July 1, 2008

Six Quick Changes That Will Lead To Better or More Cost Effective Hospital Care

It took me longer to write this then it will to implement the changes.

Consolidate the chart

A patient's medical chart is literally a big notebook.  But it's not diary format-- doctors, nurses, and other staff do not write their notes in the same places in a chart.  They're in separate sections of the chart. Yes.  Just like sixth grade.

It's hard enough to motivate doctors to read through the nurses' notes written right there on the same page; if it's in a separate tab, forget it.
One of the biggest factors in hospital malpractice cases is discrepancies between what the nurse wrote and what the doctor wrote.  The nurse wrote "patient agitated" and the doctor wrote "patient euthymic."  Maybe the nurse was wrong--a single line from the doctor might suffice ("nurse noted agitation, but this has resolved.")

But if the doctor doesn't see it--and why would he, it's in a whole other tab!-- he can't address it.  And then you have two witnesses, one of whom is unreliable but-- which one?--  saying two disparate things.  Good luck with that.
We should go back to diary format, including consultations and labs. 

Doctors must re-write the prns given in their note.

As above, the nurse will document the administration of, say, Ativan, in the nurse's note, which is in a separate section the doctor doesn't read.  But: it is common practice for nurses to chart the medications in an entirely separate notebook.  Many doctors are not aware of this, so don't know to look for it.  Even worse than that: upon discharge, this medication administration record is inserted into the real chart (notebook)--so for future lawyers, it looks like the information was there all along.

I have seen countless cases where patients were getting an extra 9-15mg of insulin a day from a sliding scale, only to be discharged back on their old regimen-- if any insulin at all.  The doctors thought the standing regimen was enough.  Nurses appropriately administer and chart the doses-- but this is done somewhere else.  Similarly, extra Haldol or Ativan doses are being given by nurses prn, charted appropriately, but the doctor doesn't know it.  He has a sense of it--perhaps in rounds he was told it was given--but it isn't real.  So when he discharges an improved patient on 15mg Zyprexa, when it really was 15mg Zyprexa + 10mg Haldol that got the patient better.

There is only one solution: doctors must rewrite the prns in their own note-- literally copy them down the way they copy lab values off the computer into their note.  It proves they know, and forces them to account for it, it makes it real.  No, this isn't a suggestion: it has to be a mandated policy, or it will never happen.

Medication templates

Medications and dosages are always at the discretion of the doctor, but many doctors prescribe according to habit or expediency.

You have to make it convenient for doctors to do the right thing, or slightly inconvenient to do the wrong thing.

Are doctors using too much cogentin (2-4mg/d) with their Haldol orders?  Make a template that says "cogentin 0.5mg/d prn EPS."  Too much Ambien, not enough Restoril?  Make a template that has Restoril as the prn sleeping med.

Too many branded SSRIs over generics?  Make a template with all the generics but none of the branded, e.g.

Celexa 10mg/d
Prozac 10mg/d
Zoloft 25mg/d
Paxil 10mg/d
Wellbutrin SR 100mg/d

But no Lexapro or Effexor.  Note that in the above example, I have used the branded name for the existent generic medications--you check off Paxil, the patient will get paroxetine.  Psychology!

Some medications need special administration instructions that may not be... appreciated by the doctor.  For example, Geodon 40mg BID is not going to work; Geodon loses as much as 40% of its absorption in the absence of fat, and BID means 8am and 10pm.  The order should be preprinted: Geodon ___ mg  with breakfast    ___mg  with dinner.

It goes without saying, the doctor can write-in any medication he wants.

Other physicians vs. you:

A chart showing your habits vs. the community is very powerful.  Are you the biggest Klonopin prescriber in the city?  Most branded meds? More Seroquel 25mg than anyone else? 

Average length of stay by diagnosis? Number of medications upon discharge?  Number of restraints, etc?

Privacy need not be a concern.  The data already exists.  Each doctor can receive an automated printout of the data monthly.  There is no punishment assigned to it, but each doctor's superego will push practice a little more to the rigorous.

If a psychiatrist wants to admit a patient to the hospital, he must do the precert himself

Wow.  This one is beyond obvious.

Ordinarily, if a patient goes into an ER, and the psychiatrist determines the patient needs to be admitted to a psychiatric ward, he will tell the nurse or social worker his decision--and then go get lunch.  The social worker will call the insurance company to "precert"-- i.e. get insurance approval for the hospitalization. 

Accept that at any given moment, at least 30% of the inpatients do not need to be there--they could be more cost effectively managed elsewhere, or treatment is more appropriate elsewhere. (Yes, being in the hospital can sometimes be harmful in the long run.)  This is even more true if the ward is a "dual diagnosis" unit, i.e. psychiatric disorders with addiction issues.  If a Medicaid hospitalization is $600/d, a perfectly legitimate question is if he is better served in a 5 day hospitalization, or in a rehab with a check for $2000 to pay his rent? 

It is extremely common that people fake suicidality to get into the hospital-- maybe they're homeless, maybe they're in drug withdrawal and want to get detoxed, maybe their girlfriend kicked them out, etc.

The problem is that even when the doctor strongly suspects the guy is lying, he'll admit him anyway-- it is the path of least resistance.  The only "work" the doctor has to do is decide to admit; the social worker has to do the rest.

If the doctor had to do it, it would be a disincentive to admit someone he did not believe needed to be admitted.

But hold on: I don't mean the resident should do this-- I mean the attending should have to do it.  Otherwise, it's no different than having a social worker do it, the attending has no disincentive to choose the path of least resistance.

Similarly, once the patient is admitted, the inpatient doctor should have to do a review with the insurance every X days--not the social worker, as it is done now.  That single phone call is a powerful disincentive to keep people too long in the hospital.

Perhaps you are worried they will be discharged too quickly: don't.  Most doctors are reasonably prudent in their discharges--they err on the side of too long, not too short.  And don't forget: as much as doctors may hate insurance reviews, they hate depositions way more.

I'll tell you this up front: many doctors will riot.  Those are exactly the doctors you need to fire.  They don't get it, they don't want to even consider trying to get it, they do not see that medicine is a system, they still think it is a solo career of infinite resources.  "You expect us to do this, on top of everything else?"  There isn't anything else.  That's the point.  It's all one thing, not several different things.

Ban smoking, or make it completely unrestricted

Most inpatient units allow 2 or 3 scheduled smoke breaks.  Here's the problem: the metabolism of Haldol and Zyprexa, among other medications, is vastly accelerated by smoking.    A pack a day cuts the dose in half.  So it looks like the guy was stable on 10mg Zyperxa on his last hospital day; then he goes back to outpatient regimen of 1-2 packs of  Lucky Strikes per day and that 10mg is now 5mg.  Wicked.

So either you get them to quit in the hospital, or you acknowledge reality and dose to reality.


Interesting post. I though... (Below threshold)

July 1, 2008 12:45 PM | Posted by Dr DJ: | Reply

Interesting post. I thought I might draw some parallels with what we do here in the UK.

Where I work the way the charts (or notes as we say here) are kept are at the discretion of each ward manager, but over the past two years we have moved over to consolidating notes into a diary format. The few clinical areas where nursing bits and doctors' bits are kept seperately causes a huge amount of dysfunctional team dynamics.

In the UK all prns are charted and kept on the same prescription cards as regular meds. Covering doctors rewriting cards generally document their actions in the notes. Junior doctors are indoctrinated into condensing multiple cards down as much as possible, although this rarely happens until the pharmacist pulls your ear.

In the UK we have lots of medication templates. Lots and lots of them. So much that people argue that we have too many. One thing that is at huge contrast with the US is we always prescribe the generic name, even if the only preperation available is a branded drug. If a british doctor prescribes Prozac instead of Fluoxetine, the pharmacist is only allowed to prescribe that branded drug, hence more cost to the NHS and more doctors' ears being pulled by pharmacists.

Individual prescribing patterns of UK doctors is not that easily available except in Primary Care or shared care prescribing between hospitals and family doctors. No comment on the precert, although in the UK if someone is coming into hospital via a detention order, it is left for the social worker to be the one to get their hands dirty.

Most psychiatric hospitals in the UK allowed free smoking policies for inpatients until the national ban (1 year ago to the day), and some hospitals have completely banned it with help for people quitting, but where I work it has been the situation you describe, cigarette runs off the premises neither here or there.

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Hi Doc, As yo... (Below threshold)

July 1, 2008 3:07 PM | Posted by Diane Abus: | Reply

Hi Doc,

As you philosophy and enter Science you -it's lost on me.

Roc on (we all have a job to do for the planet)Many interesting ideas.Good bar talk............BI

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This is fantastic informati... (Below threshold)

July 2, 2008 12:00 PM | Posted by nathaniel engelsen: | Reply

This is fantastic information towards improving a side of healthcare I don't know much about. Thanks.

On the side I do know about, i.e. backoffice procedures, we can save a lot of money going single payer. Say what you want about "socialized medicine" or what have you, having just one person to bill will save a LOT of overhead by standardizing the format that we use to submit payment.

I actually like "socialized medicine" because I believe we could get rid of medical malpractice torts as well. If you know your healthcare is going to be paid for anyway there is no need to sue for damages. And if it was malicious or if the doctor was negligent enough, just ban them for life as a punitive measure -- no 8-figure settlements.

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Some more strong statements... (Below threshold)

July 5, 2008 12:44 PM | Posted by Anonymous: | Reply

Some more strong statements that nobody wants to hear:

1. Most nurses' notes are crap. They're rote, useless, protocol-driven substatements. That's why doctors don't read them.

2. Many charts, and virtually all electronic records, do incorporate nurse's notes into the record in diary fashion. Vitals and meds are logged seperately.

3. I also despise unnecessary admissions. However, I think most docs do a decent job of justifying, whether it's true or not, the admission. If the point of this comment portion is to not admit patients that don't need it, this will result in more lawsuits. And at this stage, until the system which is utterly broken is fixed to a degree, I can't endorse putting doctors at even more risk.

4. What utopia do you practice in where inpatients will all respond to the 5 most commonly used generic ADs? This is somewhat insulting to doctors and continues to serve the generic hysteria that is only partially "right."

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I suppose in concordance wi... (Below threshold)

July 6, 2008 6:02 AM | Posted by Snipergirl: | Reply

I suppose in concordance with what Dr DJ says - in Australia almost all of what you suggest is the rule already. All notes are in the same diary style format. Additionally we have meetings - informal and formal - during which nursing and allied health concerns are communicated to the junior and senior medical staff- and vice versa. Similarly PRN medications and admissions are generally done by the medical staff - and cannot be done by anyone else. All admissions done by junior medical staff are double checked by a registrar or consultant.

Not sure about smoking in psychiatric wards but I'm pretty sure that people are allowed outside (well, in the garden) for a smoke. Just not inside the building.

And in terms of prescription, all brand names are converted to generics by the pharmacy. Therefore if I write "paxil" they'll get some sort of paroxetine- aropax, paxil, whatever. We tend to write generics however (unless it's some weird combination that's easier to write down as its brand formulation).

Also we have (similarly to the UK) quite a fair bit of medication pathways. Yay!

I don't really understand the american system- except for my social welfare background bias that states that the way we do things is superior hahaha. J/k. Very interesting to read what the other side actually does do though.

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When nurses' notes are crap... (Below threshold)

July 6, 2008 3:15 PM | Posted by Silver: | Reply

When nurses' notes are crap, it is often because the system has forced them into that mold with very specific documentation requirements for JCAHO and the like. Not always, mind you, just often.

The reason cited at my hospital for the separate nurses' notes vs. the general chart: convenience, as the nurses' notes are kept in kiosks by the rooms, whereas all the main charts are in one location at the central station.
This is in an era of multi-million dollar EHR systems, which still don't incorporate the nursing progress notes in with the medical progress notes, and, at least in our case, don't allow them to be interleafed together in date order for viewing.

When I first moved back to my state, the nurses' notes were nowhere to be found, and I very stupidly assumed that they were now being interleafed with the medical progress notes. A junior RN at my hospital was reading my notes, and she left a note for me that said, in essence, "Please see nursing notes. Mr. X's behavior is very different when you or other psych staff are not on the unit." Admin was going to discipline her. I could have kissed her. She saved my bacon.

Re: PRNs - they also need to be handwritten out on the discharge orders. Many hospitals just print out the most recent MAR orders and fax those to a retail pharmacy. Pt gets home and has 24 rx waiting for him, including 4 OTC drugs that were ordered as PRN and never given even one time (the usual constipation / diarrhea / aches and pains type of PRNs.)

As far as rx reports, we get one from Medicaid that addresses controlled substance and one for multiple prescribers for one patient. The multi prescribers report is useless, because it doesn't take groups into account, and doesn't have the other names on it - so it becomes more background noise we ignore.
I'd love a comparative report, though.

I'll add something to the templates: add the cost-to-patient-per-day of a given therapy. Zyprexa at hospital-billed cost of $40/day, or Risperdal at hospital-billed cost of $8/day?
There are times I'm going to say, well, this is gonna cost $40 but it's what I want to do here; there are a lot more times I'm going to glance at the pt's demographic and billing information and say, ah, hell, let's try the $8 option first.

And let's add one more thing to this ("6.3 changes to lead to better or more cost effective hospital treatment" - much less elegant title): if a patient is about to be discharged with a $500 rx and has no insurance, notify the prescriber, and make a fuss til the patient is discharged on something sustainable. I'm sick of seeing people get stabilized inpatient, discharged on an atypical antipsychotic they can't afford, and walking into outpt crisis clinic decompensated because they never filled the discharge prescription.
My students and residents get good and ticked off at me because I am on them about sustainability from day one in treatment team meeting. But I see the uninsured, including the working uninsured who'll never qualify for Medicaid in my state, and I know that sustainability is crucial. Otherwise it's like sending out a boat with a repair made of papier-mache... looks great as it leaves the dock, but it just gets far enough out to sink.

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Re: Consolidate the chart</... (Below threshold)

July 29, 2008 8:26 PM | Posted by Anonymous: | Reply

Re: Consolidate the chart

In my hospital, access to the chart is limited. Between unit secretaries, care assistants, discharge planners, nurses, physicians, consultants, there is precious little access to the chart. Although charts are completely bloated, important documentation is frequently missing, and access to the chart is one reason.

Movement towards computerized charting will improve this. (Hopefully. It's becoming clear to me how bad the software can be.)

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