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Last year there wasn’t a single fatal airline accident in the developed world.
So why is the U.S. health care system still accidentally killing hundreds of thousands?
The answer is a lack of transparency.

Read more from this Washington Monthly article…

We hear a lot in today’s media about huge awards for medical malpractice cases driving up the cost for health care in America.  However, according to the actuarial consulting firm Towers Perrin, medical malpractice tort costs were $30.4 billion in 2007, the last year for which data are available. We have a more than a $2 trillion health care system. That puts litigation costs and malpractice insurance at 1 to 1.5 percent of total medical costs.   In my opinion, the time for medical malpractice tort reform might best be addressed after medial errors are no longer identified as one of the top three causes of death in this country.

To put that $30 billion in perspective (which includes malpractice premiums as well as awards to plaintiffs):

• According to a 2008 study by the SOA (Society of Actuaries): “….of the approximately $80 billion in medical injury costs, about 25% were the result of avoidable medical errors.”

• (The) Institute of Medicine estimates that the average hospital patient in the U.S. is subject to at least one medication error per day (wrong med, wrong dose, wrong time, wrong patient), and that the financial cost of treating the harm done by these errors conservatively comes to $3.5 billion a year.

• After Dr. Peter Pronovost, of Johns Hopkins, partnered with Michigan hospitals to study the effectiveness of (his infection control) checklist, the reduction in infection rates saved an estimated $100 million and 1,500 lives over just an eighteen-month period.

• Twelve years ago, the Institute of Medicine issued a landmark report showing that medical errors in U.S. hospitals kill up to 98,000 Americans a year. In 2000, another estimate, published in the Journal of the American Medical Association, which included fatalities resulting from unnecessary surgery, hospital-acquired infections, and other instances of harmful medical practice, put the total annual death toll at 250,000.

By that figure, contact with the U.S. health care system was the third leading cause of death in the United States, just behind all heart disease and all cancer. Even more alarming:  In its 2008 annual report to Congress, the Agency for Healthcare Research and Quality, a part of the Department of Health and Human Services, reported that preventable medical injuries are growing each year by 1 percent, the first time it had reported such an increase.

In November 2010, the U.S. Department of Health and Human Services issued a study that covered just the 15 percent of the U.S. population enrolled in Medicare. It found that each month in one out of seven Medicare hospitals a patient is injured—and an estimated 15,000 are killed—by harmful medical practice. Treating the consequences of medical errors cost Medicare a full $324 million in October 2008 alone. Another recent study looked at the incidence of avoidable medical errors across the entire population and concluded that they affected 1.5 million people annually.

While the article in this post references many points about preventable infection and surgical errors, it is important to note that there are many other types of errors in addition that occur just simply by health care practitioners’ not paying attention and observing the patient and his/her obvious condition, such as some of those noted above.  In addition, it is very important for those in a care taking role of a very sick patient, to make sure that after shift change, he or she touches in with the staff to confirm that the prior shift documented incidents and that they are clear about the patient’s condition.

Until there is a change in our system that addresses medical error and provides for transparency to patients and their families, my advice is to never leave a loved one on their own in the hospital.

Related articles

• How Hospitals Can Avoid Medication Errors – part 1 (medleague.com)
• The Four Most Common Types of Medical Malpractice (socyberty.com)
• Medication-Related Injuries on the Rise (well.blogs.nytimes.com)
• 1 in 3 patients harmed during hospital stay (kboreilly.com)
• Hospital Errors May Be More Common Than Thought (webmd.com)

Since the 1990s, wound care took a substantial leap forward.  The new device was first marketed in the US by KCI (San Antonio, TX) in 1995 as the V.A.C. Therapy System.  It efficiently provided a means to apply negative pressure (sub-atmospheric pressure) via the V.A.C. pump ranging from 50 to 200 mmHg to the wound beds of both acute and chronic wounds (wounds, burns ulcers, flaps and grafts) – thereby promoting wound healing.  NPWT is contraindicated in the presence of exposed anastomotic sites, exposed vasculature, exposed nerves, exposed organs, necrotic tissue with eschar present, untreated osteomyelitis, non-enteric and unexplored fistulas, and malignancy in the wound.

Over the past 15 years, NPWT has gained widespread acceptance and use internationally.  A number of other NPWT products (6 to date in North America) have been brought to market. NPWT devices improve wound healing through a number of different mechanisms: by improving local blood flow (perfusion, reducing swelling, removing drainage from the wound, and by stimulating scar tissue formation. Patients feel less pain when dressings are changed because NPWT devices make it less necessary to change dressings frequently.   By reducing the frequency of dressing changes, the device has been demonstrated to be cost-effective, in spite of the cost of supplies and pump rental costs.  In the United States, NPWT is reimbursed by Medicare and Medicaid when ordered by a physician for qualifying wounds.  There are over 300 peer-reviewed articles in the literature providing a growing evidence-base for the use of NPWT.

Litigation on the Rise

Why is litigation related to NPWT on the rise?  With an increased frequency of use of NPWT for complex and difficult wound management, the chance of adverse events is increased.  Additionally, because NPWT devices have very specific and somewhat complicated guidelines for use, there is a steep learning curve (as opposed to simpler wound dressings).  With the complexity of use of the device, there is greater potential for user error.

In November 2009, the FDA issued a warning to healthcare professionals about NPWT entitled “FDA Preliminary Public Health Notification: Serious Complications Associated with Negative Pressure Wound Therapy Systems”. The FDA document noted that 6 deaths and 77 injuries associated with NPWT systems have been reported to the agency over the past 2 years.  Most of the deaths occurred at home or in a long-term care facility.  Bleeding and infection were the most serious complications.  Healthcare providers should carefully recommend selective patients for NPWT, knowing that NPWT systems are contraindicated for certain wound types, and thoroughly consider patient risk factors before using NPWT.   Details are specified in the FDA Warning.

Conclusion

Wound care clinicians who use NPWT and legal professionals who review NPWT cases focus on the same standard of care issues when it comes to NPWT:

1. Is the use of NPWT appropriate for the patient and the patient’s wound at this point in time?
2. Have device indications, contraindications, precautions and warnings been taken into consideration?  Have other treatment options been considered and offered?
3. Are the members of the interprofessional wound team properly trained in the use of NPWT?
4. Has the physician ordered the device with appropriate settings and specifications (e.g. pressure in mmHg; continuous vs. intermittent; frequency of dressing change)?
5. Is appropriate and functioning equipment being utilized (e.g. pump, canisters, tubing)?
6. Have the correct dressing materials been ordered and utilized (e.g. foam, silver foam, contact layers, gauze, drapes)?
7. Have appropriate arrangements been made for use of NPWT across the continuum of care (acute care, long term care, home care, outpatient)?
8. Have arrangements been made for wound reevaluation to determine when NPWT can be discontinued?
9. Has the patient and his/her caregivers been trained in how to monitor the device, device alarms and what to do and who to contact in case of problems or emergencies?
10. Have the providers included appropriate documentation in the medical record?

NPWT can be effective when used properly with the right patient. Misuse may result in patient harm.

Diane L. Krasner PhD RN CWCN CWS MAPWCA FAAN

dlkrasner@aol.com

http://www.chronicwoundcarebook.com

For more information on this topic, join a Webinar from Med League Support Services, Inc. entitled: Complex Wound Care with Negative Pressure Wound Therapy (NPWT): Adverse Events and Litigation by Diane Krasner.

See details at http://www.patiyer.com/vp .

The 17 year old, Case Management Society of America (CMSA), has announced the celebration of National Case Management Week.  This special week-long event seeks to unify case management professionals, educate the public about case management, and increase awareness and recognition of the significant contributions case managers make the quality healthcare for patients, healthcare providers, and payers.  This week is celebrated nationally during the second full week of October each year.

CMSA is an international organization of case managers and healthcare professionals, committed to promoting the growth and value of case management, and to support the evolving needs of the case management professional.  Founded in 1990, CMSA now has over 11,000 members and over 70 affiliated and pending chapters. I am one such member and proud to be a part of the Little Rock Chapter.

For those who are unfamiliar, Case Management is a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individuals heath needs through communication and available resources to promote quality cost-effective outcomes.  My case management practice is primarily associated with workers compensation clients.  Injured workers need prompt assistance in finding the appropriate healthcare provider who will diagnose them quickly and provide the treatment plan to help get them back on their feet and productive again.  My job is to first assess the situation which includes not only the injury itself, but also the claimant’s situation at home, emotionally, mentally, physically, socially, etc.  The next step involves locating the provider, arranging the appointments; all while educating those involved.  The plan is ever changing as the situation changes.  I am advocating for my patients to help them get their needs met all the while working to save the insurance carrier money by preventing unnecessary testing, negotiating reduced rates for services, limiting loss time wages, and eliminating waste.

Establishing a nationally recognized Case Management Week is vitally important as the field of case management becomes an increasingly recognized as a strategy of great significance across the continuum of care.  Not only does case management support patients and their families in navigating the healthcare system, it decreases the fragmentation of services, encourages health team communication, and contributes significantly to patient safety, quality of life, and cost-effective management of limited resources.  It should be recognized by the healthcare industry as a crucial element of giving.

If you wish to learn more about Case Management or CMSA, contact Cheri Lattimer, Executive Director or visit www.cmsa.org.  The association headquarters are located right here in Arkansas at 6301 Ranch Drive, Little Rock, AR 72223.  501-225-2229

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I am so proud to be a nurse case manager.  I have worked in this industry since 1999 and became certified in 2003.  October 10-16, 2010 marks National Case Management Week, recognizing the contributions and commitments case managers make and educating the public about the significant work we perform. When employed by an agency or hospital, activities typically include banquets and recognition dinners, state and city proclamations, continuing education seminars, and other community events. Case Managers are typically honored with gifts, dinners, and flowers coworkers such as doctors and administrators, and patients who want to show their appreciation.

As an independent case manager, I do not get to participate in such activities, but I can still celebrate.  Here are a few ways each of us can participate in National Case Management Week.

• Tell 10 other professionals you are a case manager
• Offer to speak at community events on case management
• Wear your CMSA Member Pin
• Promote case management by sponsoring or volunteering at a health fair, preventive screening or organizing services in your community
• Host a reception in your community
• Host a professional seminar for health professionals in your community
• Highlight a different case management practice setting each day of the special week in your newsletter or blog
• Encourage your mayor, county executive or governor to issue a local proclamation establishing October 10-1th as National Case Management Week
• Invite a politician to accompany a case manager at their place of business for a day
• Decorate with banners, posters, or flyers
• Publish newsletters focusing on CM week
• Speak to nursing organizations about case management careers
• Create a publication of case management stories
• Write a letter to your local paper
• Contact radio and TV stations to let them know about CM week
• Write a guest editorial to newspapers, journals or magazines regarding the positive impact of case management
• Distribute a press release announcing CM week

I am committing to several of these activities this year.  (I just completed one by posting this!)  I am glad I have an opportunity to impact my patient’s lives everyday.  The very things that seem so simple to me, make a big difference in the lives of others.  I just hope I can continue this for many years to come.

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Sam Albrecht, Executive Director of the Commission for Case Manager Certification, presented testimony on December 3 on the important role nurse case/care managers play today and in the future of health care system.  All case managers should review this paper which documents the current and future role case managers have in ensuring consumers of health care receive safe, quality, evidence-based care regardless of setting.  You can review the paper in its entirety here.

As outlined in his paper, Mr. Albrecht shares a comparison of nursing and case management processes which reveal the following commonalities:

• The nursing process of assessment equates to the case management process of case finding/screening and intake; assessing the patient’s needs 
• The nursing process of diagnosis equates to the case management process of identifying actual/potential problems 
•  The nursing process of planning equates to the case management process of interdisciplinary case conferencing; establishing goals of treatment and expected outcomes of care; developing/individualizing the case management plan 
•  The nursing process of implementation equates to the case management process of implementing the case management plan/interdisciplinary plan of care; facilitating/coordinating patient care activities 
•  The nursing process of evaluation equates to the case management process of monitoring the delivery of patient care services; evaluating outcomes of care/patient responses to treatment; discharge/disposition; repeating the case management process. (Cesta, Tahan, 1998)

For those unfamiliar with the CCMC-Commission for Case Manager Certification, the commission began in 1992 and has certified more than 35,000 case managers.  I am one of them.  Not only do we provide access to appropriate healthcare services and promote patient impowerment.  You can learn more about the certification process on the CCMC website.

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This week I ran across a posting by a Dr. Luks, a physician I follow on Twitter.  The information was originally written by another physician blogger.  Dr. Rob who writes Musings of a Distractible Mind posted this and it ran in the NY Time Health issue.  I was compelled to include this information here as well.

Rule 1: They don’t want to be at your office.

It may seem odd to patients, but most doctors forget that going to the doctor is generally unnerving. We work there, and being in a doctor’s office is normal to us. Not so with most patients. The spotlight is on them and their health. They stand on the scale, undress, tell intimate things about their lives, confess errors, are poked, prodded, shot with needles, lectured at, and then billed for the whole thing….There is always an underlying fear and self-consciousness that pervades when a person is sitting on the exam table. The best thing to do in response to that is to show compassion.

Rule 2: They have a reason to be at your office.

They don’t come to the office to waste the doctor’s time. Yet early in my training I was incredulous at the reasons some of my patients were coming to see the doctor. Why come in for a headache? Why come in for a cold?…It took me being in my own practice (and trying to keep my business going) to realize that there is (almost) always an underlying reason for a patient to come in. Sometimes that reason is simple: they have terrible pain that needs to be treated. Other times, however, the reason is more subtle. When a person comes to my office with enlarged lymph nodes, for example, the real reason they are coming in is that they are afraid it is cancer. If a person has chest pains, they are afraid it is their heart. On every visit I try to identify the real reason (or the real fear) that brings them to see me. I don’t end the visit until I have addressed that reason.

Rule 3: They feel what they feel.

Patients will often tell me their symptoms in a very apologetic tone. They seem to think that they have to come to me with the “right” set of symptoms, and not having those symptoms is their fault. Sometimes those symptoms make no sense to me at all, and I am tempted to dismiss or ignore them. But as a physician, you have to trust your patient….Yes, some may exaggerate what they feel out of anxiety or out of fear that you won’t hear them for lesser symptoms, but then your job is to uncover the anxiety, not ignore the complaint. I have heard from many patients that their doctor “did not believe” their complaints because they did not make sense. If you don’t trust them, why should they trust you?

Rule 4: They don’t want to look stupid.

People are often worried that they are over-reacting. They wonder what I must think for a person to come to the office with that symptom. This is especially true of parents bringing their children in. Nobody wants to be “that mother that over-reacts to everything.” In response to this, I try to specifically say, “I am glad you came to the office for this because…” or “Yeah, I can see how that worried you because it could be….”

Rule 5: They pay for a plan.

What do people pay for when they come to the medical office? They pay for opinion, yes. They pay for knowledge as well. But what they really pay for is a plan of action….They want to know what is going to be done to help. I try and give a plan, either verbal or written, to each patient that walks out of the exam room. What medications are given and why? What medications are to be stopped? What tests are ordered and what will the results mean? When is the next appointment? What should they call for if they have problems? The better I can answer these questions, the more confidently the patient will walk out of the exam room. The days of paternalistic medicine are over – no handing a prescription and just saying “take it.” Patients should know why they are putting things in their body.

Rule 6: The visit is about them.

With all of the stresses in a doctor’s office, I get tempted to complain about things. Who better to complain to than someone who feels much the same way? But patients are paying for you to take care of their problems, not the reverse. I keep my personal gripes or frustrations to myself as much as possible.

As a Registered Nurse, and more specifically as a case manager, I feel that if physicians would take the time to study these six simple rules we would see a far greater satisfaction with our healthcare system.  So much of my job is filling in the blanks left by the physicians.  I realize there is not enough time to spend with our patients.  The current payment system for medical services does not allow the face-to-face time that our patients need and deserve.  My job largely came out of this need.

Every day I spend countless hours listening to patients, helping them to determine if their symptoms warrant urgent treatment, explaining medication usage and side effects, aleviating fears, sharing alternative treatment options, and just being there for them.  I love the patient advocacy part of my job, but not everyone has access to a nurse when needed.  The average patient goes to their primary care doctor for these very same things.  Even when I attend an appointment with my client, I find myself having to reiterate the entire visit because they did not have time to digest the information due to the very quick face-to-face interaction.

It is time our doctors realize what a huge difference they can make even in the ten minutes they spend with their patients.  Putting yourself in the place of the patient should help alleviate any attitude you might have.  Secondly providing time for questions.  Make sure when the patient leaves they have a written plan of action that they can review after they leave the office.  Provide an avenue for questions that arise only after they leave your office.  It would make my job a lot easier. 

Do you have any other suggestions in providing care for our patients?  As a nurse what interactions do you have with patients outside of the doctor’s office?  What recommendations would you make to extend the few minutes one has in front of the physician?

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October 11th, 2009 starts the weeklong celebration of case managers and the commitments and contributions we make in educating the public.  I have previously been employed with national case management firms who would honor us with activities such as lunches, continuing education seminars and gifts of appreciation.  As a business owner I no longer get to participate in such functions, but it certainly does not diminish my pride in what we offer to the community, our patients, and our fellow healthcare providers.

If you have a firm or facility are are looking for ways to recognize the work of your case management staff, consider suggestions made by CMSA (Case Management Society of America).  They have downloadable resources as well as promotional products that you might wish to use to make this year’s celebration the best ever.

Perhaps you could like to join this exciting field.  To learn more about becoming a certified nurse case manager, check out the Commission for Case Manager Certification.  Even before you become certified you can join CMSA for networking, educational opportunities and assistance in positively impacting and improving patient wellbeing and healthcare outcomes.

Happy Case Management Week!

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Doctors fail to report clinically significant findings to their patients in more than 7 percent of cases, a new study has concluded. According to the study, published Monday in the Archives of Internal Medicine, use of electronic medical records tended to lower instances of failures to inform. However, practices that used a combination of electronic and paper records failed to inform patients of abnormal results more often than practices that used only paper or electronic records.

As a former office nurse, I know that the number of results received in a single day can be overwhelming. My experience has been limited to the specialist’s office and can only imagine the astronomical number of results a primary care physician might be expected to review. Our office practice was to have all results signed off by the physician. We did not call back for normal results, but always encouraged the patients to call back for results when they were to be available. Abnormal results were called to the patient along with any instructions for change in treatment plan.

As someone who teaches patient advocacy, I always tell my clients to not only follow up on their test results, but to also receive and retain a copy for their own records. By asking that they obtain a copy it is less likely to be forgotten. It might result in a few extra phone calls to the clinic to complete the retrieval and obtain any explanation or clarification, but it beats the alternative!

To read more about this study, check out the article in The New York Times.

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AARP has renewed its efforts to have Medicare close the gap in prescription coverage known as the “doughnut hole.” Roughly 3.4 million Medicare Part D beneficiaries fall into this gap in coverage each year. The bigger problem is that of these only 15% end up spending enough out of pocket money to hit the upper limit and receive catastrophic coverage.

This gap in coverage totals $3,454 in out-of-pocket spending. By 2016, that gap is expected to exceed $6,000. AARP is fighting this stating it is much too high. Higher costs for prescription drugs lead people into skipping doses or discontinuing their prescriptions all together. They put their health in jeopardy and drive up long-term costs due to poor health.

The “doughnut hole” gap in coverage is difficult for most people to understand. Here is a breakdown for you.

To read more about the AARP campaign, check out this article by Chris Silva of AMNews.

Many changes are coming to our health care system.  The US Senate Finance Committee is working on Health Reform Policy.  As a nurse case manager I am an active member of the Case Management Society of America (CMSA) which is based right here in Little Rock, Arkansas.

In it’s official response to the call for public comments, CMSA encouraged legislators to “align reimbursement to physicians for care/case management activities performed by nurse care/case managers or other qualified professionals and that those activities need to include appropriate transitions of care interventions for patient and their family caregivers.”

Case managers are responsible for the transition and care coordination of patient care.  Care coordination performance is measured through the National Quality Forum support and appropriate payment alignment for those services should be mandatory. CMSA would like to see specific payment codes developed and aligned with performance measure for case/case management services within the collaborative team model. This should support hospital, outpatient, medical home and long term care coordination.

CMSA encourages all Members and allied health care professionals to submit their own individual public comments to the Senate Committee on Finance. Public comments should be emailed in PDF or Microsoft Word format to Health_Reform@finance-dem.senate.gov.

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