An Australian hospital will investigate an incident in which staff declared a woman dead and notify her family, only to realize minutes later she was still breathing. Rita Ring was admitted to Innisfail Hospital from a local nursing home on May 3, and was wrongly declared dead shortly before midnight. Staff informed the 92-year-old woman's next of kin, but had to call back a short time later to inform them there had been a mistake. Ring died in the hospital three days later.
Innisfail Hospital is investigating the circumstances around the error, and has apologized to the family.
An ongoing shortage of nurses and other healthcare workers across Canada has led some rural community hospitals and other health facilities to down-size their services or temporarily close for short periods of time because they do not have the staff to cover shifts. The trend is forcing rural healthcare employers to find creative ways to attract nurses to rural areas.
In response to the number of patients seeking medical and surgical care overseas increasing in recent years, the American College of Surgeons studied the issue and developed an official "Statement on Medical and Surgical Tourism." The ACS statement "was developed with the patient's interests in mind," according to James Unti, MD, FACS, a medical associate with the ACS Nora Institute for Surgical Patient Safety.
Constructing a tracer process from scratch for a 645-bed hospital is no simple matter, but that was precisely the task before the facility's survey readiness committee, says Carol Carach, RN, BSN, MPH, regulatory and accreditation survey supervisor at Medical City Dallas (TX) Hospital.
"When I arrived in November of 2006, we didn't have any sort of formal readiness process and we were up for our Joint Commission survey in 2007," says Carach.
The facility did have a survey readiness committee, however, which decided it would institute mock drills and tracers.
"That's where we got started," says Carach. "We did maybe three units as part of our initial drill, and then instituted a more formal tracer."
An initial signup sheet garnered teams for two patient care units immediately, and the facility was able to begin tracers in all units roughly six months later.
"We leave it up to the teams to schedule the tracers with their partners. They are encouraged to invite the unit manager or a designee," says Carach. "We don't surprise the unit, we invite them to participate in the learning process."
Medical City has a 35 two-person tracer teams roving the halls to cover the facility's 645 beds. Maintaining those teams can be somewhat of a challenge.
After the first round of recruiting, Medical City had 25 teams and started running tracers for all units that had teams assigned to them, while simultaneously looking to fill in the blanks.
"There was some recruiting at first, but we got very good participation generally," says Carach.
There were certain areas that required more active recruiting, and in more challenging cases, unit managers selected or assigned their team members.
The team members were educated on the tracer process and then took this knowledge back to their own units. They were then assigned to trace another department.
"Part of the set-up is that you do not trace your own unit. You'll pass over things that are not in compliance" simply because of familiarity, says Carach.
The turnover rate has been small but regular, leading Carach to actively recruit new managers or staffers recently assigned to a leadership role to see if they want to be a part of the tracer team.
Carach had previously helped implement a tracer program at another institution, but the process, she has found, is extremely different from facility to facility.
"The process has to be designed specifically for your facility," she says.
In addition, Carach recommends the following:
Divide up the labor on each tracer team by area of expertise. Often, the non-clinical member of the team focuses on Environment of Care issues, for example. Allow for individuality among the various tracer teams.
As a leader, occasionally join a tracer team. This is not only an opportunity to observe the unit but to educate the team as well, answer questions about process or requirements. This is especially important for teams with newer members.
Some California physicians are already calling the idea "naive," "worthless," and "another unfunded mandate." But if the president of the Medical Board of California has his way, all practicing physicians in the state as well as medical school students will enroll in certified wellness programs, perhaps as a condition of licensure.
"What I want is a policy, preferably a statute, that dictates there should be wellness education that starts in medical school, so it becomes part of our culture through all the years of practice," says Richard Fantozzi, MD, a San Diego head and neck surgeon. Such a program would be evidence based, perhaps run through hospital medical executive committees as a condition for staff privileges. It would be administered by the private sector, not the medical board.
Whatever form it takes, the program would help physicians recognize the first signs of depression or burnout, abusiveness, out-of-control anger, inappropriate behavior with patients, peers or staff, serious family issues, as well as problems with substance abuse and dependence.
"Usually," he says, "all of the things that doctors eventually get in trouble for with the medical board are consequences of these unrecognized stresses."
"We want to help physicians realize signs they are going through life changes, and not be afraid to get help." No other state in the nation has such a uniform program, he says.
An eight-person board committee is studying how the education program might work, and has initiated talks with medical malpractice insurance companies about the possibility of offering discounts for the first doctors who enroll. The programs would have no disciplinary functions.
Physician groups, such as the California Medical Association, are staunchly opposed, saying such education programs would do nothing to prevent physicians with behavior problems. They favor a return to a system now discontinued in which physicians with substance abuse problems enter a confidential monitoring program while they recover from their addictions.
Fantozzi says officials from other state medical boards are exploring the idea as well, possibly replacing programs they now run for doctors whose substance abuse problems harmed patients.
"The direction Dr. Fantozzi is heading in is the right one," says Raymond Pomm, MD, medical director of the Florida Physician Health Program.
Today, Pomm says, the way we deal with physician behavior is through coercion, "and that we know doesn't work. We need to empower physicians to take responsibility for their own health, and turn around their concept of what it means to be ill."
Pomm says that it's unfortunate some physicians react so negatively to the concept. “We're talking about a change of culture that's not a negative change, but one intended to lessen stigma, and let people know it's OK to have a problem if it decreases denial so the person can get help.”
The concept of requiring physician wellness education was launched a year ago after the medical board closed down its controversial "diversion" program last June. The program was intended for "diverted" substance-abusing physicians from having their licenses disciplined into a five-year system that attempted to monitor their recovery.
But a series of reports and a state audit concluded that diversion had failed to protect patients from harm caused by enrolled physicians who were still impaired. About 250 physicians were enrolled at any time, without disclosure to patients under their care and often without limits on their practices.
The board decided it could not ethically safeguard patients while being aware that impaired physicians were continuing to practice. The needs of the physician wrongly had more priority than the needs of patients.
A $500,000 effort to correct major loopholes was unsuccessful.
The program's failure prompted Fantozzi to consider what to do next. Whatever the diversion program did or didn't do, it never tried to prevent physician behavior problems in the first place, he says.
Studies suggest that at any given point in time, 3.5% to 4% of physicians are impaired by substance abuse and another 10% are at risk of becoming so. Among California's 100,000 active physicians, "we should have had 3,500 in diversion, but we only had 250. And we know there were 10,000 to 15,000 others who are at risk," he says.
Fantozzi knows most medical schools already expose students to a variety of such wellness education programs. "What's not being done at all is anything consistent for the practicing physician, something that reminds them that the career they've chosen is stressful, and maybe not now, but in 10 or 20 years, they may find the rigors affecting their decisions as a practitioner," he says.
One program he uses as a model is that of Kaiser Permanente Northern California, where 6,800 physicians have a mentoring system, social activities, and educational classes focusing on watching out for and preventing the stresses that can destroy a practice.
"Every one of our 19 sites has a budget and a committee that oversees wellness, in addition to committees that are required by law," says David Schearn, MD, director of physician education and development. "They have various social activities, scheduled retreats, with family or without, to deal with burnout, or address financial issues that can be an enormous cause of stress."
Fantozzi says physician committees that grant physician staff privileges would be a good place to launch such programs. "But when you survey those committees, you see their understanding of what they do is to deal with bad behavior, a doctor who made a bad choice. They don't see themselves providing education. They see themselves as a prosecutor," he says.
But Jerrold Glassman, MD, head of credentials for Scripps Mercy Hospital in San Diego, disagrees that such committees should serve such a purpose, saying it's "another unfunded mandate. You can't pile these requirements on for the general physician population when the problem only affects a few," he says.
Fantozzi's idea is "naïve," says James Hay, MD, the CMA liaison to the Medical Board, who doesn't think such programs would reduce physician addictions that lead to misconduct. "There's no evidence that mandating a course in anything increases quality in anything," he says.
Already, the medical board requires 50 hours of continuing medical education coursework every two years, and requires a one-time 12-hour course in pain management. They don't have time to take more, he says.
Hay and the CMA are still bristling over the Medical Board's vote to end the diversion program, which they felt could have been fixed. "Under the old program, there were 250 doctors in diversion. Now there are 30 on probation. It's clear to us the public is less safe than they were two years ago."
And he thinks it's silly to believe educating doctors about those behaviors will prompt those with problems to come forward. "You never meet an alcoholic who tells you how much they drink," Hay says.
Luis Sanchez, MD, director of physician health services for the state of Massachusetts, also adamantly disagrees with Fantozzi's idea. Instead, he thinks the medical board is using wellness education as a way to side-step the fact that it's no longer overseeing physicians with problems.
"What he wants is so off base," Sanchez says. "He's saying, ‘Let's ram this down their throats, and then we're no longer responsible because we've done what we have to do," says Sanchez, a member of the board of the Federation of State Physician Health Programs. "There's a huge gap between required to take a course and seeking help."
President Barack Obama earlier today applauded businesses that have lowered their own health costs by paying for health and wellness programs for their employees. That concept is the same as his own, Fantozzi says. While California physicians are not in the strict sense of the word "employees" of the medical board, the board has a commitment to promote wellness in its physicians in the spirit of its mission to protect the public.
Fantozzi knows the idea is going to be politically hard to mandate, and already he is getting what he calls "pushback." But he thinks reason will ultimately prevail.
"We shouldn't be thinking about what we can do for one doc, or the next doc. We should be thinking how to help all docs," says Fantozzi.
The HHS healthcare reform team is beginning to take shape with the announcement of Office of Health Reform personnel on Monday.
The HHS office will “spearhead the department’s efforts to pass urgently needed health reform this year and coordinate closely with the White House Office of Health Reform.” President Barack Obama created both offices by an Executive Order April 8 in hopes of passing comprehensive healthcare reform in 2009, which is one of Obama’s top priorities.
“The skyrocketing cost of healthcare is crushing families and businesses and we must enact health reform this year,” says HHS Secretary Kathleen Sebelius. “The HHS Office of Health Reform and the White House Office of Health Reform will work in tandem to advance legislation and take immediate actions to cut costs, assure quality and affordable healthcare for all Americans, and guarantee Americans can choose their doctor and their health plan.”
On Monday, Sebelius named a number of staff members:
Jeanne Lambrew, PhD, director of the HHS Office of Health Reform, will lead the health reform effort in the HHS office and help the secretary promote the department. She was previously an associate professor at the LBJ School of Public Affairs, senior fellow at the Center for American Progress, and worked on health policy in the Clinton Administration.
Michael Hash will serve as a senior advisor, which includes running the inter-agency process for developing specific aspects of health reform legislation consistent with the president's priorities. He will be an assignee at the White House Office of Health Reform and assist in the preparation of administration positions and in communication with the Congress. Prior to his appointment, Hash held senior positions at the Health Care Financing Administration (now known as CMS) and on the staffs of the House Energy and Commerce Committee as well as a private health policy consulting firm.
Neera Tanden will work as a senior advisor, developing healthcare policies for HHS and the administration. She is the former domestic policy director for the Obama-Biden campaign and policy director for the Hillary Clinton campaign, and oversaw healthcare work on both campaigns. She has worked in think tanks, in the Senate, and in the Clinton Administration.
Rounding out the new hires for the office Monday were:
Linda Douglass, director of communications:
Meena Seshamani, MD, PhD, director of policy analysis
Caya B. Lewis, M.P.H., director of outreach and public health policy
Jennifer Cannistra, policy analyst and director of special projects
President Barack Obama met at the White House Monday with a coalition of healthcare providers and other healthcare organizations who pledged in a May 11 letter to reduce the annual healthcare spending growth rate by 1.5%—saving an anticipated $2 trillion over the next decade.
The symbolism of the meeting was not lost on the president. "It's a meeting that might not have been held just a few years ago," the president said. "The groups who are here today represent different constituencies with different sets of interests. They've not always seen eye to eye with each other or with our government on what needs to be done to reform healthcare in this country."
Among those in attendance were: George Halvorson, chairman and CEO of Kaiser Foundation Health Plan; Karen Ignagni, president and CEO of America's Health Insurance Plans (AHIP); Jay Gellert, president and CEO of Health Net Inc.; Thomas Priselac, president and CEO of Cedars Sinai Health System; Rich Umbdenstock, president and CEO of the American Hospital Association (AHA); Ken Raske, president of the Greater New York Hospital Association; J. James Rohack, MD, president elect of the American Medical Association (AMA); Richard Clark, chairman, president, and CEO, Merck; and Andy Stern, president of the Service Employees International Union.
The president even poked fun at the fictional television couple Harry and Louise, who initially became the iconic faces of those who opposed healthcare reform in the 1990s in ads produced by one of the groups at the meeting Monday. He commented that these characters now "desperately need healthcare reform in 2009."
Among the proposals that the healthcare representatives said could hold costs down are: simplifying administrative costs, making hospitals more efficient, reducing hospitalizations, managing chronic illnesses more productively, using proven clinical prevention strategies, and expanding healthcare information technology.
The president did not specifically address how this coalition's proposals jibe with his vision of a public insurance plan. However, he did say that he still is "committed to ensuring that whatever plan we design upholds three basic principles": bringing rising healthcare costs down; permitting individuals to keep their current physicians or health plans—or choose new ones if they want to; and promoting quality, affordable care.
"Their efforts will help us take the next and most important step comprehensive healthcare reform so that we can . . . save a typical family an average of $2,500 on their healthcare costs in the coming years," the president said. "What they're doing is complementary to—and is going to be completely compatible with—a strong, aggressive effort to move healthcare reform through here in Washington."
"Our message is clear: the private sector will do its part to bend the healthcare cost curve," AHIP's Ignagni said in a statement. "We also agree...that universal coverage will not be sustainable, and that Medicare and Medicaid will not remain solvent—unless the nation addresses the cost issue head on."
"Defensive medicine continues to be a major factor in rising costs," the AMA's Rohack said. "We need medical liability reforms that help physicians provide the best care—without needing to order additional services to guard against possible lawsuits."
The current healthcare system is "fragmented and complex, making it hard for patients to get the care they need at the right time and in the right setting," said AHA's President and CEO Rich Umbdenstock. "We need to build a better system—one that puts a premium on wellness and prevention, places a greater focus on quality, harnesses the promise of information technology to improve care, and provides coverage for all at an affordable cost."
Senate Finance Committee Chairman Max Baucus (D-MT), who had met recently with several of the White House attendees at two committee roundtables, said he was "very pleased that the ideas proposed by these industry groups" meet his goals of "increasing focus on value, efficiency, and prevention in the healthcare system."
For babies born prematurely, even the noise generated from a normal conversation can be too loud for proper development. Mothers who give birth to premature babies at The Women's Hospital in Newburgh, IN, however, need not worry about the noise level in the hospital's neonatal intensive care unit (NICU).
Women's Hospital installed both sound meters and visual feedback cues to ensure that babies receive the safest possible care.
"We think that the developing brain, especially of the premature baby, is influenced by its environment," says Kenneth Herrmann, MD, medical director for newborn services for the Deaconess-Rile NICU at The Women's Hospital. "The environment is either promoting healthy development of the brain, or its not. There is a school of thought that says any noxious stimulus—too bright a light, too loud a sound—is distracting to the task of growing and developing."
The American Academy of Pediatrics recommends that NICUs noise levels remain at or softer than 45 decibels. This is a nearly impossible task, says Herrmann.
The necessary equipment found in a NICU, such as ventilators and monitors, all generate a certain amount of noise, the room's infection-preventing but echo-inducing design is not conducive to keeping quiet, and the nurses who work in the NICU and family members who visit all add to the sound level.
Many NICUs operate at sound levels closer to 80 or 90 decibels, says Herrmann. The noise levels generated from equipment and hospital design cannot, for the most part, be altered without significant hospital renovations.
Women's Hospital seized its chance to change the behaviors of staff members working in and family members visiting the NICU. The hospital installed both sound meters to evaluate the sound level in the room, and light "trees" to give staff members a sense of the decibel level (the light trees resemble an overhead traffic light).
Using a computer system called SONICU, the sound level is measured every five seconds and that data is transmitted to the light trees, which either show a green, yellow, or red light, depending on the noise level. If the noise level reaches the designated "red" zone, the overhead lights in the NICU also begin to flicker, alerting anyone in the NICU they must be quieter.
"In the intensive care nursery where there are no complainers, sound levels can get out of control," says Herrmann of a premature baby's inability to verbally alert a caregiver to discomfort. "You can have an automated system that is non judgmental, that signals to everybody when it's getting too loud."
When The Women's Hospital first started using visual cues in 2007 to alert staff members and visitors to noise levels, the red light was triggered to go off at 75 decibels and the yellow light was triggered at 60 decibels. Since then, staff members have learned to keep their voices down enough so that the red light is now triggered at 60 decibels, and the yellow at 48.
Although the light trees help spread awareness about the NICU's noise level, they are directly overhead and can blend in with the environment. The flickering overhead fluorescent lights, a special system that The Women's Hospital NICU had installed, act as a visual cue that is harder for staff members to ignore. The lighting system has also allowed the NICU to simulate the effects of sunrise and sunset to get the premature babies ready for the real world.
"People have to be willing to cooperate. SONICU enables us to get rid of the policemen, the person who has to walk around and say 'you're being too loud,'" says Herrmann. "It means the staff has to embrace the idea that sound levels are important to the babies and that they are part of the reason why the care is better or worse."
Beyond the NICU
Although this technology is being used in a NICU at The Women's Hospital currently, Herrmann sees potential for the SONICU system in a more general hospital setting, especially for those hospitals looking to improve their patient satisfaction scores. Herrmann says the technology could be used in noisy hospital hallways where most of the patients are adults. Adult patients often express dissatisfaction with noise levels during a hospital stay, especially because they are most likely uncomfortable in some other way because of their sickness or treatment.
Any hospital being built today would be wise to include this type of technology, says Herrmann. In addition, hospitals undergoing renovations could easily implement an automated system, such as SONICU, to create a quieter, less stressful environment for the patient.
"The noise commonly enough is people's voices out in the hall, which, if it's during a no-visiting time, it's nursing staff in the middle of the night talking too loud outside of the patient's room," says Herrmann. "It's a big deal in the adult world, and yet not much is done about it."
President Obama appeared to put his faith in pledges from some of the healthcare interest groups that have pledged to cut the rate of growth of national healthcare spending by 1.5 percentage points each year—an amount that's equal to over $2 trillion. Administration allies cheered the news that the health lobby is eager to join reform negotiations, but many offered a cautionary note that warm words from the industry cannot be mistaken for enforceable policy change.
From blogs to social networking sites like Twitter, hospitals and public health agencies across the country employed a variety of new technologies to spread the word about H1N1 (also known as swine flu).
It's safe to say that the face of emergency management communications has changed drastically since the last national disaster response of the September 11 attacks. Back then, hospitals primarily used phones, television, and e-mails to talk to staff members or communities, with sporadic Web site updates.
Less than eight years later, hospitals and the public can receive instant updates about new HlN1 cases from the Centers for Disease Control and Prevention's (CDC) Twitter page. As of Monday, the CDC had more than 130,000 Twitter users following its updates.
Many hospitals also tried the following approaches:
Posting videos. "One of the unique things we wanted to do was focus on staff safety" during the swine flu outbreak, says Chris Bellone, CHEP, an emergency preparedness coordinator for Rockford (IL) Memorial Hospital.
Emergency planning organizers there were able to develop an online video within 24 hours of approving it that showed staff members how to properly put on and take off personal protective equipment, such as respirators. The clips were posted on the facility's Intranet.
Meanwhile, Lucile Packard Children's Hospital in Palo Alto, CA, used online video to show the public handwashing techniques and explain ways to talk to children about H1N1. The hospital posted the videos on its Web site and also on You Tube.
Updating blogs. Blogging became part of the frontline battle for preventing flu infections. The chief medical officer of Children's Hospital Wisconsin in Wauwatosa, WI, updated his facility's blog with information about swine flu precautions. He did not mince words: "Those who report having two or more flu symptoms will not be allowed to enter. The same restrictions apply to staff."
Utilizing mass notification. A more modern version of the old phone tree, mass notification systems allow hospitals and other parties to reach hundreds, if not thousands, of people instantly by phone and Blackberry.
Rockford Memorial uses vendor Everbridge of Glendale, CA, for the hospital's mass notifications, in which a designated person dials a number, records a voice message, and then sends it off to a predetermined list of people, Bellone said.
Rockford Memorial's set-up allows the messages to be grouped by administrators and regional contacts for added convenience. For example, morning H1N1 briefings at the hospital could be relayed by mass notification to competing hospitals regionally so that the medical centers could collaborate during the swine flu outbreaks, Bellone said.
Drawbacks that need to be addressed
As with any new technology, there are concerns. Bellone has a profile on the Web-based business network Linked In, via which he waded through many posts and tidbits about H1N1. He found himself questioning the sources of some information.
"It's great to talk about it, but is this official or unofficial communication?" he asked. As the H1N1 scare slows down, hospitals and public health agencies will err if they curtail the use of new communication means, says Ric Skinner, GISP, owner of The Stoneybrook Group in Sturbridge, MA. Stoneybrook is a consulting firm that helps hospitals with emergency preparedness and geographic information systems.
"I think hospitals and healthcare facilities should … be comfortable with using multiple communication resources for emergency management," Skinner says. "That said, I don't believe systems should be activated just for emergencies. Rather, they need to be part of the daily routine."
Twitter and other social media avenues need to integrate into general hospital operations—including educating employees on how to use these sites—so that they can be ramped up when a disaster occurs rather than dusting them off during an emergency and hoping people remember the training, Skinner adds.
He hopes a positive after-effect of the H1N1 response is that hospitals will receive clear direction from federal agencies and The Joint Commission about "how best to provide the right information, at the right time, in the right format, and to the right people using redundant and robust technologies."
