Let Me Sprinkle Some Fairy Dust On My Patient.

I saw today on the WSJ Health Blog an article titled :

Insurers: Hospitals Should Pay For Mistakes

It gives reference to the "National Quality Forum "never events"'

Most of them I agree with.

Like lemmings who drop reimbursement at any indication that Medicare drops theirs, private insurance companies Aetna and Wellpoint, now say they will not pay for 28 "never events"

I agree with almost all of the findings.

However, I strongly disagree with three of them. Two of which require each other to prevent each other.

These are never events that will NEVER be 100% prevented, no matter what you do to prevent them.

Patient death or serious disability associated with a fall while being cared for in a healthcare facility


Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility


Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility

What's next. I can see it now. Never events.
1) Development of delirium which results in death or disability
2) Development of acute renal failure which results in death or disability
3) Development of pneumonia which results in death or disability
4) Development of any number of complications of living a life of chronic medical conditions which result in death or disability.


Part two deals with "never events" resulting in tying somebody down or them falling resulting in death or disability.

First of all. People fall at home and injure themselves. That's how they get hip fractures. That's how they get head bleeds.

Coming to the hospital will not magically turn an event of living life, into a never event in the magical unmanaged expectations of the hospital confines.

It is a ridiculous assumption that we in the health care delivery service industry can somehow prevent a normal act of life into a 100% preventable process.

If you don't want somebody falling out of bed, you have to tie them down. Guard rails, for anyone one involved in patient care does not prevent somebody from falling out of bed.

The most common and widespread complication of being ill is delirium, a state of in and out of alertness. A state of confusion.

It is universal in just about every sick elderly patient in the hospital, the ones that fall and break their hips and hit their head.

It is treated by treating the underlying medical condition, reorientation techniques, agitation/anxiety medications with sedative properties, anti psychotic medications acutely, and getting them out of the hospital into a familiar environement.

And tying the patient down for their own safety.

If you sedate them, you risk aspiration pneumonia, stopping breathing, cardiac arrhythmias, fever and a whole slew of side effects from the medications.

But now Aetna and Wellpoint tell me that if I choose to restrain them for their own safety to prevent a fall, and the patient experiences a complication of tying them down, then they are trying to have it both ways.

What they are asking is to have a paid body that sits in the room

"a sitter"

for every confused, delirious patient in the hospital.

That includes just about every elderly sick patient I take care of.

This will never happen.

So patient after patient will get tied down, as a first response.

The risk of injury from falling clinically is far greater than the risk of tying someone down, against their will, to protect them.

I hope the families accept this a necessary part of their care, in the spirit of preventing "never events"


You can't create a never event out of something that happens as a common event of living. People fall down every day. Even more so when they are confused.

Sick people also have erratic blood sugars.

Some are getting TF's
Some are getting TPN.
Some are getting steroids.
Some have acute liver failure
Some have acute Renal Failure
Some have everything failing.
Some have raging infections.

Some are brittle insulin dependent diabetics on admission.

Every one of these factors plays a key role in the blood sugar management of inpatients both critically ill and otherwise not.

It is a physical impossibility to prevent hypoglycemia in every patient 100% of the time, if your goal is tight blood sugar control. There is no way I could prevent hypoglycemia, knowing from patient to patient, who are all different in many ways, who will respond to insulin in what way with out a trial and error process, even using standardized protocols, which I use 100% of the time.

And guess what. Hypoglycemia still happens. Sick people get hypoglycemic because they are sick. It's part of being sick. It is not a never event.

It is an expected response of being ill.

My goal is to minimize that risk. But I will never, every be able to make it a zero event.

Ever

With all the data pointing to aggressive insulin control in critically ill patients, hypoglycemia, is one accepted side effect of very intense control, that we try to minimize. By categorically stating that injury from hypoglycemia will not be paid for, as a never event, these insurance companies are basically mandating that I not do aggressive blood sugar control.

It is ridiculous that hypoglycemia should be considered a never event. It is a part of the disease process. Patients get hypoglycemic at home. How does being in the hospital magically prevent that?

Spoken from somebody who see's these "never events" evey day, preventing them is logistically impossible, and biologically not possible. We can minimize the risk, but that does not make it a never event.