Wednesday, February 21, 2007
CRNA Independent Practice: Deciding Which Question to Answer
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In doing some more reading on the CRNA independent practice issue, I found what I thought was a curious quote in a Centers for Medicare and Medicaid Services press release from January 17, 2001. The press release is an announcement that Medicare will leave decisions on whether physician supervision of CRNA's is necessary to the States. Here's the quote from the second to the last paragraph:
"There is no evidence that CRNA independent practice would cause adverse outcomes."
I think asserting that there is no evidence that CRNA independent practice would cause adverse outcome is the wrong question to address. I think the question should be, 'is there evidence that CRNA independent practice would be as safe for patients as the present system?' (we're a six sigma specialty, remember).
The Safe Seniors Assurance Study Act of 1999 was to address the issue but it never made it out of committee:
"(1) The Secretary of Health and Human Services shall conduct a study of mortality and adverse outcome rates of medicare patients by providers of anesthesia services. In conducting the study, the Secretary shall analyze the impact of physician supervision of providers of anesthesia services, or lack thereof, on such mortality and adverse outcome rates.
(2) In conducting the study, the Secretary shall consult with appropriate national professional organizations with respect to the methodology of the study, and shall use medicare operating room anesthesia data, adjusted for patient acuity and other relevant scientific variables."
Sounds like a good starting point for this discussion, however...
JAMA: Off-Pump vs On-Pump CABG and Cognitive Decline
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Five years after surgery, there is no difference in cognitive decline between on-pump and off-pump CABG.
Cognitive and Cardiac Outcomes 5 Years After Off-Pump vs On-Pump Coronary Artery Bypass Graft Surgery
"Results After 5 years, 130 patients were alive in each group. Cognitive outcomes could be determined in 123 and 117 patients in the off-pump and on-pump groups, respectively. When using a standard definition of cognitive decline (20% decline in performance in 20% of the neuropsychological test variables), 62 (50.4%) of 123 in the off-pump group and 59 (50.4%) of 117 in the on-pump group had cognitive decline (absolute difference, 0%; 95% confidence interval [CI], –12.7% to 12.6%; P>.99). When a more conservative definition of cognitive decline was used, 41 (33.3%) in the off-pump group and 41 (35.0%) in the on-pump group had cognitive decline (absolute difference, –1.7%; 95% CI, –13.7% to 10.3%; P = .79). Thirty off-pump patients (21.1%) and 25 on-pump patients (18.0%) experienced a cardiovascular event (absolute difference, 3.1%; 95% CI, –6.1% to 12.4%; P = .55). No differences were observed in anginal status or quality of life.
Conclusion In low-risk patients undergoing CABG surgery, avoiding the use of cardiopulmonary bypass had no effect on 5-year cognitive or cardiac outcomes."
[free full text]
(Another Reason Why) I Like Desflurane
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I've
posted before on why I think the desflurane Tec 6 vaporizer is a good design (it doesn't need to be turned off to be refilled). I'd like to add another reason to the list: it has alarms.
The Desflurane Tec 6 has a 'low agent' alarm and a 'no output' alarm, in addition to the ability to detect when it has been tipped (and therefore shouldn't be used). The other common agent, Sevoflurane, is delivered via a vaporizer that has none of these things. I am personally aware of two cases where no volatile anesthetic was delivered despite the vaporizer being 'open'. Two cases that would have been uneventful if desflurane and a Tec 6 vaporizer had been used. I'm going to ask the Society for Technology in Anesthesia listserv if there is any reason the Sevoflurane vaporizer couldn't have these features.
DaVinci Surgical Robots. A Hospital CEO Asks Advice.
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Running a hospital: da Vinci Uncoded -- or, Surgical Robots Unite!
"Here you have it folks -- the problem facing every hospital, and especially every academic medical center. Do I spend over $1 million on a machine that has no proven incremental value for patients, so that our doctors can become adept at using it and stay up-to-date with the "state of the art", so that I can then spend more money marketing it, and so that I can protect profitable market share against similar moves by my competitors?"
I just discovered this blog today via Medgadget and am already impressed. The large health system our group works in purchased a DaVinci last year. I don't know outcomes yet but it was apparent to me before the purchase that it was largely driven by regional competition in Central Pennsylvania. I think it's telling that many of the institutions which were the early adopters no longer use the systems.
I'm hoping to pick one up cheap in a couple of years so I can do labor epidurals from home. ;-p
Monday, February 19, 2007
Is CRNA Independent Practice Coming to Pennsylvania?
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Governor Rendell's 2007 budget document includes a section titled Prescription for Pennsylvania on page A3.32. The first paragraph of that section states:
"Ensuring that all licensed health care providers – including nurses, advanced nurse practitioners, midwives, physician assistants, pharmacists and dental hygienists – can practice to the fullest extent of their training. Pennsylvania consistently lags behind other states in fully utilizing health care providers who are not physicians. Prescription for Pennsylvania will seek to eliminate the barriers in existing laws, regulations and insurance reimbursement policies that limit the ability of health care providers to practice to the fullest extent allowed by their training and education."
Sounds like independent practice to me. Rather than write a knee-jerk reaction right now, I'd like to take some time to educate myself and consider the ramifications...
Sunday, February 18, 2007
Keeping Patients Warm Means Generating Heat
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Once anesthetized with a general anesthetic, patients are largely defenseless. The anesthesiologist is responsible for protecting the patient from their environment--an environment that can be increasingly hostile. One key facet of that environment is temperature, but control of it has never been more contested in the operating room than it is today.
My perspective may be skewed because I do so much anesthesia for orthopedic surgery--a surgery in which the surgeon is physically working hard under an OR gown, gloves, and hot lights. Certainly in pediatric rooms no one ever complains during times when we make the room hot. That's not true, actually. They complain, but they know full well that we are all there to keep the pediatric patient safe and keeping them warm is part of that. They don't expect us to drop the room temperature until we have the child anesthetized and covered.
But why does room temperature matter? It matters because it can affect patient body temperature, and patient body temperature matters for the following reasons:
- Mild hypothermia (1-3 deg. C) reduces resistance to surgical wound infection.
- Mild hypothermia prolongs hospital stay.
- Even mild hypothermia can cause shivering and be a very uncomfortable feeling after surgery.
- Shivering increases stress on the heart. In patients with heart disease this may cause ischemia.
Under anesthesia, our normal mechanisms for keeping warm are limited. Anesthetics significantly impair our ability to control blood flow to the skin. Although there are five mechanisms of heat loss from the body in the operating room, 90 percent occurs through the skin via radiation and convection
For those wanting a detailed review article and that have a NEJM subscription, see: Mild Perioperative Hypothermia by Daniel Sessler, M.D. in the Department of Anesthesia at UCSF.
I'm sure patients would be gratified to know that it's not the person with the most knowledge and training in patient temperature management that decides in most cases, but the person that whines the most (or is the sneakiest).
For example, last year I was scheduled to provide anesthesia for a 16 year old athlete having an ACL reconstruction. This was not the first case in that room, so the room was already as cold as a meat locker--64 degrees. I reset the room thermostat to 72 degrees, and placed a sticky note saying 'Please Do Not Change,' printed my name, and went to go see the patient.
When I came back to the room several minutes later, the note was gone and thermostat reset to 64 degrees. I replaced the note and reset the thermostat two more times. Both times the note was gone and thermostat reset. The final time there was a note from the charge nurse asking me to come see her.
What did I do? I did what any self-respecting anesthesiologist would do--I told the OR nurses the case was on hold until the room temperature came up and went to get some coffee. Not long after that the charge nurse paged me to discuss the issue. (Nothing gets management's attention more than a case delay.)
Why had she reset it? Because, she claimed, biomedical engineering (some guy with a Bachelor's Degree) said that bringing surgical instruments into a 72 degree room would cause them to sweat and possibly impair sterility. I thought back to my years of doing anesthesia for burn surgery in 85 degree operating rooms and found this explanation novel and fascinating. 'So', I asked her, 'you're taking the advice of a four year college graduate over that of a board certified anesthesiologist?'
Well, you can guess how the conversation went after that. These days, if someone in the OR is feeling hot they either turn the thermostat down themselves or ask the circulating nurse to do it. If all this done without asking me when I'm in the room, I point out to them that they should have asked me before making that decision and ask instead that the room temperature be increased several degrees. If they do ask me if they can turn the room temperature down, provided the patient is reasonably warm and covered, I'll oblige and say 'Thank for asking me. The patient appreciates it. You may set the room temperature to whatever you like.'
In days past everyone acknowledged room temperature was the anesthesiologists choice. These days I have to fight to control it, as I do for every other shred of professional respect. What I'm working on is to get a ruling from the OR committee that states room temperature is my bailiwick. With impending pay for performance measures that will include patient temperature on arrival to the recovery room, this issue has been forced to a head.
Wednesday, January 31, 2007
In West Virginia, Tort Reform Has Improved Physician Recruitment
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PointOfLaw Forum: Hospital chief: liability curbs rev up W.V. medicine
" The Charleston Daily Mail reports on the aftermath of West Virginia med-mal legislation: Charleston Area Medical Center is attributing its rise in new doctors to statewide medical malpractice reforms passed in 2003. Dr. Glenn Crotty Jr., chief operating officer, said the hospital has recruited around 30 doctors annually over the past few years, for a total of almost 100 new hires. Before the Legislature passed a comprehensive bill limiting the amount of payouts in medical malpractice lawsuits, the hospital would have been lucky to recruit one new doctor each year, Crotty said. "We were at almost zero before tort reform," Crotty said about the hospital's recruiting efforts. "And we had several doctors leaving.""
Senator Rendell, are you reading this?
Saturday, January 6, 2007
Vista Vs. OS X UI Comparison
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Review: Mac OS X Shines In Comparison With Windows Vista - News by InformationWeek
"I've yet to see anything in Vista that blows away the Mac OS, even a version of the Mac OS that's over a year old. Microsoft still can't manage to make something simple and easy to use. Vista reeks of committee and design by massive consensus, while OS X shines from an intense focus on doing things in a simple, clear fashion and design for the user, not the programmer."
Can't wait until Tuesday!
Friday, January 5, 2007
What Primary Care Physicians Really Do
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From a recent JAMA section called A Piece of My Mind is an excerpt that gives a good summary of what primary care physicians spend a lot of time doing. The author describes what she will no longer be doing after moving to a new practice:
"No more primary care. No more forms to fill out for workers comp, disability, SSI, student loan forgiveness, longer-term-care insurance coverage, FMLA, or temporary suspension of billing for credit card or mortgage or rental furniture payments owing to customer illness.
No more forms for nebulizers, commodes, handrails, oxygen, home health nurses, adult diapers, wheelchairs, cock-up splints, lift chairs, physical therapy, or the dreaded power wheelchair/scooter doctoral dissertation.
No more forms to attest that someone can enter a nursing home, play soccer, work out at a gym, be in an assisted living facility, do chair exercise at the senior center, train to become a medical assistant, wrestle, teach school, or that he or she is, above all else, free from communicable diseases. "
The list of non-direct patient care tasks goes on for several more paragraphs, but you get the picture.
[JAMA]
Thursday, January 4, 2007
Page Rank Gone Bad--Google and Vaccination Information
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Medgadget brings up an important issue today. Using Google to search for information on vaccinations does tends to return anti-vaccination 'propaganda.'
"Google's search for 'vaccination' returns 10 results on its first page. Of them, two are from the CDC (Centers for Disease Control and Prevention). One result from Wikipedia that has some questionable statements , such as "...the overall effect might, in theory, be to cause more deaths than before the vaccination was introduced." The remaining seven results are from vaccination-haters and moonbats that accuse governments, pharmaceutical companies, the medical lobby, you name it, of untold millions of dead children. The second page of the vaccination search is even worse."
I didn't have any personal experience with families not immunizing their children until this year when I became a Cub Scout leader.
[Medgadget]
Sunday, November 26, 2006
A Cell Phone for the Elderly
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I was looking for a cell phone for my in-laws last year but couldn't fine one I thought would ideal for older users--big buttons, simple menus, stuff like that. Samsung now has one out called the Jitterbug. The phone is not available for use with just any carrier. You have to order service from them too. See gojitterbug.com.
[PhoneScoop]
Friday, November 24, 2006
Anesthesia is safer than ever (even in France)
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Anesthesiology--Survey of Anesthesia-related Mortality in France.
" Conclusion: In comparison with data from a previous nationwide study (1978-1982), the anesthesia-related mortality rate in France seems to be reduced 10-fold in 1999. Much remains to be done to improve compliance of physicians to standard practice and to improve the anesthetic system process."
Thursday, November 23, 2006
On Negotiations With Hospitals, Insurers, and Physicians
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Contract Negotiations Between Insurers, Hospitals Increasingly Acrimonious
" The AP/Arizona Daily Star on Monday examined how contract negotiations between insurers and hospitals increasingly have "taken an ugly turn" as both sides work to control rising costs. Insurers "are under pressure to lower premiums to win business," while hospitals believe that insurers are "skimping on payments to boost their earnings," the AP/Daily Star reports."
The exact same can be said for negotiations between hospitals and physician groups and insurance companies and physician groups. It all reminds me of that scene in Star Wars where the good guys are stuck in a trash compactor after their escape from the brig--all attempts to stop the walls from moving from the inside fail. (what, you were expecting a reference to Greek mythology?)
National Influenza Vaccination Week starts November 27th
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National Influenza Vaccination Week -- November 27--December 3, 2006
[A]nnual influenza vaccination is recommended for the following groups:
Persons at high risk for influenza-related complications and severe disease, including:
- children aged 6--59 months,
- pregnant women,
- persons aged >50 years,
- persons of any age with certain chronic medical conditions
and
Persons who live with or care for persons at high risk, including:
- household contacts who have frequent contact with persons at high risk and who can transmit influenza to those persons at high risk, and
- health-care workers.
Bring Your Own Applications--Portableapps.com
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PortableApps Suite | PortableApps.com - Portable software for USB drives
" PortableApps Suite™ is a collection of portable apps including a web browser, email client, office suite, calendar/scheduler, instant messaging client, antivirus, sudoku game, backup utility and integrated menu, all preconfigured to work portably. Just drop it on your portable device and you're ready to go."
Hospital computers tend to have Internet Explorer as the only web browser. It works (mostly), but it's not as secure, extensible, fast, standards-compliant as, say, Firefox. Besides that, I use Firefox at home and like to have the same bookmarks available. Portableapps.com allows me to carry my own apps in on a USB thumb drive.
