case where they knew who was putting them to sleep and what type of anesthesia was going to be administered.

So here are some basics.

1. Who will be directly administering the anesthesia? For example; an M.D. trained and board certified (or not) in anesthesiology; an anesthesiology resident-in-training; a sub-specialist such as a cardiac, neurosurgical, obstetrical or pediatric anesthesiologist; an M.D. in residency training in another specialty (e.g., general surgery, ob/gyn, dentistry) rotating through anesthesiology; or a Certified Registered Nurse Anesthetist (CRNA).

2. What type of anesthesia will you be getting?

“In general anesthesia, you are unconscious and have no awareness or other sensations. There are a number of general anesthetic drugs – some are gases or vapors inhaled through a breathing mask or tube and others are medications introduced through a vein.

In regional anesthesia, your anesthesiologist makes an injection near a cluster of nerves to numb the area of your body that requires surgery. You may remain awake, or you may be given a sedative, either way you do not see or feel the actual surgery taking place. There are several kinds of regional anesthesia; the two most common are spinal anesthesia and epidural anesthesia.In local anesthesia, the anesthetic drug is usually injected into the tissue to numb just the specific location of your body requiring minor surgery.” (3)

3. Where will your procedure be done? In a hospital operating room. In an OR in a surgi-center on the hospital campus. In a free-standing surgi-center in the community. In a doctor’s office with an operating room. In a dentist’s office.

4. Is the anesthesiologist in-network?

A rule-of-thumb worth considering. The more serious the surgery and the use of general anesthesia, have the procedure done in a hospital “O.R., or in a surgi-center on a hospital campus.

Talk to your surgeon about anesthesia options well before the day of surgery and discuss whether you should meet with whoever will be administering your anesthesia too. And…it is always a good idea to talk to your primary care practitioner, the clinician who knows you best.

(1) http://www.nytimes.com/2002/08/09/us/surgeon-who-left-an-operation-to-run-an-errand-is-suspended.html

(2) http://www.nytimes.com/2016/05/13/nyregion/settlement-reached-in-joan-rivers-malpractice-case.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

(3) https://www.asahq.org/lifeline/types%20of%20anesthesia

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

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What’s in your wallet? Are you prepared for a medical emergency while on vacation? Some suggestions…

When preparing for your vacation here are some health care preparedness steps to consider taking.

First, make sure you carry all medications (prescription and “over-the counter”) that you take daily, or when needed, with a few extra days worth in case you are delayed getting home.

Second, if travelling abroad make sure your vaccinations/ immunizations are up-to-date.

Third, carry the following information:

1. All your health insurance and prescription drug cards and the “800” numbers to call if you need “prior approval” or are “out of network” (if you have a card listing copayments, that too)

2. The business cards of your PCP and any other physicians you see regularly

3. A list of all the medications you take daily (and as needed)

3. Your immunization record ( I still have mine from the Air Force circa 1967)

4. A card with anything you are allergic to….medications, foods, stings etc..

5. If doable how to connect to your Electronic Health Record (EHR or EMR)

6. Ask your physician if you should carry a copy of a recent EKG

7. And for seniors your Living Will and Health Care Proxy

Go over this list with your Primary Care Physician.

Make sure a family member knows what you are carrying or has a complete set as well.

And remember EMERGENCY ROOMS are not all created equal!    http://doctordidyouwashyourhands.com/2016/04/emergency-rooms-are-not-all-created-equal/

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

To read previous posts click on http://doctordidyouwashyourhands.com/

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About Jonathan

http://icahn.mssm.edu/profiles/jonathan-m-metsch

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Hospital web site archeology

When “googling” for hospital information we often wind up at hospital web sites.

Hospital web sites are marketing based so how does one find and aggregate key elements and then do comparative analysis?

You can use these web sites for this exercise, all hospitals I have been involved with

Jersey City Medical Center (I was President & CEO from 1989-2006)   http://www.barnabashealth.org/Jersey-City-Medical-Center/About-Us.aspx

Mount Sinai Hospital (various positions at the medical school and medical center from 1979-1989, leaving as an SVP)   http://www.mountsinai.org/?lastName=O

CarePoint Health/ Hoboken (I was on the Board of the Hoboken Municipal Hospital Authority for three years)   https://www.carepointhealth.org/hoboken-university-medical-center#xDk1A

Meadowlands Hospital Medical Center (was part of LibertyHealth with Jersey City Medical Center) http://meadowlandshospital.org/

Ok, let’s get started:

Find ABOUT US. This is the picture painting how the hospital wants to be envisioned.

Find the MISSION STATEMENT, a formal summary of the aims and values of the hospital, as approved by the Board of Trustees and required for accreditation.

Compare ABOUT US and the MISSION STATEMENT. Are they clear and consistent?

Find ACCREDITATION. This gets trickier. A long list of certifications is not in of itself important. What is important is are they evidenced-based, completed by an arms-length review, and for a fixed period of time then must be renewed. You can google the agency and find the methodology used.

Find QUALITY. Again quality recognition awards should be evidenced-based, completed by an arms-length review, and for a fixed period of time then must be renewed. You can google the agency and find the methodology used.

Find AFFILIATIONS. A medical school affiliation is an excellent benchmark, however is it robust or ceremonial?

Go to LEADERSHIP/ BOARD OF TRUSTEES. Are Board member recognized community leaders?

And then go to

HOSPITAL COMPARE https://www.medicare.gov/hospitalcompare/search.html At this MEDICARE site you can compare hospital performance metrics.

THE LEAPFROG GROUP http://www.leapfroggroup.org/compare-hospitals an independent organization where you can compare hospital quality metrics

AGENCY FOR HEALTHCARE RESEARCH AND QUALITY http://archive.ahrq.gov/consumer/qnt/qnthosp.htm “How can you choose the best quality hospital for the care you need?”

AVOID for-profit “hospital quality” web sites which sell marketing packages to hospitals which pay to be surveyed!

 

 

 

 

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Stress Tests for super-size NFP hospital systems already too big to fail!

When I was growing up in Queens in the late mid-1950s the two “go-to” hospitals were Long Island Jewish and Booth Memorial.

In the early 1970’s the hospital system in the NYC metropolitan area was anchored and dominated by internationally renowned academic medical centers (then defined as a medical school and its primary teaching hospital on the same campus) – e.g., Columbia Presbyterian, Mount Sinai, NYU and Cornell. Academic affiliations were in place with area hospitals for teaching medical students and training residents.

Probably triggered by the North Shore/ LIJ merger in 1997 (North Shore was already a regional system with 10 hospitals) we have seen a rapidly accelerating merger trajectory from regional hospital systems focusing on becoming integrated health care delivery systems, to mega systems focusing on geographic reach, to super-size systems which have started or taken over medical schools, functioning almost like insurance companies and investment banks.

Some examples of the scale of super size systems:

North Shore, recently rebranded itself as Northwell Health, has annual revenue of $7.0 billion.  The LIJ name is history. http://medicine.hofstra.edu/about/history/history_nslij.html

The Mount Sinai Health System * has 3,535 beds on 7 hospital campuses.http://www.mountsinaihealth.org/about-the-health-system/facts-and-figures

New York Presbyterian includes two medical schools. Booth Memorial is now NYP Queens. http://www.nyp.org/about-us

RWJBarnabas Health, created last month by the merger of two mega systems, serves a geographic area that covers 5 million people, or more than half of New Jersey’s population. http://www.mycentraljersey.com/story/money/business/consumer/2016/03/31/robert-wood-johnson-barnabas-health/82489800/

To be followed imminently by the merger of Hackensack and Meridian https://www.meridianhealth.com/media/press-releases/2016/hackensack-university-health-network-and-meridian-health-announce-board-members.aspx

Geisinger, the powerhouse in central, south-central and northeast Pennsylvania now includes AtlantiCare in New Jersey http://www.geisinger.org/pages/about-geisinger/index.html  A number of New Jersey hospitals have academic and programmatic affiliations with NYC and Philadelphia medical schools.

All of the super-size systems are not-for-profits.

The NFP corporate veil has been weakened by the Atlantic Health System, owners of the Morristown Medical Center, agreeing to pay the town $15.5 million over the next 10 years in a property tax settlement based on its for-profit subsidiary profits. http://www.nj.com/morris/index.ssf/2015/11/atlantic_health_to_pay_morristown_155m_to_settle_t.html This is a template for all NFP hospitals in New Jersey and nationwide.

In New Jersey for-profit systems have been created or bought previously NFP hospitals. While “prohibited” in New York, recently there was talk of allowing for-profits demonstration projects particularly focused on rebuilding the hospital system with “other people’s money.”

In April “The Federal Reserve and the Federal Deposit Insurance Corporation said on Wednesday that five of the nation’s eight largest banks — including JPMorgan Chase and Bank of America — did not have “credible” plans for how they would wind themselves down in a crisis without sowing panic.” http://www.nytimes.com/2016/04/14/business/dealbook/living-wills-of-5-banks-fail-to-pass-muster.html

Are NFP super size hospital systems structured to handle a “bubble”? Are we ready for some to become “for-profits” to have access to capital?

The FTC opposed the 1997 North Shore/ LIJ merger, which was “approved” through litigation. Now in New Jersey and New York Certificates of Need for super-size mergers are awarded in a few months time.

Maybe it’s time for STRESS TESTS!

 

 

* Disclosure: I have been on the faculty at Mount Sinai for over forty years.

 

 

 

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