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.