Category: Hospitals

Snail mail is alive and well at Children’s Hospital

published date
February 12th, 2007 by

Early in my consulting career I complaining to my manager about the level of bureaucracy at a big client. It was like nothing I’d seen before. My manager agreed it was bad but told me about an even more extreme example; when he consulted to the World Bank it routinely took 5 days for a fax to be delivered. After all it had to be picked up off the fax machine, logged into the system, sent through inter-office mail and so on, all of which took time. This was in the days before email and voicemail.

But super slow document delivery lives on, at least in health care. A friend has a child whose speech is delayed. She made an appointment for an assessment at Children’s Hospital in Waltham, MA –and had to wait six months for the appointment, even in our capitalist system! A couple months beforehand she received a “parent intake questionnaire.” Here’s what it said at the top of the first page:

Intakes often take up to three weeks to be delivered to the appropriate department/clinician. To ensure your intake is received, please completed [sic] and mail back to us as much in advance of your appointment as possible. If we do not receive this intake before your child’s appointment, you will be asked to complete it in the waiting room before your child can be seen. Thank you for your understanding and cooperation.

I found this appalling. After all:

  • The form should have been electronic and distributed to the “appropriate department/clinician” instantly
  • If the form can be filled out in the waiting room, why bother sending it ahead? It doesn’t sound like anyone will read it in advance anyway?

Children’s should be ashamed of itself for such poor service.

Another reason to avoid the ER if you possibly can

published date
January 31st, 2007 by

Here’s one more reason to stay away from the emergency room: there might not find an experienced specialist when you get there:

Specialists such as neurosurgeons and orthopedists more often are saying no to a rising number of calls from emergency rooms and there doesn’t seem to be a simple way to get them to answer again, reports Josh Fischman. With ER visits up sharply over the past decade, the specialists say they are expected to do too much while on call and the risk of being sued has increased. At the same time, free-standing surgical clinics mean specialists can increasingly do without the operating rooms that hospitals have typically offered in exchange for going on call. Three-quarters of ERs reported a shortage of specialists, according to a 2006 survey by the American College of Emergency Physicians.

Contrast the madness of trying to get off-hours care in the US with the common sense approach of the UK’s National Health Service. While on a visit to a business in Milton Keynes in the UK, I picked up a brief brochure in a business’s reception area. It laid out the services provided by the local “Walk-in Centre,” describing the minor ailments (such as coughs, colds, stomach ache, vomiting, rashes) and minor injuries (such as minor head injuries, sprains and strains to limbs, recent eye injury) that are handled there with no appointment.

The brochure also specifies services not provided, which include x-ray’s, Rx renewals, and immunizations.

The facility is open 7 am to 10 pm every day, including weekends and holidays. I’m sure it’s not perfect but it sounds a lot better than a trip to the ER in the US. Its existence must also help the ERs run smoother.

Now available in your friendly neighborhood ER: Norovirus

published date
January 18th, 2007 by

I’ve been ranting recently about physicians recommending visits to the ER partly/mainly/largely to mitigate the risk of being sued instead of basing recommendations entirely on medical grounds. That costs patients and caregivers time (often a lot) and money, slows treatment for real emergencies, and makes health insurance more expensive by driving up costs to the system.

Does this phenomenon also represent a threat to public health? From yesterday’s Boston Globe (Intestinal germ leaves trail of misery)

More than 3,700 patients stricken with nausea, vomiting, and diarrhea have visited Boston’s emergency rooms during the past six weeks in a wave of gastrointestinal illness… “We have seen a large number of cases of what appears to be a sudden onset and intense, short-lived diarrhea, nausea, and some abdominal pain,” said Dr. Jonathan Olshaker , Boston Medical’s emergency department chief.

The cause?

[N]orovirus, an intestinal germ that travels easily from person to person.

The article says public health officials can’t quite figure out why it is spreading.

My first concern (attention commenters, get ready to pounce!) is why so many norovirus patients are in the ER in the first place. Sure some are at risk of dehydration. But how many are sent there by on call docs “just in case of lawsuit” for an illness that passes in 24 hours?

My second concern is the number of other ER patients and caregivers –some at the ER for no good reason as described before– who may be getting infected while they wait around for hours.

SARS spread in a similar fashion in Canada, after all.

The outbreak surfaced in February 2003, when a woman from the Toronto area contracted the virus on a trip to Hong Kong and returned home, dying soon after. Her son went to a hospital with an unidentified condition that was later diagnosed as SARS. While waiting for 16 hours in a crowded emergency room, the man transmitted the virus to two other patients, and it continued to spread, the commission’s report says.

It could have been worse

published date
January 10th, 2007 by

One reason I went to the ER before my trip is that ER waits are even worse –and sometimes more deadly– in my destination, Canada.

A provincial commission investigating the SARS outbreak in 2003 reported Tuesday that poor hospital infection-control procedures led to the epidemic in the Toronto area that killed 44 people.
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The outbreak surfaced in February 2003, when a woman from the Toronto area contracted the virus on a trip to Hong Kong and returned home, dying soon after. Her son went to a hospital with an unidentified condition that was later diagnosed as SARS. While waiting for 16 hours in a crowded emergency room, the man transmitted the virus to two other patients, and it continued to spread, the commission’s report says.
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On May 17, 2003, three months after the first case in Ontario, the authorities declared the crisis over. As a result, the report released Tuesday found, surveillance and prevention measures were relaxed, and an outbreak brewing at another hospital was not detected until it was too late. On May 23, health officials announced a second, larger outbreak.

What would Mickey do?

published date
January 10th, 2007 by

I’m taking a lot of flak –some deserved, most not– for yesterday’s post about my recent ER experience. When I have a moment I’ll address some of the comments. Meanwhile I asked Mickey (who’s a pediatrician) for his perspective. Here it is:

If you suspect a fracture outside of regular office hours and a doctor can’t rule it out over the phone you should go to an ER.  The solution is to make the ER faster.
When I was a resident our chief of service told us that families should not be kept up after 10 PM for scheduled admissions.  This is reasonable, but often 5 families come in for scheduled admissions after 6 PM and one resident can’t admit them all and take care of other priorities (such as the ER) without some people waiting a long time.  We decided amongst ourselves to create an overflow system in which we’d ask other residents on the team to stay late to do some of the admissions.  We needed to invoke this backup system only about 10% of the time, but it made things run more smoothly, and everyone got more sleep.  One of my most memorable nights on call began with my diagnosing a tumor that I noticed incidentally on a skull X-ray of a kid hit by a car while bicycling.  After that, one after another fascinating patient showed up, and each got great care because I got two other residents involved, people who are today among the top clinicians in the field.  We did a great job and no one waited around for 5 hours.
Hospitals should use similar backup systems to cope with peak load problems.  Ironically, measures taken to reduce doctors’ working hours have limited this flexibility by banning the others on the team from staying around.  Yet, using such a flexible system, everyone got more sleep.
Two of us from that memorable night wrote a letter to the NYT that appeared on June  8, 1987 arguing for such a backup system instead of heavy-handed regulation of doctors’ work hours.  The WSJ got me to expand this as an Op-Ed, run on 18 June.