Talking rationally when health care goes wrong

What’s the best way to talk about it when something goes wrong with patient care?

The Minnesota Department of Health this week released its annual report on “never” events that occurred at Minnesota hospitals and surgery centers over the past year, and as usual I had an internal debate over whether to use the term “adverse event” or “medical error” or, simply, “mistake.”

You might ask, “What’s the difference?”

But if I’ve learned anything from a decade’s worth of reading and studying the yearly adverse health events report, it’s that none of this is as straightforward as it seems.

The incidents catalogued in Minnesota’s adverse health events report represent the most serious things that go wrong in hospitals – wrong-site procedures, advanced-stage pressure ulcers, patients who die by suicide while in the hospital, serious medication errors and so forth. By definition these are considered “never” events – events that should never, or only rarely, happen in the hospital.

The world of patient safety is a huge ecosystem, however, with many layers that are less easy to categorize. Does an error lie behind every bad event or is it more complicated than this? Those who work in patient safety would say to beware of oversimplification.

Not all adverse patient events are directly the result of a mistake. Not all mistakes lead to adverse events.

For that matter, not all adverse events end in harm, although plenty do and patients can be seriously disabled or even die as a result.

Sometimes it’s the individuals delivering the care who are at fault. More often, it’s the system itself that’s faulty and vulnerable and sets people up, patients and health care professionals alike, for something to go wrong.

And sometimes, in spite of everyone’s best efforts, in spite of doing all the steps correctly, things just don’t go well.

Teasing out these nuances is one of the challenges in patient safety, especially when it comes to how the public perceives and talks about patient safety. It’s still difficult for hospitals to speak openly about adverse events, partly because it’s painful to do so but also partly because of the barrage of blame and judgment that’s likely to be unleashed.

This isn’t to say providers are entitled to a free pass whenever a patient is harmed. Accountability is necessary, always. But there’s a difference between holding people accountable and being harshly punitive. When the energy is focused on blame, the attention can be deflected away from learning what went wrong, why it happened and how it can be prevented from happening again.

Because, in the end, isn’t that what everyone wants? To learn, so the vulnerabilities can be fixed and future patients are less likely to have something go wrong with their care.

One of the big lessons from 10 years of experience in Minnesota is that reporting and open discussion about adverse events is making health care measurably safer. At times the progress has been achingly slow and at times it has gone backwards, but the overall trajectory has been in the direction of improvement.

This doesn’t happen, though, unless there’s a rational conversation about it. At some point we all need to make it less scary for people to ‘fess up so the real work of learning and improving and making care safer can take place.

Read the Minnesota Department of Health 2014 report on adverse events here. A 10-year evaluation of the adverse health events reporting system can be found here.

My weekend as an emergency patient and what I learned

If you want to see what health care is really like, there’s no better way than by becoming a patient yourself.

To paraphrase the wisdom of Dr. Seuss, “Oh, the things you’ll learn!”

The truth of this was recently hammered home for me during a weekend in the hospital that started with a Friday night trip to the emergency room, devolved into IV antibiotics, painkillers and surgery, and ended in a (minor) complication that luckily resolved on its own.

Who doesn’t benefit from undergoing a reality check every so often? It’s safe to say I encountered some old lessons that were reinforced and some “Aha!” moments that were new.

Here are a few of them, in no particular order of importance.

- Most of us pay no attention to our gallbladder until it unexpectedly stages a major rebellion. Then we notice very much indeed, especially when it becomes gangrenous.

- The word “patient-centered” can be rather nebulous. What does it mean, anyway, and how do you know patient-centered care when you see it? Here’s a clue: When the emergency room staff’s immediate response is to deal with your medical situation and worry later about seeing your health insurance card, that’s patient-centered.

- People in health care work really, really hard – days, evenings, nights, weekdays and weekends. It can be easy to judge their efforts by the amount of time they directly spend with you, the patient, but this is only the tip of the iceberg.

What you don’t see is the amount of time spent assessing the patient’s situation, reviewing lab results, communicating with the rest of the team, scheduling procedures, making decisions, following safe, evidence-based practices and documenting everything accurately in the medical record. When the behind-the-scenes action is done well, you likely are receiving better care and will have a better outcome, even though most of the work on your behalf will never be visible to you.

- When it’s your health at stake, it’s hard to be objective about costs. The effort has to start somewhere, though. Although physicians have a responsibility to avoid potentially harmful and expensive overtesting and overtreating, this is a two-way street. It needs to be OK for the doctor to say, “We’re not doing a CT scan because it’s unnecessary” and not meet with instant backlash from the patient. It needs to be OK for patients to let go of the I-want-you-to-do-everything security blanket and not fear they’re receiving substandard care. In health care, more does not automatically mean better.

However:

- Cost can’t be the sole consideration. Sometimes it’s OK to delay care and sometimes there’s a less expensive option. But sometimes the patient needs immediate care and sometimes the care needs to be aggressive. This, rather the goal of simply being as cheap as possible, is the real challenge in health care: providing the right care at the right time, not too much, not too little, not too soon and not too late.

- It’s good to ask questions but patient engagement is much more than this. It’s about listening, absorbing information, understanding how and why key decisions are being made, and seeing the big picture. It’s about communicating clearly and accurately. It’s about following directions. This is complex stuff, and a sudden hospitalization is not the best time to try to learn the language and behavior of patient engagement. Far better to start cultivating some of these skills when you’re well, rather than in the middle of an emergency.

- Who wants to be the patient who arrives at the emergency room and is forced to say, “I don’t have one” in response to the question, “Who’s your regular doctor?” You can probably get by, but your hospital visit will likely go more smoothly if you have a primary care doctor who knows you – or, at the very least, if you have a usual source of care.

- Being sick and hospitalized is disruptive, to families as well as to patients. It upsets the normal routine and adds unexpected stress. It can take several days, or several weeks, for everyone to regain their equilibrium. What patients and families don’t need is more frustration from a health care system that’s cumbersome, confusing to negotiate or slow to respond. Organizations that work to minimize this for patients are doing them a favor.

- Health care is organized around systems but it’s delivered by individuals and reinforced by organizational culture. Every one of those interactions counts, and every one of them helps define the line between having a good experience and having a bad experience. This is your shout-out, Rice Memorial Hospital and Affiliated Community Medical Centers, for knowing where that line should be. Bad experiences don’t happen by design but good experiences rarely happen by accident.

Additional reading: Choosing Wisely; Image Wisely; Costs of Care; Center for Advancing Health; minimally disruptive medicine.

You’ll like sharing your hospital room. Really.

American hospitals have spent millions of dollars scrapping old-fashioned patient wards and double rooms in favor of private hospital rooms for everyone.

But maybe this strategy is entirely wrongheaded, suggests Dr. Richard Gunderman, a professor at Indiana University, who last week lamented the decline of shared hospital rooms and the resulting loss of human contact between patients.

Yes, patients might resent having their sleep interrupted by a roommate who snores or watches TV all the time, Dr. Gunderman writes. But deep down, don’t most of them long to connect with others who are going through the same thing?

Hospitals these days “increasingly resemble high-security prisons” designed to keep patients from interacting with each other, he writes.

In our haste to control infections, we isolate them. In our zeal to preserve confidentiality,  we prevent patients from getting to know each other. They sometimes begin to feel as though they are being kept like specimens in hermetically sealed containers.

What patients really want, he concludes, is to connect with other people who know what it’s like from the perspective of the hospital bed. And even though they think having a room to themselves is preferable to giving up their privacy in a group ward, “perhaps… they don’t know what they are missing out on,” writes Dr. Gunderman.

In many cultures, hospital patients often share a room with one or perhaps many people and can mingle freely with them. But the notion of privacy is deep-seated in American culture. Contemporary Americans value the ability to live their lives without intrusion or outside interference, and this spills over into how we manage our shared social space. How we feel about privacy can especially be put to the test when we’re sick, vulnerable and hospitalized. Do we want company or would we rather be left alone?

Many Americans (Canadians too) frankly prefer the latter, as evidenced by the reaction to Dr. Gunderman’s essay.

Here’s the response from Heart Sisters blogger Carolyn Thomas, who says she could “scarcely believe what I’m reading here.”

“As a heart patient who has become a frequent flyer of the health care system, I can tell you flat out that I don’t ever go into hospital to make friends with other sick people. Ever!” she wrote. “While the disruption of ‘a roommate’s television viewing or snoring’ may seem minor to you, it’s a very big deal if you’re the sick person being held hostage amidst this kind of noise.”

“This article had to be penned by an extrovert,” someone else wrote. “I cannot imagine anything worse than being in a forced social situation with some stranger while both of us were sick enough to be in the hospital… This whole premise almost sent me to the ER.”

There are obvious inconveniences to sharing a hospital room. Maybe you’re stuck with a roommate whose family and friends crowd the room at all hours of the day and night when you’re trying to rest. You’re forced to share a bathroom. You might overhear conversations that aren’t meant for your ears. There’s always a chance of unwanted proximity to vomiting, bleeding and other distressing physical functions – or of experiencing the humiliation of being the one to vomit in front of a roomful of strangers.

The serious question here is whether private rooms result in better outcomes for patients or whether they’re merely nice to have.

Although the evidence is somewhat mixed, the bulk of research has found that single-bed hospital rooms are linked to better infection control, less stress for patients, fewer sleep interruptions, especially in intensive care units, and improved recovery times resulting in a shorter hospital stay. Case studies also have found private rooms more conducive to patient education, medical consultations and the ability of family to be with the patient.

Does it also count for something that when patients are asked for their opinion, the vast majority say they prefer a private hospital room?

The problem of clinician overload

At the 45-bed hospital in rural Alaska where Dr. Janice Boughton is a hospitalist, her shift starts at 7:30 a.m. Here’s what greeted her when she arrived one recent morning:

The night shift doc told me about the 13 patients who I needed to take care of that day. Seven of the patients were new to me, admitted the night before. For those patients, I needed to review their medical histories in the computerized medical record and get to know them, with a focused physical exam and an interview to determine what needed to be accomplished in the hospitalization. For all of the 13 patients, I needed to review all of the lab tests completed in the last day and all of the radiological studies and check their vital signs and review the nurses’ notes about what had happened in the previous 24 hours. Each person had an average of about 30 blood test values and some of them also had microbiological results that needed to be reviewed.

And the day had barely even started.

For the next 12 hours she saw patients, reviewed tests and medications, dictated notes, updated medical charts, admitted two new patients from the emergency room, transferred two patients out of intensive care, answered the phone, did five bedside ultrasounds, talked to patients and families about end-of-life care, discharged patients who were ready to go home, discussed patient care with referring physicians and tried to track down incomplete test results from a pathologist.

No wonder doctors become frazzled by the amount of multitasking they’re required to do. “I love every little part of my day, but I don’t necessarily love trying to do all of it at the same time,” Dr. Boughton writes.

Patient care has always been demanding. But if you listen to clinicians when they talk about what their days are like, it’s clear there’s a rising tide of frustration with the overload.

Perhaps it’s no coincidence that around the same time Dr. Boughton wrote about her hectic day in the hospital, JAMA Internal Medicine published a survey that uncovered serious, quantifiable issues with the workload that many hospitalists experience.

Just over 500 hospitalists from across the U.S. took part in the survey, which was conducted online. Among the findings:

- 40 percent of the respondents said their patient load exceeded safe levels at least once a month, and 36 percent said this happened weekly.

- One in four reported that the excess workload often resulted in being unable to fully discuss treatment options with patients and families or answer their questions.

- About 25 percent said their workload affected patient care.

- 19 percent felt the heavy workload was detrimental to patient satisfaction.

The overload isn’t limited to hospital medicine. Nurses worry about high patient-to-staff ratios and the impact this has on patient care and safety. A study that looked at pharmacy workloads found that when pharmacists were overloaded, there was increased potential for error.

And when researchers tracked the workload at a private internal medicine practice in Philadelphia a few years ago, they found some startling statistics on how the physicians spent their day. Each of the five doctors saw an average of 18 patients per day, made 23.7 phone calls, received 16.8 emails, processed 12.1 prescription refills, and reviewed 19.5 laboratory reports, 11.1 imaging reports and 13.9 consultation reports.

It’s a recipe for harried providers, frustration, mistakes and ultimately professional burnout.

None of this is good news for patients who increasingly are having to make do with a smaller slice of the doctor’s time and attention.

Patients can help reduce some of the overload by being organized and focused when they talk to the doctor. They can help by knowing their health history and what medications they’re taking. They can quietly grit their teeth and be patient when a phone call isn’t promptly returned. They can show up on time to their appointment, because even though doctors are often late, the schedule gets further clogged when patients arrive late too.

This is only a fraction of the solution, however. Moreover, there’s a limit to how much should be expected of patients to help reduce the doctor’s workload. There are times, after all, when someone genuinely needs the extra attention.

No, the real problem lies with the system itself. Perhaps even more than cost or quality, clinician overload is a major – and often ignored – issue that threatens to swamp the progress toward better, safer care. And the near future doesn’t seem to hold many fixes.

Young adults in the emergency room

Who goes to the emergency room – and why?

A new report from the U.S. Centers for Disease Control and Prevention sheds some light on emergency room use last year among a subset of folks not typically associated with needing much emergency care – young adults ages 19 to 25.

It’s a demographic worth studying for two reasons: First, these individuals are often working entry-level or temporary jobs or attending school and are vulnerable to being uninsured. And second, the report provides some idea of how young adults are faring under the Accountable Care Act, which allows them to remain covered by their parents’ health insurance until age 26.

The statistics, which were collected from January through September of last year through the National Health Interview Survey, don’t contain any big surprises. Young adults who were poor were more likely to lack a usual place for receiving health care and more likely to have visited the emergency room than those who weren’t poor. Young adults with public health coverage also were more likely to have gone to an emergency room than their counterparts who had private insurance or were uninsured.

The report confirms something else that’s echoed in other recent studies about health care utilization: The young adults who were surveyed were much more likely to delay needed care if they were uninsured. Nearly one in three who were uninsured said they had skipped seeing a doctor in the past year because of the cost. For those with public coverage, it was 10.1 percent; for the privately insured, it was 7.6 percent.

In fact, the statistics more or less mirror what’s happening with the rest of the adult population under age 65. Contrary to popular belief, most studies indicate that emergency rooms are not being unduly clogged with the uninsured. Indeed, this group seems to be the least likely to visit the ER except as a last resort – probably because they fear being saddled with a large bill they won’t be able to pay.

Regardless of age, the highest ER utilization tends to be among those on Medicaid. Various studies have pointed to a number of reasons: These folks might have more difficulty finding a primary care doctor and more difficulty making a timely appointment, forcing them to turn to ER care instead. Problems with transportation and lack of medical clinics close to where they live have also been identified as barriers.

The persistence of these patterns, even among a fairly narrow subset of young adults who belong to one of the healthiest age groups, is troubling. It suggests there are deeper issues involving socioeconomics, physician supply and demand and overall access than can be cured simply by providing more young adults with health insurance.

The truth about nurses

It’s National Nurses Week this week, which means gratitude, a few days of attention and maybe some free cookies for the hard-working individuals who make up the American nursing profession.

Only I can’t quite get on board with the feel-good fuzziness that tends to accompany this annual celebration, because many nurses aren’t feeling the love these days. They’re overwhelmed, tired and angry – overwhelmed and tired with the workload and constant pressure, and angry at the persistent gap between how they’re so often perceived as handmaidens and pillow-fluffers and how much they actually do.

What other category of health professionals would be expected to put up with the likes of a recent NBA halftime show featuring the Mavericks Dancers gyrating in skimpy “nurse” costumes? Or sexy pseudo-nurses in heels and red lingerie appearing on TV with Dr. Oz to illustrate exercises for weight loss?

According to the venerable Gallup Poll, nursing consistently ranks as one of the most trusted professions in America. But it seems we often have trouble connecting the word “nurse” to the word “professional”, and it shows in how nurses are often portrayed in popular culture and even in how they’re treated by patients, families and employers.

There’s some provocative research on how the role of nurses in health care is often influenced by inaccurate or incomplete images of who they are and what they do. One study that analyzed the websites of 50 leading American hospitals found that nurses were mostly invisible. Another study ties a nursing shortage to the lack of attention they receive in the media.

The truth about nurses?

- There are some 3 million licensed registered nurses in the United States.

- Nurses are trained. About one-third of RNs hold four-year bachelor’s degrees or graduate degrees and about one in five holds an additional academic degree.

- Increasingly, nurses are gaining advanced practice degrees as nurse practitioners, clinical nurse specialists, midwives and certified registered nurse anesthetists. In 2008, the most recent year for which statistics are available, about half of RNs had a bachelor’s degree or higher. More than 600 million patient visits are made annually to nurse practitioners.

- While more than half of nurses work in hospital settings, they can also be found in nursing homes, medical clinics, ambulatory care centers, community health centers, schools and retail clinics. Nurses also provide care at camps, homeless shelters, prisons and in the military.

- About 12 percent of nurses with master’s degrees work as academic educators.

- The nursing workforce is increasingly diverse. Just under 6 percent of registered nurses in the U.S. are men, 4 percent are African American, 3 percent are Asian, Native Hawaiian or Pacific Islander, and just under 2 percent are Latino.

Although it might not always seem like it to nurses who are on the front lines of daily patient care, there are signs their profession is (finally) getting more respect. There’s been some landmark research in recent years by the Robert Wood Johnson Foundation on how nurses are uniquely qualified to lead efforts to transform care at the bedside.

A number of studies have directly linked the role of the nurse to safer, better care for patients and better outcomes. And a major new initiative by the national Institute of Medicine calls for more development of the nurse workforce of the future, with an emphasis on more education and training, allowing nurses to practice at the full extent of their license and giving them full partnership – along with physicians and other health professionals – in redesigning the U.S. health care system.

A nurse might fluff your pillows if you ask nicely because for most of them, their choice of profession still comes down to a desire to care for others. But it’s time to move past the limited, inaccurate stereotypes and embrace the truth about nursing – that nurses are, and are capable of, being key players in health care and that they deserve full inclusion.

Sources: American Nurses Association; American Association of Colleges of Nursing; Minority Nurse; The Truth About Nursing.

Afraid to err

There was dispiriting news this week from the patient safety front: Despite efforts by hospitals to create a culture that encourages employees to report their mistakes, many still fear they’ll be punished for doing so.

The U.S. Agency for Healthcare Research and Quality issued a report this month on the state of safety culture in U.S. hospitals. It’s the second such report in five years, and the results show minimal progress in developing non-punitive responses to medical errors.

Survey information was collected from nearly 600,000 workers at 1,110 hospitals across the U.S. Half said they felt their mistakes were held against them, and 54 percent said that when an adverse event was reported, it felt “like the person is being written up, not the problem.”

Two-thirds worried that their mistakes were kept in their personnel file. Less than half were comfortable speaking up and questioning the actions of someone in authority.

Some of the survey findings were downright scary. Nearly 40 percent of the survey respondents said it was only by chance that more mistakes didn’t happen at their hospital. About the same number believed hospital management is only interested in patient safety when there’s an adverse event.

Is this perception or is it reality? It’s a little hard to pin down why so many hospital workers responded to the survey the way they did. Even if their attitudes are based on belief rather than fact, however, the outcome is the same: People don’t speak up if their perception, rightly or wrongly, is that they’ll be punished for it.

It’s not enough for hospitals to say they won’t take the shame-and-blame approach to mistakes – they need to show that they mean it, Brian Sexton told American Medical News in an article published this week.

“They say all politics is local. Well, all culture is local. That’s why it is that we say this is so important and yet we don’t see a lot of traction,” said Sexton, a medical psychologist and director of the Duke University Health System Patient Safety Center in Durham, N.C.

“We’ve given more rhetoric than we have resources to this problem in health care.”

Health care isn’t unique in taking a hard approach to human mistakes, but many observers say blame and punishment seem to be especially entrenched in the culture of hospitals and, to a lesser extent, medical clinics. This isn’t necessarily surprising; after all, the stakes are enormous. Patients can be killed or permanently disabled when things go wrong.

Moreover, many who work in health care expect a lot of themselves and those around them. Maybe the health professions are somewhat self-selecting for people who tend to seek control and perfection; maybe some of these attitudes are born out of rigorous training environments. Whatever the case, they can result in merciless condemnation when the inevitable mistake gets made. Fear of being sued and/or ripped apart by the media adds to the pressure even more.

Consider the anonymous nurse in an online nursing forum who was summoned to a case review after a patient was found unresponsive during her shift. She was quickly exonerated of any misjudgment but the process was agonizing, she wrote. “…This feeling of being a horrible cruel person is not what I ever thought would have happened… to me.”

It’s no wonder people are afraid to report their errors.

But here’s an important question: How much of patient safety is about safe systems and how much of it is about safe practices by individuals? In promoting a blame-free culture in hospitals, is there a risk of going too far in the opposite direction and doing away with accountability for reckless or careless behavior?

A nurse responded to Fierce Healthcare’s coverage of the AHRQ survey with this comment:

What is not mentioned in the study is for how many of the respondents, was this the fifth, sixth or seventh error? Where is the line drawn between reporting errors and a negligent practitioner?

A good review process that everyone participates in, is the way to distinguish between the inadvertent error, perhaps based upon bad process or other mitigating circumstances and the negligent practitioner. That’s the environment that needs to be fostered.

Some balance seems to be demanded – hospital cultures that are neither heavy-handed nor permissive, that encourage openness about their failures yet take responsibility when things go wrong.

Making this happen isn’t easy but it needs to be done, Sara Singer, an assistant professor at the Harvard School of Public Health, told American Medical News. “I don’t think you should give hospitals a free pass on this. Yes, it’s hard – and it’s critically important that they do it anyway.”

The noisy hospital

Everyone knows that hospitals aren’t the best place to go for a good night’s sleep.

A study published this week in the Archives of Internal Medicine adds more proof with several new findings, including one that’s truly startling: The average noise level in patient rooms can reach 80 decibels – almost as loud as a chainsaw.

How about a little more peace and quiet, please?

Researchers at the University of Chicago Medical Center studied about 100 adult patients, tracking how well they slept in the hospital and how much noise they were exposed to.

Among the findings:

- Although hospital rooms were less noisy at night than during the day, they were far from quiet.

- The average nighttime noise level in inpatient rooms was around 50 decibels, which exceeds recommendations by the World Health Organization; 30 to 40 decibels is considered the maximum for a hospital setting.

- At times, noise levels spiked to 80 decibels. This is the equivalent of a chainsaw or the typical home stereo listening level. It’s louder than the noise of an average factory or office, a busy street or a small orchestra, and only a couple of notches below the noise level of heavy truck traffic.

- The noise came from many sources: staff conversations, roommates, alarms. The loudest source? Intercoms and pagers.

- The noisier the room, the less likely it was that the patient slept well. On average, patients exposed to the highest nighttime noise levels slept 76 minutes less than those exposed to the least amount of noise. Sleep quality for patients in the noisiest rooms also tended to be worse.

Dr. Vineet Arora, who led the study, told Reuters Health, “One of the most common complaints that patients will report is that they had a difficult night sleeping.” The risk is that it could hinder the patient’s recovery, she explained.

Sleep experts who reviewed the study say there could be additional factors to blame for sleep disruption in the hospital. Patients simply might not sleep as well when they’re sick, they suggested. Also, patients who are sicker often have more nurses coming in and out of the room to monitor them during the night, administer medications and so on.

There doesn’t seem to be a cheap or easy fix to the hospital noise problem. Long-lasting solutions often involve engineering, such as installing wall and floor coverings that absorb sound or ditching overhead intercoms in favor of wireless pagers.

Although I don’t advocate tearing down older hospitals and starting over, new construction does offer opportunities to incorporate better noise reduction strategies. When Rice Memorial Hospital here in Willmar built a new patient wing a few years ago, considerable attention was paid to creating an environment that would be healing for both patients and staff. For starters, all the patient rooms are now private. The layout is designed so that no patient room is directly opposite a nurse’s station or utility closet or other potentially noisy location. Corridors for staff use, carts, equipment and so on are separate from patient corridors. Overhead paging also was replaced with wireless communication. When I’ve visited friends and relatives hospitalized at Rice, one of the first things I usually notice is how quiet it is.

Unfortunately, many hospitalized patients will have to continue to put up with a certain amount of noise. For them, sleep experts have these suggestions: Ask staff to keep the room door closed. Wear noise-canceling headphones. Open the window blinds during the daytime to let in natural light and try to walk around the day if they’re physically able. Patients might not be able to change the environment but small changes can help make hospital noise levels less bothersome.

Photo: U.S. National Archives and Records Administration

A toxic place to work?

Talk about ironic: A new survey suggests that many hospital employees don’t practice what they preach when it comes to staying healthy.

The survey, conducted by the Thomson Reuters consulting group and released this week, found that health care spending for hospital workers was 10 percent greater than for the U.S. workforce as a whole. Hospital employees also were more likely to have chronic medical conditions such as asthma, diabetes, high blood pressure and congestive heart failure.

The report is based on an analysis of health care costs and utilization by 1.1 million hospital employees and their dependents who had employer-based coverage.

I’m not sure what to think of these findings. Are people who work in hospitals really less healthy than everyone else? Or is the real issue that hospitals often are stressful, unhealthy places for people to work?

I once spent a day shadowing a registered nurse. She was on her feet almost all day and barely even had time for lunch.

Multiple studies have documented the occupational stress nurses face every day and the toll it takes on them. Many observers believe the stress is only increasing as the work load intensifies, putting nurses at greater risk of burnout and chronic disease.

But it’s not just nurses who work in stressful conditions. It would be hard to find a hospital employee anywhere these days, from the kitchen to the intensive care unit, who isn’t feeling the pressure to do more with less, to be more efficient and deliver safe, quality services while reimbursement continues to be ratcheted down.

Despite a mounting body of evidence that 12-hour and rotating shifts are associated with fatigue, decreased physical and mental functioning and even lower life expectancy, these schedules are still commonplace at many U.S. hospitals.

Fast meals, often grabbed on the go from a vending machine, can become the norm during a busy day. Even eating in a hospital cafeteria isn’t necessarily the better option, especially when menus are designed to appeal to visitors rather than the workers who eat there every day.

Put it all together and it should no longer be surprising that hospital employees statistically comprise one of the least healthy occupational groups.

When the University of Michigan tackled an initiative in 2002 to develop a wellness program at Allegiance Health in Jackson, Mich., the researchers’ baseline assessment found some of the unhealthiest workers they’d ever seen. Only half of the employees who underwent the assessment were considered low risk; 19 percent were classified high risk.

All of this is to say that it’s usually not enough to tell people they should shape up. The environment must support this as well.

I had the opportunity recently to visit with a couple of local employers about some of the changes they’ve adopted to encourage better food choices and more physical activity among their workforce during the work day. They haven’t been draconian about it; employees can still get a candy bar from the vending machine if they’re really craving a Milky Way. But both these organizations – Affiliated Community Medical Centers and West Central Industries – have become more intentional in their policies and practices: smaller portions for catered meals, more low-fat entrees and fresh fruit and vegetables in the cafeteria, fewer high-calorie snacks in the vending machines, walking programs that encourage employees to log some exercise time each day.

Studies to date have shown mixed results on the benefits of employee health initiatives. The payoff – healthier workers and lower health care costs – generally isn’t immediate; in fact, costs can rise in the short term as issues such as high blood pressure are identified and treated. Corporate wellness initiatives seem to work best when they target the workforce as a whole, not just those who are deemed at risk. They can also be counterproductive if workplace hazards and other environmental barriers aren’t dealt with first.

The lesson here, it seems, is that wellness doesn’t begin and end at home. If we want hospital workers to be healthier, part of the solution will have to come from their employers.

Photo: Wikimedia Commons

Rethinking hospital readmissions

There’s long been a belief that hospital readmissions are largely preventable, and that if a patient is readmitted after an earlier hospital stay, it’s a sign of lower-quality care. In recent years, hospitals in the U.S. and elsewhere have poured untold amounts of time and resources into lowering their readmission rates.

A new study from Canada has come along to challenge this thinking. The study, which appeared this week in the Canadian Medical Association Journal, analyzes emergency readmissions among 4,800 patients at 11 hospitals in Ontario and concludes that only about one in five could have been prevented.

Moreover, the researchers learned that the number of readmissions may be lower than previously thought. In this particular study, 13.5 percent of patients in the sample group had an urgent, unplanned readmission within six months after a hospital stay.

One study doesn’t make a trend. For one thing, the analysis didn’t include patients who were readmitted after being discharged to a nursing home and who may have been older, more frail and more vulnerable. For another, the determination of whether an admission was avoidable was to some extent subjective.

But it certainly calls into question the widespread belief, especially among health policy folks, that readmissions are a reliable indicator of whether a hospital is “good.” It also challenges the assumption that readmissions can be avoided if only hospitals work diligently and hard enough.

Among the many nuggets of information in the Canadian study: The majority of patients who had an urgent readmission were more likely to have chronic or serious health conditions and a history of previous hospital admissions than the sample group as a whole.

There appeared to be multiple reasons why these patients had to be readmitted. Case reviewers found that some readmissions were obviously avoidable but others were less clear-cut. Errors in patient management were among the most common factors. So were surgery-related complications and medication-related issues. Some patients were readmitted because they developed a hospital-associated infection, others because there was a diagnostic error during their initial hospital stay.

One point worth noting: Readmissions that were deemed preventable mostly occurred within a few days after the patient left the hospital. This could suggest many things – for instance, that this subset of patients was perhaps simply more sick to begin with, or not quite ready yet to be sent home.

Another crucial point: The case reviewers couldn’t always clearly determine whether a readmission was truly avoidable and often needed more information before classifying it as preventable or not.

Dr. Carl van Walraven, a clinical epidemiologist at the Ottawa Hospital Research Institute and lead author of the study, told the Ottawa Citizen, “Not all urgent readmissions are avoidable, despite the care that is provided. This means that a lot of them are caused by a patient’s condition, or other factors that are not treatable or modifiable.”

The use of metrics, or statistically measurable indicators of hospital care, is widespread in the industry. Increasingly, the federal government, payors and quality assurance organizations are tieing metrics to how much hospitals are paid – more money for hospitals who meet the standard, less for those that don’t. But what if the metrics are based on faulty assumptions, i.e. that most unplanned readmissions are avoidable?

If anything, this study seems to underscore how difficult it is to define and measure quality in health care. Can every pressure ulcer be prevented? Perhaps not, although the most serious pressure ulcers are probably avoidable and the goal should be to make them a very rare occurrence. Much more can be done to lower the rate of hospital-acquired infections but it may not be possible to get down to zero.

This isn’t to say that high-quality hospital care doesn’t matter, because it does. But hospitals deal with sick human beings in all their infinite variety and the results aren’t always standard or predictable. The risk with metrics is that they can reduce the definition of quality to “that which can be measured” instead of the complex, nuanced, many-faceted creature that seems to be emerging the more we study it.

Photo: Wikimedia Commons