Critical Lab Values That Aren't Really Critical.

 As a hospitalist I get to see critical lab values every day. Patients come in sick. And their labs are often sick as well. Some of the most common criticals that are called to me include

• low potassium or high potassium
  
• high bicarbonate
• low platelet count
• low hemoglobin
• INR
  
• decreased urine output

This is my hit list of unnecessary pages and phone calls. Things that can wait until rounds. Things that get called at 4 am when I'm either sleeping or busy. Things that interrupt my daily rounds, pull me away from a patient and make me wait for 2-3 minutes on hold while the nurse comes to the phone.

These are critical lab values without critical thinking. What do I mean by that? In the ultimate wisdom of patient safety and hospital liability , very rigid and defined critical lab values are assigned to most labs. If a patient's value falls into the critical range, a phone call is placed from the lab to the nurse and from the nurse to me. If it's critical, it must be called. Everyone is covering their butts according to protocol, because of course, patient safety is the issue. Of course it is.

Unfortunately, patient safety is rarely an issue. It's a giant game of shifting liability. The lab documents they notified the nurse-->lab off the hook if something bad happens. The nurse notifies the doctor ---> nurse off the hook if something bad happens. Doctor is left with a critical value called 10 or 20 times a day, interrupting the entire flow of patient evaluations and discharges. Every time, I must stop what I'm doing and answer a page for a critical lab value, I lose valuable face time with patients. And it all adds up over the course of a day. I wouldn't have a problem with the system, except that critical thinking has been removed from the equation. The nurse is not allowed to make judgments as to whether a phone call is warranted or not.

As a default protocol of calling all critical lab values, the liability is shifted up the educational food chain, landing ultimately on the physician's lap. Often times a nurse is not allowed to not call a critical lab value. The problem is, what the hospital has defined as critical, does not apply to the vast majority of critical lab values reported. What's considered critical by hospital standards, is a normal or chronic value for the patient.

The low urine output gets me every time. Old people. 90 year olds with chronic kidney disease. I'm being called with decreased urine output. "Why?" I ask. She's 90. Her kidneys don't work well because they are 90 year old kidneys. Critical thinking allows a nurse to use their brain and make educated decisions on the importance of decreased urine output in a 90 year old with bad kidneys. Sometimes that critical thinking has left the building. Or perhaps hospital protocol fails to allow a nurse to use their skills. This has resulted in me writing an order not to call me decreased urine output.

The platelet and hemoglobin criticals are right up there with the most frequent time wasters. A hemoglobin of 8.5 is not critical when the last 7 days have the same value. A platelet count of 25K is not critical when the last seven days have the same value. A bad COPDer with a bicarb of 45 is not critical when that is their normal value for them. The problem is, hospital protocol often does not allow for nurses to use critical thinking. It's frustrating. All that wasted time spent documenting and paging and discussing things that don't need to be discussed urgently or otherwise.

So I define my own critical values. I write an order for the nurses not to call me. I find myself writing it more and more often. Don't call me that potassium value. Don't call me that hemoglobin or platelet count. Don't call me urine output. You are wasting your time and mine. Since nurses are forced to work like robots, I am forced to reprogram their input data. They have been stripped of their higher intelligence.    I like to say I have my very own fleet Roombas.  When you organize hospital systems around universal default mode, you fail to appreciate all the individual nuances that don't follow the rules and  that causes lots of unnecessary work for everyone involved.

What you may believe you are gaining in safety, you lose in efficiency, and that efficiency comes at a cost.  Resources that are pulled away from other pressing issues, like say, patient care.  It draws valuable resources and time away from everyone's busy schedule.  Part of being a hospitalist means addressing hospitalist efficiency issues, just like this one.  

The other day I spent an hour in a committee meeting full of highly trained professionals.  Nurses.  Directors.  Pharmacists.   Educated folks from across multiple disciplines.  And what did we do? We spent an hour meeting just to create a schedule going forward to have more meetings.   These meetings?  JCAHO mandated patient safety initiatives.  I suspect, when you take the combined salaries of the folks in the room,  you are looking at $500 an hour in resource utilization.  Now multiply these meetings by thousands of times a year across the whole hospital spectrum.  Do we want perfect care for a few? Or do we want affordable care for all?  You can't have both.  When you look at the pie chart of health care costs, you see hospitals are responsible for the largest chunk.  Physician fees pale in comparison to what you are paying in premiums to cover a catastrophic hospital stay.

The perfection being mandated by the never event policies and patient safety initiatives of the Medicare National Bank are paid for by you and me in the form of higher administrative costs that must be passed on to the consumer patient.  We can't have perfect and cheap because perfect comes at a cost.  Every mandate for perfection adds a layer of cost that is pricing many families and businesses out of the third party insurance market.   How long can  Joe Public afford $13,000 premiums for him and his family.  How long can Widget's R Us continue to pay them?

And you wonder why health care is so expensive. The cost structure for these behind the scenes unfunded perfection mandates by our government would blow your mind.  I experienced it first hand.  That 10 dollar Tylenol you get billed for is paying for 10 highly educated folks to meet for an hour, just to make a schedule of more meetings.

Lean and mean health care delivery it is not. It's a dinosaur.  Hospitals would never survive in the real world of real world economics.  But Medicare economics is not the real world.  It is government intervention.  It is socialism.  It is a gravy train of money that never ends.  But that party is ending.  The Medicare Hospital Insurance Trust Fund went cash flow negative this year and is expected to be bankrupt in nine short years.  If you think this 700 Billion dollar bailout is a lot of money.  Try 60 trillion dollars in unfunded entitlements for your next generations.  Money that is currently promised, but doesn't exist.

Be afraid.  Be very, very afraid.  With that said, have a great weekend.  I'm off to ride roller coasters, Halloween style.