Healthcare professionals tend, like everyone else, to make some choices based on habit or training. The web site Choosing Wisely encourages physicians and patients to question some of those routine choices.
Choosing Wisely® aims to promote conversations between physicians and patients by helping patients choose care that is:
- Supported by evidence
- Not duplicative of other tests or procedures already received
- Free from harm
- Truly necessary
One of the lists on the site is from the Critical Care Societies Collaborative; five things physicians and patients should question:
1. Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.
2. Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 g/dL.
3. Don’t use parenteral nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay.
4. Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.
5. Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.
Read the explanations for these five recommendations here:
There are numerous benefits to applying blood conservation principles in patient care, most often referred to as Patient Blood Management. For example:
- Allogeneic transfusion is emerging as a potent risk factor for many complications commonly seen in hospitalized patients. – Mt. Sinai Journal of Medicine http://onlinelibrary.wiley.com/doi/10.1002/msj.21290/full
- Donated blood doesn’t transfer oxygen from the blood to the body tissues as effectively as the patient’s own blood does. - Forbes http://www.forbes.com/sites/marijkevroomendurning/2013/08/14/blood-transfusions-after-surgery-multiple-units-of-blood-add-to-infection-risk/
- An analysis of more than 31,000 patients who underwent isolated coronary artery bypass grafting (CABG) surgery… showed that receiving one or more blood transfusions conferred a nearly threefold increased risk of operative mortality… – Internal Medicine News http://www.internalmedicinenews.com/index.php?id=514&tx_ttnews%5Btt_news%5D=57604&cHash=5eb08f03e2
- In 2010 Englewood Hospital and Medical Center (Englewood, New Jersey) received nearly $4.7 million in federal funding to train military and civilian physicians in bloodless surgery and other medical procedures. – NorthJersey.com http://www.northjersey.com/news/012910_Englewood_Hospital_to_train_military_others_in_bloodless_surgery_techniques.html
- Patients receiving too many blood products… are more likely to experience medical complications, including infections and organ damage. A growing number of hospitals hope to reduce these risks by limiting their use. - USA Today http://www.usatoday.com/story/news/nation/2013/12/08/hospitals-look-to-limit-transfusions/3905353/
- The work group reached consensus on the need to identify and remediate the drivers of the variability in transfusion practice to further optimize practice in line with available clinical trial data. – The National Summit on Overuse, 2012 http://www.jointcommission.org/assets/1/6/National_Summit_Overuse.pdf
Experienced Caregiver Shares 3 Tips for Injecting Humanity into an Often Cold & Arbitrary Heath-Care System
As a well-traveled, well-educated couple who spent most of their lives in New York City, Philip and Ruth Barash had witnessed and experienced much as they approached their golden years. A savvy New York couple, they’d learned to anticipate challenges.
Philip was a U.S. Army veteran who’d served in the Korean War and later became an attorney; Ruth’s education and experience includes philosophy, art, real estate, public relations and executive-level civic work. But one problem they didn’t foresee was navigating their own country’s health-care system. In the most prominent city of the wealthiest nation on the planet, how bad could it be?
“Philip’s health problems began in 1988 and steadily continued until his death in 2012,” says Barash, who shares her health-care experiences in a new book, “For Better or Worse: Lurching from Crisis to Crisis in America’s Medical Morass,” (http://forbetterorworsebook.com/).
“We were in and out of doctors’ offices, hospitals and emergency rooms a lot, and I was shocked by the lack of compassion we frequently encountered, as well as the number of health-care professionals who simply are not good diagnosticians.”
Barash’s cautionary tale traces her husband’s long death through a medical journey fraught with mismanagement and excess, useless interventions and a sometimes complete disregard for pain – even when there was no hope of healing.
“The art of intuitive, compassionate health care is dying as doctors rely more on technology and are guided through an arbitrary template established by insurance company policies,” she says.
Barash discusses some of the lessons she has learned while navigating overcrowded and dingy emergency room lobbies, callous staff and tech-absorbed doctors.
• Have an advocate! Through the years of Philip’s health problems, we encountered extreme kindness, thoughtfulness and high intelligence; we were also confronted with arrogance, indifference and self-serving staff during some of the worst moments. As hard as it was for both of us, we always knew we had each other. If and when you find yourself requiring medical assistance, avoid going it alone; it will be exponentially more difficult, and your chance for survival will exponentially decrease.
• Ask what benefits a proposed treatment will have. We all like to think we have good doctors, and that if we’re hospitalized, we’ll be competently cared for. We also like to think Santa will bring us nice presents if we’ve been good children. Realize that invasive and expensive tests are often not necessary; in fact, they often make things worse. Be as skeptical about a procedure proposed by a doctor as you would by any salesman.
• Don’t get sick! While this may seem like a facetious bit of advice, since we all succumb to illness at some point – it’s actually a sincere sentiment. Do not take your health for granted; do not think “they” will invent a quick fix between now and the time you find yourself in need of serious medical attention. Unnecessary health risks such as smoking; illegal drug use; excessive alcohol intake; and a diet filled with sugar, salt and fat will take you sooner rather than later to the hellish journey known as the U.S. health-care system.
About Ruth Fenner Barash
Ruth Fenner Barash studied philosophy at City College of New York and did graduate work at the University of Chicago. In 1958, she met and married Philip Barash, a private practice attorney. She went on to work in public relations and real estate, served education and civic organizations at the executive level, and taught art in various media. Her long marriage was a “harmonious adventure” despite the couple’s treacherous journey through the health-care system. Her husband died in 2012.
The Joint Commission is developing a Patient Blood Management certification program for Joint Commission-accredited hospitals. Patient blood management incorporates a patient-centered approach into the blood utilization activities and blood conservation strategies that occur within the hospital. Blood conservation strategies minimize the need for blood transfusions.
Patient blood management applies to all patient populations from pediatrics to geriatrics. It also spans the entire continuum of patient medical care, including the management of anemia, minimization of blood loss, and optimization of coagulation, in addition to evidence-based transfusion.
The proposed standards are open for comment until October 10, 2013.
Bloodless medicine programs have been formed in hundreds of leading hospitals around the globe in the last 20 years. Initially established to meet the needs of patients who decline transfused blood for religious or personal reasons, as healthcare consumers become more educated a growing number of patients are now requesting care without the use of donated blood whenever possible.
What lessons in blood management have we learned during the past two decades?
Transfusion triggers have been lowered.
In 1998 the “10/30 rule” (i.e., RBC transfusion indicated below a hemoglobin concentration of 10 g/dL or a hematocrit of 30%) was standard in most hospitals. “There is now increasing evidence that RBC transfusions are associated with adverse outcomes and should be avoided whenever possible.” 1
Most hospitals now use a transfusion trigger of around 8 g/dL hemoglobin.
The value of treating pre-operative anemia is more recognized
Studies have indicated that nearly 50% of patients entering an OR may be anemic at the time of incision.
An article in The British Medical Journal stated “Previously undiagnosed anaemia is common in elective orthopaedic surgical patients and is associated with increased likelihood of blood transfusion and increased perioperative morbidity and mortality. Anaemia should be viewed as a serious and treatable medical condition, rather than simply an abnormal laboratory value.” 2
It is important to know your hemoglobin level, just like you know your cholesterol and blood pressure numbers.
Many hospitals are moving toward patient blood management
An advisory committee of the US Department of Health and Human Services issued a letter in 2011 that stated, in part, “Blood transfusion carries significant risk that may outweigh its benefits in some settings and add unnecessary costs. Improvements in rational use of blood have lagged behind improvements in the quality and safety of the products.” 3
Organization-wide patient blood management incorporates lessons learned in managing the care of bloodless medicine patients into improved care for all patients.
- Anemia and perioperative red blood cell transfusion: a matter of tolerance. Crit Care Med 2006 May;34 (5 Suppl):S102-8. PMID:16617252
- Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines Br. J. Anaesth. (2011) 106 (1): 13-22. doi: 10.1093/bja/aeq361
- US Department of Health and Human Services Advisory Committee on Blood Safety and Availability www.hhs.gov/ash/bloodsafety/advisorycommittee/recommendations/reommendations_201106.pdf
Healthcare transparency took a step forward this week. The Association of Health Care Journalists (AHCJ) and the Centers for Medicare and Medicaid Services (CMS) have collaborated to bring HospitalInspections.org online.
The searchable database contains information about serious federal safety rule violations in U.S. hospitals since January, 2011. It does not contain hospital responses to deficiencies cited during inspections. Those can be obtained by filing a request with a hospital or the U.S. Centers for Medicare and Medicaid Services (CMS).
Searching is free.
One example documents a lengthy trail of CMS interviews with hospital personnel related to a patient’s complaint regarding a grievance letter to which she had received no response..
“An interview was conducted with S2 Divisional Director, Regulatory Management on 9/19/12 at 9:05 a.m. She reported the hospital was unable to locate what happened to the grievance letter after it was signed for on the loading dock. Also the hospital has been unable to locate the letter sent by regular mail by the mother of Patient #7.
Review of the policy titled Patient Rights, Complaint, and Grievance Process, policy reference # OrgClin/020, revealed in part, ” …All expressed concerns regarding care or treatment are entered into the approved complaint tracking software program …”
Example: Environment of Care / Fire Safety
“The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 8:00 am to 9:45 am on 7/24/2012 that the fire doors going into the generator room had the closers removed and the doors were propped open. The doors must be self-closing. If the facility requires the doors to be open, they must be placed on hold opens that will release with activation of the fire alarm.”
The site also has a list of states that post their hospital inspections online.
Kaiser Health Plan reports on a long-festering problem that many hospitals have been reluctant to address: disruptive and often angry behavior by doctors. Experts estimate that 3 to 5 percent of physicians engage in such behavior, berating nurses who call them in the middle of the night about a patient, flinging scalpels at trainees who aren’t moving fast enough, demeaning co-workers they consider incompetent or cutting off patients who ask a lot of questions.
Experts say that doctors’ bad behavior is not merely unpleasant; it also has a corrosive effect on morale and poses a significant threat to patient safety.
To be fair to physicians, bad behavior is not limited to them. Administrators, nurses, and others can also subject co-workers and subordinates to what could only be termed as work-place bullying. Physicians, however, impact patient care in ways that others do not. When those caring for a patient hesitate to call a physician about care concerns for fear of being subjected to a wrathful outburst, hospital and medical staff leadership must act.
Variant Creutzfeldt-Jakob disease (vCJD) is a rare, but deadly infection that can be transmitted in transfused blood or blood products.
An article in the UK Telegraph Killed by a needless blood transfusion, notes that Deryck Kenny, who died in 2003, was the first recorded death from vCJD traceable to contaminated blood. His widow, a retired nurse, later reviewed his medical record and could find no documented reason for the three units of blood Deryck received during surgery for prostate cancer. She concluded that it was simply the surgeon’s routine to transfuse patients.
Routine is a more common reason for transfusion than most would think. As a result, hospitals around the globe are beginning to adopt patient blood management as a key safety concept. The roots of the program lie in alternative treatments developed for patients who decline all blood transfusions in their care, in the past primarily Jehovah’s Witnesses, but now a choice that is being made by an increasing number of others as well.
For those anticipating a planned surgery, consider asking your physician to do a routine blood count in advance, and if anemia (low hemoglobin / hematocrit) is noted, to take steps to correct that anemia prior to surgery. That simple step alone would eliminate the need for many transfuions during or after surgery. In cases of mild anemia iron supplements may help, or if the problem is more pronounced, IV iron or medication that stimulates a patient’s own bone marrow to produce red cells, may be needed.
It has been said that “the safest transfusion is the one not given.”
The Other Side of the Drape is the story of a mother waiting for her young son to come out of surgery. It is also the story of an anesthesiologist waiting on the outside of the OR.
…And now came the hardest part: waiting. Waiting sucks. It was six in the morning. Even though all I wanted to do was sleep, I could only doze off for about twenty minutes. I wandered aimlessly through the parents’ lounge. I watched the slice of sky between buildings outside the window change from black to grey to light blue as dawn broke over the city of Boston. Over an hour later the liaison called into the operating room for an update, and the specimen still hadn’t been taken out of my son’s body. I found that a little worrisome…
And the thank-you note.