26 June 2011

14 June 2011

The day of reckoning

Tomorrow we'll be far away

Tomorrow is the judgement day

Tomorrow we'll discover what our God in heaven has in store

One more dawn...

On an unrelated note, tomorrow morning at 5AM our new ER opens and the old one closes down. I'll be there working clinically. To the degree that it doesn't interfere with patient care, I'll live-tweet the experience.

For those not familiar with the institution or the project -- it's a 110,000 annual visit ER closing down and reopening next door in a new, state of the art 83 bed ER, with an entire new 10-story hospital opening directly above at the same time, more or less. The logistics of the transition are pretty staggering. The ER will be the first unit to open. The old ambulance bay will have a barrier put up at 5AM and the new department's ambulance bay and drop-off will be illuminated at that time and all new patients will go there. The staff closing out the old shop will dispo all the patients they can, and at a certain point, maybe by ten AM, any patients still in the old ER will roll across the skybridge to the new facility. We will open one cath lab and one OR in the new hospital while retaining capability at the old rooms. New patients admitted will go to the new tower and the old inpatient units will start discharging patients. By Friday, any patients still in the old tower will move across to the new inpatient units. They'll be bringing the other ORs and interventional labs online in a stepwise fashion during the week. Interestingly, a lot of expensive equipment is being "salvaged" from the old hospital. For example, the telemetry monitors in the ICU -- about half of the new ICU beds have monitors now. When a patient is discharged from the old ICU, they will take that monitor across to the new building and install it in a new ICU bed, which will only then become open for a new patient. Eventually, all the monitors will be re-installed in the new units. Elective surgeries are pretty much out this week. When everything is open we will have 16 ORs and 8 cath/vascular/EP labs with room for four more as need demands.

For the ER (and more importantly for ER patients) this will be a banner day. For too many years we have had many patients who received the entirety of their ER care in a hallway gurney. While the care has been good, it's a miserable experience to be in the hallway. Now all the rooms are private, both visually and acoustically.

New ED

And did I mention it's kinda big? A football field on each side, for perspective. 63 regular treatment rooms, 8 resuscitation rooms, 4 trauma rooms and 4 secure psych rooms. All the treatment rooms are identical in size and equipment. The "major" rooms are also identical to one another -- no hunting for gear. Major rooms also have built-in patient lifts mounted in the ceiling (as do all inpatient rooms). Subdivided into three autonomous sub-ERs with the NW zone being peds/fast track focused. One CT scanner in the ER with more CTs and MRI one floor up. Our processes are tight now in the old ER -- the average time from door to bed is 9 minutes and the time from bed to doctor is about another 20 minutes. We hope to improve that in the new ER. The idea is "no triage" -- patients come directly back to a bed and have their registration and nursing assessment performed there. This eliminates the latent period, wasted time in layman's terms, of triage and the waiting room. 

I walked through the hospital today and watched folks on every single unit frantically preparing for the opening. They were stocking all the little last-minute items -- spectralink phones, toothbrushes, etc. It's amazing to see a hospital slowly come alive like this. Not all was quite right -- some workers in their wisdom decided to install the wall-mounted chart rack directly on the whiteboard the ED docs were to use for communication. Huh? Oh well, that will all get ironed out in time. 

For my part I am terrified about the parts I had responsibility for -- how many docs will be there and when they are there and what rooms they are assigned to. If the patients don't show up (there is a new freestanding ER ten miles south) we could be horribly overstaffed and take a financial bath. If the "Field of Dreams" principle holds -- "If you build it, they will come" -- we could be understaffed with no way to rapidly hire more doctors. I have no clue. If our finely engineered complex processes break down, it could be chaos. As they say, the best battle plan lasts only until the first bullet flies. We will, I am sure, be rapidly re-engineering things.

This has been a huge project, in which I've played only a tiny peripheral role. I can honestly say that I am incredibly impressed by the foresight, the preseverance, the effort and the care that has been put into this undertaking from every level, from the CEO to the nurses to the housekeeping staff. Hundreds and hundred of people have dedicated years of their lives to planning for this. I can't take the least bit of credit for this accomplishment but I am incredibly proud to be part of this organization.

07 June 2011

Wow oh wow oh wow

Amazing photos of the volcanic eruption in Chile:

So so cool. Also amazing. More stunning pix at the Atlantic.

 

While I'm BLOWING YOUR MIND, here is a cool video of a huge explosion on the surface of the sun. 

This sent over a billion tons of material into space, and the explosion was nearly the entire diameter of the sun itself.  More video with a wider field of view here

 

Both via the Bad Astronomer.

02 June 2011

Further evidence of the death of journalistic standards

The New York Times will let any idiot write for them.

Tort Reform does not end Defensive Medicine

It's ever so satisfying to be proven right. Well, maybe "proven" is too strong a word to use, but there is a bit of strong evidence that, as I have said in the past, the practice of defensive medicine is driven by powerful multifactorial incentives and is very unlikely to change even if the most often-asserted motivator, liability, is controlled. Today, Aaron Carroll guest blogs at Ezra Klein's WaPo digs:

The argument goes that doctors, afraid of being sued, order lots of extra tests and procedures to protect themselves. This is known as defensive medicine. Tort reform assumes that if we put a cap on the damages plaintiffs can win, then filing cases will be less attractive, fewer claims will be made, insurance companies will save money, malpractice premiums will come down, doctors will feel safer and will practice less defensive medicine, and health-care spending will go way down.[...]

Health Affairs in December, estimated that medical liability system costs were about $55.6 billion in 2008 dollars, or about 2.4 percent of all U.S. health-care spending. Some of that was indemnity payments, and some of it was the cost of components like lawyers, judges, etc.; most of this, however, or about $47 billion, was defensive medicine. So yes, that is real money, and it theoretically could be reduced.

The question is, will tort reform do that?

That’s actually an answerable question. You could look at areas where tort reform has already happened and see how things have changed. For instance, we could look at Texas, where non-economic damages on malpractice lawsuits were capped at $250,000 about eight years ago. [...]
So what happened to costs of care after that law was put in place? Citizen Watch analyzed just that (pdf) using data from the Dartmouth Atlas of Health Care.

[Graph omitted] Texas is blue, the nation is red, and the law went into place at the dotted line. If anything, Texas’s Medicare spending seems to have gone up faster than the nation’s since 2003. Hardly a persuasive argument for tort reform = cost control.

You'll have to click to the piece for the graph, but it's as described. Now I can admit that there are confounding factors and alternative explanations for this finding. Maybe it just takes more than 8 years for doctors to adapt to a new liability climate. Maybe doctors didn't really trust the new liability protections and so continued their old ways. Maybe the national culture of defensive medicine is strong enough than a single state can't exert change. Maybe health care costs went up faster in TX for unrelated reasons unique to that state. All are possible.

However, my interpretation is that the fear of being sued is just one and not even the strongest driver of defensive medicine. As I have said before, there are many powerful reasons doctors practice in this fashion:
  • When we take risks, patients sometimes die. Doctors don't like that.
  • When bad outcomes happen, peer review can be very harsh in retrospect. Not only is this humiliating, it is as career-threatening as a malpractice lawsuit.
  • While you get sued only in a small fraction of bad outcomes, almost all unexpected bad outcomes are scrutinized in peer review/QI fora, making these very powerful disincentives for physicians to take risks.
  • We are educated to practice in a cautious fashion, and the experts in the fields commonly assert very conservative "standards of care." Cowboys and gunslingers are viewed very unfavorably.
  • Old habits die hard, and doctors are as conformist as any other profession, perhaps more. When the bulk of providers still proactive defensively, there's a real risk for an individual doctor to adopt a more permissive standard of care.

None of this is to imply that I am not in favor of tort reform. My reason, however, is not a belief that tort reform will end defensive medicine or save the health care system money. My reason is that the current system functions poorly and too slowly, injured patients frequently receive nothing, and meritless cases can impose huge financial and emotional costs on physicians. It's inefficient and horribly unfair. But when we look at the $2 trillion the nation spends on health care every year, tort reform should not be looked at as a potential game changer.