MEDICAL ETHICS CHECKLISTS

Hospitals using a checklist designed for the World Health Organization (WHO) cut deaths after surgery by 46% and surgical complications by 36%.

Using this as an example medical residents working in the intensive care unit at the Washington Hospital Center in Washington, D.C., got a different kind of reminder when caring for patients -- an ethics checklist.

The idea is the brainchild of Daniel K. Sokol, PhD, a medical ethicist at the University of London St. George's Hospital Medical School who served as a visiting bioethics scholar at the Washington Hospital Center in January and February. Sokol wrote about the ethics checklist in the March 4 British Medical Journal and said bioethicists at hospitals in Canada and the United Kingdom also are considering the idea.

"Having an ethics checklist changes the focus away from the purely clinical to include the ethical dimension," Sokol said. "In the back of my mind I had this idea of the surgical checklist, where uniformly the results have been quite astounding. I see no reason why there shouldn't be a similar thing for ethics."

The eight-item checklist at Washington Hospital Center -- actually an ID-sized badge that residents wear on lanyards -- covers ethical issues that commonly arise in the hospital setting. Is the patient able to make medical decisions? Is there a do-not-resuscitate order? Is there a disagreement among family members about how care should proceed?

Residents are asked to review the list for each patient, note any potential issues and call the hospital's bioethics staff if they need help resolving problems. The hospital's three ethics consultants already handle about 300 queries a year, said the director of bioethics and spiritual care. She said getting doctors to use the checklist could help avoid ugly squabbles with families and prevent lawsuits.

"We want to recognize the potential for an ethical problem earlier downstream and intervene early enough so that patient care doesn't get compromised and the family doesn't get negatively impacted by the emotional rollercoaster the ICU presents," he said. "It's preventive ethics at its best."

The ethics checklist will be considered at the Loyola University Chicago Stritch School of Medicine, said Kayhan Parsi, PhD, a clinical ethicist."What the checklist does, in my mind, is it more formally integrates ethics into the care of patients so it really just becomes part of the culture," Parsi said. "It actually standardizes care so everyone gets treated in a similar fashion."

Clinical Ethics Patient Assessment
• Patient's wishes unclear/refusal of treatment
• Questionable capacity to consent to, or refuse, treatment
• Disagreement involving relatives/surrogates/caregivers
• End-of-life (advance directive/power of attorney, do not resuscitate/allow natural death, withdraw/withhold Rx)
• Confidentiality/disclosure issue
• Resource or fairness issue
• Other (please note)
• No notable ethical issues


Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

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A GREAT IDEA -- SPECIALIZED HEALTH CARE COURTS

“Never events are now the going payment standard of care as far as hospital re-imbursement. But that means to many a never event will probably also be viewed as representing “below standard medical care.” Thus "the mere designation of never events will likely result in both more numerous and more valuable plaintiffs’ verdicts nationwide,” says Charles Brown.

In an op-ed in the New York Times Philip K. Howard, chairman of Common Good, a legal reform coalition, writes that currently, "fear of possible claims leads medical professionals to squander billions in unnecessary tests and procedures." This practice, known as "defensive medicine," is now "so prevalent that it has become part of standard protocol," Howard notes.

And, "under instructions from lawyers," physicians "don't apologize or offer explanations when things go wrong." As a result, "patients, sensing distrust, demand second opinions." "it would be relatively easy to create a new [health] system of reliable justice, one that could support broader reforms to contain costs." But, with "special health courts aimed...delivering fair and reliable decisions," patients and physicians would have "expedited proceedings with knowledgeable staff."

He also points out that "one benefit" of a "quicker, streamlined system would" be "drastically lower legal costs." Howard concludes that "restoring trust in law," an "essential reform, can be accomplished with the creation of reliable courts." Restoring a foundation of trust requires a new system of medical justice, says Howard. Medical cases are now decided jury by jury, without consistent application of medical standards. According to a 2006 study in the New England Journal of Medicine, around 25 percent of cases where there was no identifiable error resulted in malpractice payments. Nor is the system effective for injured patients — according to the same study, 54 cents of every dollar paid in malpractice cases goes to administrative expenses like lawyers, experts and courts.

America needs special health courts aimed not at stopping lawsuits but at delivering fair and reliable decisions. A special court would provide expedited proceedings with knowledgeable staff that would work to settle claims quickly. Trials would be conducted before a judge who is advised by a neutral expert, with written rulings on standards of care.

All information about each incident, including details learned in settlements, would be compiled and disseminated so that doctors and hospitals could learn from their errors.

Proponents of special health courts have estimated that the total cost of such a new liability system would be about the same as the existing system — less than 2 percent of America’s total health care costs. One benefit would be that the quicker, streamlined system would compensate far more people, with drastically lower legal costs. Most important, it would restore faith in the reliability of medical justice. This country has a long tradition of courts and tribunals to deal with issues like bankruptcy that require special expertise. Nowhere is that expertise, along with the stability and trust it would bring, more needed than in health care.

Several prominent hospitals, including New York Presbyterian, have said they are interested in being part of a health court pilot project. Some large consumer and patient safety groups support the idea. The fastest way to do this would be for Congress to authorize and finance pilot courts around the country. These ideas already have some bipartisan support: Bills for alternative medical justice systems have been introduced in Congress.

Cutting back on the notorious inefficiency of American health care is essential to achieve universal care, as well as make the American economy more competitive.
Part of the solution — overhauling the reimbursement model so that doctors get paid only for what is needed — is unavoidably complex.
But restoring trust in law, the other essential reform, can be accomplished with the creation of reliable courts.

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Hospitals Should Aim for 'As Soon As Possible' Standard for Door-to-Balloon Time

Hospitals Should Aim for 'As Soon As Possible' Standard for Door-to-Balloon Time
Balloon time is measured in minutes from the time the patient arrives at the hospital with a heart attack [myocardial infarction] to the time appropriate coronary artery intervention is performed, usually with balloon dilation of the obstructed coronary artery via primary percutaneous coronary intervention, [PCI].

Any delay in door-to-balloon time is associated with higher mortality rates in patients undergoing PCI. Therefore hospitals should strive for times well under the recommended 90-minute benchmark, according to a thorough BMJ study. Using a national registry, researchers examined outcomes among nearly 44,000 patients who underwent PCI for ST-segment-elevation myocardial infarction. In particular, they looked at time from hospital arrival to first balloon inflation or device deployment, as well as mortality rates.

The median door-to-balloon time was 83 minutes. Patients who underwent PCI by 30 minutes had an adjusted mortality rate of 3.0%, while those with door-to-balloon times of 240 minutes had a mortality rate of 10.3%. The recommended 90-minute time yielded a mortality rate of 4.3%.The authors conclude that their data "support calls for an 'as soon as possible' standard for patients undergoing primary percutaneous coronary intervention."

The authors stated that any delay in primary percutaneous coronary intervention after a patient arrives at hospital is associated with higher mortality in hospital in those admitted with ST elevation myocardial infarction. Time to treatment should be as short as possible, even in centres currently providing primary percutaneous coronary intervention within 90 minutes Clinical guidelines recommend that hospitals providing primary percutaneous coronary intervention to patients with ST segment elevation myocardial infarction should treat patients within 90 minutes of contact with the medical system or admission to hospital.

SUMMARY:
What is already known on this topic
Clinical guidelines recommend that hospitals providing primary percutaneous coronary intervention to patients with ST segment elevation myocardial infarction treat within 90 minutes of contact with the medical system or admission to hospital
The specific shape of the relation between mortality risk and time to treatment, and the incremental benefit of reductions in door-to-balloon times beyond 90 minutes, is unclear

What this study adds
Any delay in door-to-balloon time for patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention is associated with higher mortality, even among patients treated within 90 minutes of admission
Reducing door-to-balloon time to the greatest extent possible for all patient, including those currently treated within 90 minutes of admission, might reduce mortality

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PART III of III: IN DEFENSE OF THE DOCTOR WITH A BAD REPORT CARD WHEN NOT ADHERING TO PAY FOR PERFORMANCE [P4P] GUIDELINES

PART III of III

The WSJ ran several letters received in response to Groopman and Hatzband alarming data- most from “quality professionals” pointing to 30 years of data in the Dartmouth Atlas showing widespread variation in the quality of care in many common chronic conditions. The Rand Corp statements that patients receive only about 56% of recommended care is also quoted. This widespread U.S. variation in healthcare is equated with low quality, injurious and costly medical care by these quality professionals instead of Groopman’s “what is best sometimes deviates from the norms.”

One letter writer from San Diego pathetically wrote that “Drs. Groopman and Hartzband state very well the dangers of general mandates in the practice of medicine. At our institution we are very concerned about the emergence of multi-drug resistant microbes, and we designed a treatment regimen for community acquired pneumonia to avoid certain antibiotics notorious for causing antibiotic resistance and Clostridium difficile infection. We were informed, however, that if we varied from the prescribed medication directive we would be out of compliance and suffer the consequences. Naturally, we caved to the pressure. Long-term consequences are not involved in the ‘metric.’"

But not answered adequately by these letter responses are the lack of outcome studies showing proof that the use of process quality measurements or metrics will improve morbidity or mortality in the real world. This unfortunately if addressed by the letter writers was not printed in the responses.

The devil in the details of “quality care” outlined by the letter-writing physicians is what the medical expert can use in his defense of the defendant physician “straying from the guidelines as we’ll see in a later chapter.

These devil in the quality details are:

• First, the federal incentive program entitled "pay-for-performance" is really "pay-for-process."
• Rather than measuring and rewarding improved outcomes, the program which is also being adopted by state and private insurers rewards adherence to practice guidelines.
• Second, there is little or no evidence the quality measures that comprise the guidelines correlate with improved outcomes, and
• If government and private insurers want to penalize and reward physicians for their practices they should measure those physicians' outcomes.
• This is dramatically demonstrated by the UCLA study mentioned above of over 5,000 patients at 91 hospitals published in 2007 in the Journal of the American Medical Association found that the application of most federal quality process measures did not change mortality from heart failure.
  

One must agree that using quality guidelines seems like good thinking superficially, but these rigid rules cannot fit the complexity of the human condition.

I spoke about this matter with my good friend Dr. Bernie Rosof, a pioneer in the Quality movement about this controversy on P4P guidelines. He replied that

• These guidelines must be nimble, i.e. they must quickly change as the profession believes in a new guideline prompted by an appropriate study.
• In addition he believes that more recent guidelines should based on both process and outcome studies.
• And finally the new money on the health care scene will drive us to do more comparative studies to make sure the guidelines are appropriate and to drive down the high variability that is now the current scene in medical care.
  

What we need most are evidence based outcome studies showing the benefits of quality metrics on mortality/morbidity in concert with the application of such studies rather than experts getting together to hammer out compromised clinical practice guidelines as exists today.

Until such time my opinion as a medical expert based on a reasonable degree of medical probability is that a good defense can be offered to a physician defendant on an individualized basis.

REFERENCES:

Book I - “Medical Malpractice Expert Witnessing: Introductory Guide for Physicians and Medical Professionals” (Hardcover) by Perry Hookman, MD (Author) : 592 pages.27 chapters. Publisher: CRC; Potomac Press; Language: English ISBN-10: 1420058959 ISBN-13: 978-1420058956; Dimensions: 10.1 x 7.1 x 1.4 inches; Shipping Weight: 2.6 pounds; price $239.95.
For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com


Book II –“Medical Expert Testimony: Advanced Syllabus for Physicians and Medical Professionals”
(Hardcover) by Perry Hookman MD (Author) 32 chapters; 936 pages. Proj.Pub date Spring 2009. Publisher: Potomac Press-CRC; ; Language: English ISBN: 978-0-9817570-0-1; ISBN:10:0-9817570-0-6 - Barcode (9780981757001.eps) Dimensions: 10.1 x 7.1 x 2.1 inches; Shipping Weight: 3.0 pounds; Price $289.95; includes CD-ROM. For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com

GOOD NEWS AND BAD NEWS

The voluntary Leapfrog Hospital Survey results are as of Dec. 31, 2008, and include 1,276 hospitals in 37 major U.S. metropolitan areas, representing 48 percent of the urban, general acute-care hospitals (53 percent of hospital beds in these areas),

Individual hospital results can be viewed and compared with other hospitals at www.leapfroggroup.org

First The Good News:

• Thirty-one percent of hospitals now meet the Leapfrog ICU staffing standard, up from 10 percent in 2002.
• Hospitals with all of Leapfrog's recommended policies in place to prevent common HAIs jumped from 13 percent to 35 percent between 2007 and 2008.
• Sixty percent of hospitals have agreed to implement Leapfrog's "Never Events" policy when a serious reportable event occurs in their facility.

Now the Bad News: Most hospitals fall short on safety measures. Survey shows low rates of adherence to hospital safety, quality standards.

Only 7 percent of hospitals meet Leapfrog medication error prevention (CPOE) standards and few hospitals are meeting mortality standards, according to the 2008 Leapfrog Hospital Survey, released 4/15/09.

The healthcare watchdog organization surveyed 1,276 hospitals in 37 US metropolitan areas and found that "low percentages of reporting hospitals are meeting volume and risk-adjusted mortality standards or adhering to nationally endorsed process measures for eight high-risk procedures, where following nationally endorsed and evidence-based guidelines is known to save lives." Also, efficiency standards among surveyed hospitals "are met by only 24 percent of hospitals for heart bypass surgery, 21 percent for heart angioplasty, 14 percent for heart attack care and 14 percent for pneumonia care."

Other alarming features of the 2008 hospital survey include:

• Low percentages of reporting hospitals are meeting volume and risk-adjusted mortality standards or adhering to nationally endorsed process measures for eight high-risk procedures, where following nationally endorsed and evidence-based guidelines is known to save lives:
• 43 percent for heart bypass surgery;
• 35 percent for heart angioplasty;
• 32 percent for high-risk deliveries;
• 23 percent for pancreatic resections;
• 16 percent for bariatric surgery;
• 15 percent for esophagectomy;
• 7 percent for aortic valve replacement; and
• 5 percent for aortic abdominal aneurysm repair.
• Sixty-five percent of participating hospitals do not have all recommended policies in place to prevent common hospital-acquired infections (HAIs).
• Seventy-five percent do not meet the standards for 13 evidence-based safety practices, ranging from hand washing to nursing staff competency.
• Only 26 percent and 34 percent of reporting hospitals are meeting standards for treating two common acute conditions, heart attacks (AMI) and pneumonia, respectively.

Summary: Only 30 percent and 25 percent of hospitals are meeting standards to prevent hospital-acquired pressure ulcers or hospital-acquired injuries, respectively.