I've been involved in discussions as to whether or not there is any evidence as to whether or not wearing blood stained shoe covers in the hospital cafeteria (or anywhere outside the operating room where the covers became blood stained) is harmful to patients. What about some common sense? Or meetings where the administrator du jour upset about his departments surgical site infection rate wants a bigger, broader, antibiotic for longer used as "prophylaxis" in the name of "doing the best for our patients" and gets upset when the theory behind the use of surgical prophylaxis and risks associated with the use of the "baddest" antibiotic out there haphazardly is discussed. I mean how about we start with the basics? How about your physician hand hygiene rates for example? Hmmm?
Not too long ago, I went to a meeting where physicians were urged not to order too many esoteric tests. That's fair enough because there is a lot of waste in medical tests but the reasoning, in part, was that we were not an academic institution, and couldn't we possibly give the patient a prescription for the esoteric test in question to be done as an outpatient...as an outpatient...for cost savings and better reimbursement? That day, I looked at the administrator with my "are you kidding me eyes". I'm an infectious disease physician. I get called when physicians can't figure out what's going on with their patients. It's my duty to think outside the box and if that means ordering an esoteric test to help diagnose why a patient has had fevers for 3 weeks straight, I'm going to do that, academic center or not...especially when you claim we are a tertiary referral center and tell us to accept all transfers. I mean what is the transfer center to say to the outlying hospital who wants to transfer a sick patient here. Oh, sorry, we are not an academic institution so we won't be able to work up your patient appropriately? How about tackling the complete blood counts (CBC) virtually all patients in the hospital get drawn every day at 5am or the urinalysis with urine culture that almost everyone presenting to the emergency department for admission gets (in my opinion) to prove that they had a urinary tract infection (UTI) present on admission (POA) so that the hospital doesn't get dinged a couple days later for causing a preventable catheter associated infection?
And I understand the reasoning behind this request at least simplistically. It's bureaucracy. It's the Centers for Medicare and Medicaid Services (CMS). Prior to sometime in the 1980s, hospitals were paid on the basis of the actual cost for providing care to Medicare beneficiaries.So the hospitals probably made bank, and the federal government saw things as wasteful. So now medical and surgical services are bundled into diagnosis-related groups (DRGs). CMS dictates how much it costs to provide inpatient care to a patient with a particular diagnosis (say pneumonia). Well actually make that the admitting diagnosis. Let's say in this example it's $2000. So if patient A gets admitted to the hospital with admitting diagnosis pneumonia, and ends up having a simple pneumonia that responds to antibiotics and is discharged in a day or so, great for the hospital. But if patient B gets admitted to the hospital with admitting diagnosis pneumonia but in the course of their two-week hospitalization gets diagnosed with leptospirosis (because the infectious disease physician came by and ordered esoteric tests), required mechanical ventilator support for their respiratory failure and hemodialysis for their acute kidney injury, there's not that much of the $2000 left over (in reality none whatsoever) to make a profit.
So see. My little pigeon head physician brain understands some of all this administrator mumbo-jumbo. But still! Can't I just be a physician and take care of my patients?
So imagine my disgust when at a subsequent meeting we were urged to make sure we (the medical staff) order "lots of labs" on patients we accept from outlying hospitals so that their expected mortality on admission is fairly demonstrated. You see, physicians aren't always that wasteful. If a patient is being transferred from another hospital, we have no qualms looking at the blood work drawn there, just a few hours prior, to guide our medical decision making rather than duplicating all that blood work. Of course, we would repeat those that may be critical like electrolyte derangements to see if any improvement has been made as a response to therapy received in the interim. But apparently, to the administrator-powers-that-be, by not ordering the entire lab panel for the patient on presentation to our hospital (despite the fact that we have a printout of said labs two hours old but performed at a different hospital in our hand), we do not prove that the patient is very ill and were that patient to subsequently die (because they were already on death's door anyway when the outlying hospital asked us to take over "the care" and we are urged to accept all transfers) there is a mis-match between the hospital's predicted mortality rate and the actual rate. Supposedly this is CMS's definition and supposedly there is a time frame within which these labs need to be done thereby arguing for repetition of labs within hours. Within hours. Imagine the poor veins.
And this matters because several years ago CMS decided to release mortality data on hospitals to show how they compare to other hospitals so that consumers can be better informed. The next trend of course is to penalize hospitals (financially) for poor data. So it's all about the data. It's all about massaging the data to make it look good. To order tests so there's institution specific data. To order tests so the data looks good. CRAZINESS.
The US health care system needs such a major overall it's not even funny.
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