Failing to wash your hands can kill!

There’s a lot of hype about hand-washing now that it’s flu season, and we have the new kid (H1N1) in town, too– but let’s not forget our good old hospital buddies, MRSA, C-diff, VRE. . .

There was a recent French study discussed on NPR’s health blog that showed that healthcare workers who move throughout a hospital working on different units– like radiology techs, physical therapists, lab techs, and others, who don’t wash their hands can become “super-spreaders.” One person who doesn’t practice good hand hygiene can cause hospital-wide outbreaks of some pretty nasty bugs.  Now, hospitals have different strategies to combat this kind of recklessness, but usually the upshot of an infraction is a reminder or a slap on the wrist. Given the severity of the problem– realistically, this behavior can kill someone– is that enough? Should a certain number of documented infractions be a fireable offense? Should licensed personnel have their licenses at risk? We’ve all forgotten a few times, or had our hands full, or been super-rushed or in an emergency situation, sure. But is that an excuse? Is there a line?

This should happen more often!

A few weeks ago, Nurse & Lawyer brought you a critique of the industry-sponsoed “Smart Choices” program, labeling foods that were. . . less horrible for you than other foods with a big green check mark. And suggesting that perhaps the FDA would be a better regulator of such labeling than the sugary-cereal industry.

Turns out everyone else thinks so, too. Pepsi is backing out, and Kellogg’s is phasing out the labeling, according to the New York Times, thinking that the FDA might be better situated after all.

Sorry folks: Froot Loops aren’t good for you after all.

ps. Can you be the first person to guess, in a comment, who Lawyer got to meet today?

Quickie: Can you prove WHY you got sick?

One of the things I’ve been studying in law school (torts again. Hi, Professor Engstrom!) is how you can prove that somebody else’s bad behavior actually caused your injury — rather than merely preceding it and being capable of causing it. This mainly comes up in the question of your trying to make them pay for your care (and possibly compensate you for your pain and suffering.)

We generally agree, these days, that agent orange caused a whole lot of health problems for the people who were exposed to it while the US used it in Vietnam. We can also be fairly certain that some of these vets would’ve had some health problems by this age, with or without agent orange. So… which ones is the VA particularly responsible for? If we made vets prove causation, the way we make most people filing tort claims prove it, they simply wouldn’t be able to. (And most of those who tried were denied, getting sicker and sicker as they tried to navigate an impossible appeals process.) To solve this problem, the Department of Veterans Affairs compiled a list of diseases known to be caused by agent orange, and if a vietnam vet presented with one of those diseases, well, okay, claim approved. (Yes, I know, oversimplified.)

The reason it’s in the news this week is that they’re adding a couple of diseases to the list. Three diseases, actually. (So reported by NYT.) And the VA is all, “Look! We’re making it easier for veterans to get the care they deserve!”

Um, okay.  Yes, you are making it easier for a few veterans to get the care they deserve. But your health care is still pretty terrible. Long waits, denials, etc, etc. This is a baby step, guys. Don’t start flying your Mission Accomplished banner.

So I ask: Is this even a good way to address the problem? Presuming that agent orange caused certain diseases, thus streamlining claims for those veterans who were in Vietnam and have those specific diseases? Is it just a good band-aid, when what we really need is a much better, much different system? Is it a bad band-aid, making things just good enough to scrape by while allowing us to ignore the greater change that needs to happen?

Hitting the bottle. . . in the hospital?

So, I have a good-old-fashioned question of “ideal vs. practical” for us.

I work in an ICU– people come in with heart attacks, sepsis, pnemounia. . . in addition to planned surgeries. As you probaly know on some level, there are A LOT of alcoholics out there– and when someone tells us they drink, and we ask how much, a good rule of thumb is to at least double that to get the truth. So people come in with some kind of critical illness (which, granted, are somewhat more common among people addicted to alcohol), and the within a few days, they’ve got the shakes, and we have to detox them and use lots of meds and close observation to keep the DT’s away– which can be lethal if untreated. This process is expensive, excrutiating (for the patients– don’t get me started on the nurses) and uses ICU beds and staff. Their stays are extended beyond what they initially would have needed. These people, by and large, don’t want to be detoxed. They aren’t going to quit drinking. Breaking the immidiate physical dependence doesn’t free them from their alcoholism– the first thing a lot of them do when they get out is get a drink.

So, why do we detox them? In our ideals about health promotion, we feel that it’s our duty. . . that it’s protecting their health, and that alcohol is a dangerous drug for these people? I know this sounds ridiculous and there are a million reasons this is an even worse idea, but why don’t we give these folks some booze– just an amount that will prevent severe withdrawl?  Is this an even bigger liability? Does it create incentives we don’t want? We certainly can’t force them into longer-term treatment options. We can counsel them and refer them, sure, but if they don’t want to quit or have no intention of doing so, what good have we done them? And at what cost?

Is there a good solution to this problem? Any thoughts?

More on flu shots. . .

As is the case with many vaccines, part of the benefit of vaccinating a lot of people is not just to stop those people from becoming seriously ill, but to prevent the spread of the virus. As a health care worker, I should be vaccinated not just so that I don’t miss work, but so that I don’t carry and pass the virus to vulnerable people. This also works in schools and nursing homes– the more people are vaccinated, the fewer potential carriers there are. Unfortunately, this argument doesn’t seem to work well with the general public: individual risk– even if it’s imagined, is more powerful. And what really gets me– even though I work at a hospital where seasonal and H1N1 shots are available free to employees, with no appointment, without even having to leave the unit, people aren’t getting them! Nurses!

Should health care workers be required to get vaccinated?

Blogging: boundaries?

I recently read an interesting post over at Code Blog about a nursing student who was expelled– and later reinstated– over her blog. She had written about clinical experiences in a way that seemed to mock the patients and conveyed a general lack of compassion and sensitivity. But she did not– and this is why she won when she sued– divulge enough information to constitute a HIPPA violation. So it’s really a first amendment issue– HIPPA is essentially an exception to the first amendment. So although she didn’t violate the law (or the school’s honor code), did she do something wrong? If you scoot on over and read some of her words, it’s hard to argue that she’s profession, ethical, and discreet, but that isn’t illegal.

So here’s my question: is there a way to identify this kind of line-crossing and discourage it without turning into a censor-happy autocracy? How can we legally protect freedom of speech while also guarding the special case of things like a nurse-patient relationship? Is this a case for the school to take up in its own code of conduct? For professional organizations and lisencing boards?

Lawyer jumping in here: It’s only a FIrst Amendment issue if the government is telling her she can’t post it.  (And you’re right, HIPAA is an exception — that’s the government telling you what you can’t disclose.)

The issue here was whether she violated the school’s honor code, and without seeing the code itself, it’s tough to know. Not being the government, the school can dismiss her by any process they themselves have set in place. (No notice, no hearing? Well, did the school’s written policy demand notice and hearing?) Basically, the government doesn’t get to say what the school can and can’t do here. (Obviously, there are exceptions protecting all kinds of groups — they can’t expel you for being black, etc.) She seems to have sued them over violating the terms of their agreement with her (the honor code, etc)  – not over unconstitutionally restricting her speech.

Leaving aside this particular incident and looking to professional codes of conduct, I think that is indeed the right place to regulate this type of behavior. Earlier this month, the Times had an article about lawyers getting in trouble with the Bar for criticizing judges on their blogs. Law, like nursing, is largely a self-regulating profession, so it was the Bar, not the government, that stepped in. I think the same would be appropriate here. Does the relevant professional association have guidelines about this sort of thing? If not, in this day and age, they should. People have blogs. And facebook. And Twitter. And they write about the things that happen to them. Especially as the “digital natives” enter the professions, they (we?) need clear guidance about where the line is. Not from the law — from our professions themselves.

UPDATE: The NBA is apparently going to issue social networking guidelines for players, coaches, owners, etc. Hat tip to lawyer’s husband for this one!

Coincidences happen. Even when you get a flu shot.

The New York Times has an article about the CDC’s concern that people who get flu shots this year will blame anything that goes wrong with their health on shots. (i.e. Someone gets a flu shot, two days later he has a heart attack, so obviously flu shots cause heart attacks. RIGHT?)

So, those of us who remember our stats or are science-trained sometimes utter the phrase “correlation does not prove causation” in our sleep. But much of the rest of the country world isn’t so quick to remember this fact. The CDC is especially worried that the news media will seize on individuals’ claims that the vaccine made them sick, and publicize them, which will spread that misinformation to the general public who believe anything they hear on TV or read in USA Today.

Why do we care? If people want to make themselves crazy freaking out, why would nurse and lawyer want to get in the middle of that?

One big reason: we don’t want people who really need the protection to be afraid of getting it. Pregnant women are one such class — need the protection, but wanting to be extra careful. Senior citizens are another group who need the protection and may be more susceptible to scare tactics. It could really interfere with our public health goals of preventing this from becoming a pandemic if people are afraid to get the shot. Right, nurse?

So what can we do? We obviously can’t forbid “news” organizations from reporting these kinds of stories. (Hello, First Amendment.) What about some kind of voluntary agreement, where news organizations are made aware of the problem and its potential consequences, and agree not to report these kinds of stories without appropriate context describing the nature of the correlation? What if we set a threshold for how many incidents of the same sort must be observed before it becomes a “trend” that they could report? Admittedly this is more a question of journalistic ethics than of law, but… I want to be able to do something about it!

Other ideas? Anyone?

Background reading

Nurse: As there’s been so much bloviating about health care and reform lately, I’ve done lots of reading and listening on the subject and found lots and lots of opinions and propaganda, but i’m having a very hard time finding accessible information that isn’t distorted by political idiologies and agendas. There are books by politicians and pundits with giant lettering on the cover. There are pieces in Right and Left wing news magazines. There are more balanced articles in some academic and professional journals– but it doesn’t seem like there is any good source of  information on this history of american health care systems, the comparison between it and the systems of other countries, or anything of that nature that is accessible to the public– looking around Barnes & Noble the other night, I was horrified.

Has anyone found a good source of information and insight that doesn’t reek of partisan agendas?

Here it is. Obamarama.

Lawyer: I went through the transcript with a highlighter to mark places where he actually said something concrete. I got to page 3 before I found anything.

Nurse: Overall, I think he’s doing a good job with this– it’s actually politically quite a tightrope between being too vague and making concrete promises that have to be shifted in some way later, and this always bites you in the ass. That said, it’s kind of disapointing to see how safe the approach is. While I recognize that it is largely impossible to enact sweeping dramatic change in a democracy which is beholden to so many interested parties, I wish it wasn’t. There are so many roots of the problems we have with healthcare delivery that are not addressed in this proposal– in a way, we are treating symptoms instead of making smart lifestyle choices. But I suppose that’s inevitable. Sigh.

Here are the substantive points he made, one by one:

1. We’d better build on what we have, rather than trying to build a whole new system.
Lawyer: Agree!

Nurse: Reluctantly agree out of pragmatism, not true belief.

2. This plan has three basic goals.
a. More security and stability for people who have insurance
b. Insurance for people who don’t have it
c. Slow the growth of health care costs

Lawyer: He doesn’t say much about how (c) is going to happen…

Nurse: And indeed, a lot of the most promising ways to do that are not possible in what amounts to a conservative (in the true sense of the word) reform effort.

3. Insurance regulation:
a.companies can’t deny coverage for preexisting conditions or drop/water down coverage when you get sick.
b. No arbitrary limits on how much coverage you get
c. Limits on out-of-pocket charges
d. Routine check-ups and preventive care must be covered

Lawyer: I mean, yeah.

Nurse: Right, this should be obvious. It’s not, but it should be. Even if this was the only thing that changed, we’d be better off.

4. Rather than out-right legislating what insurance companies must do, we will make these above reforms requirements for joining the health insurance exchange. Companies will want to join it so that they can compete for new customers. The exchange will give customers bargaining leverage.

Lawyer: I think this is a sound approach. Better to make people want to do things your way than to try to force them. Anyway, it worked with the whole drinking age thing. As long as it actually works. And insurance companies do actually participate. And follow the rules. Anybody know how this is actually going to function?

Nurse: It’s a tasty carrot. Mmm. carrots.

5. Tax credits for individuals and small businesses who can’t afford insurance, based on need.

6. Immediate low-cost, minimal coverage for the currently uninsured.

Lawyer: Um… details?

Nurse: Provided by? And covering. . .? People who can’t pay are still given care, but they are generally bankrupted by it. Maybe we are just getting around that.

7. People will be required to carry basic health insurance (just like auto insurance.) Businesses required to at least chip in. (Hardship waivers.)

Nurse: This at least makes sense, if we are going in a insurance-based model (See my previous post for a little discussion on that).

8. (wait for it…) Yes, there will be a public option available as part of the insurance exchange. (As one of many options.) CBO estimates that fewer than 5% of Americans would choose this option. The option will be self-sufficient, relying on the premiums it collects.

Lawyer: Wow, that low estimate makes me super-nervous.

Nurse: I think this is an essential part of the plan, not just in what it will actually do, but in the message it says. I do worry that it won’t truly be self-sufficient because people who elect it may have reasons not to buy private insurance or may find it too expensive. Depends on how the rest of that regultion reform plays out.

Lawyer: That’s too bad. Because people seem to be saying that it’s going down the crapper.

9. This will be paid for by cutting wasteful spending we already have, rather than expanding the deficit. If the projected savings don’t happen, we’ll cut spending, rather than adding to the deficit. Medicare trust will not pay for it.

Lawyer: Sounds good in theory. But I have a feeling that substantial savings will take a long time. I mean, longer than four years. Because our spending is really wasteful, yes, but we can’t just snap our fingers and quit doing that.

Nurse: And this is one place where we really need a cultural shift to fix it. A cultural shift involving how physicians and patients conceive of thorough care, and how malpractice suits are both perceived and actually used. Which leads into the next issue.

10. We’ll have some sort of panel to reduce defensive medicine. HHS is going to handle it. (vague, fuzzy, proclomations.)

Lawyer: I want to hear more about this! Ring ring, hello, Kathleen? Can we talk?

Nurse: Again, this is a deeply rooted cultural issue, in a way. I think we need some good evidence-based practice here– which means we need some research.

Lawyer: cf. Stimulus Bill.

Nurse: I have heard vaguely about studies which show that high-tech intervention can actually be harmful rather than helpful– as in using electronic fetal monitoring, which has been shown to cause unnecessary c-sections with no better outcomes, yet it’s become a standard of practice. HHS, can you work on this angle??

11. Poor Teddy Kennedy! This was his dying wish!  Also, as he said, this is a moral issue, not just a policy issue.

Lawyer: Aww. Shot to the heart.

Nurse: Ok. Cool.

12. People thought we were socialists back when we invented social security and medicare, too, but can’t we all agree now that we need those things and they were a good idea?

Lawyer: JEEZ, thanks Obama, I’ve been trying to tell people that for a while now.

Nurse: well, what’s wrong with socialists? And another thing: he talks about requiring insurance to cover preventive care, but I think we could make huge progress by going a step further and offering incentives for preventive care. Maybe that would just be smart business for an insurance company, I don’t know– but i think it would help!

Lawyer: Mmm,  more carrots. Carrot cake. I have to go…

Insurance?

Nurse: A recent article in the Atlantic, by David Goldhill, discussed health insurance reform from an angle we haven’t heard a lot of: why do we expect all of our healthcare expenses to be paid for by insurance? Everything from a checkup to our daily prescriptions to our accidents to our catastrophic illness is, in most people’s minds, the provenance of insurance. This, he argues, has the effect of making the insurance companies, rather than the patients, the customers, and it throws the whole free-market dynamic off entirely. He proposes mandatory health savings accounts as another path. Now, there a problems there, too, and I don’t agree with many of his points, but he raises an interesting question. If we own a car, we are required to have car insurance– but that doesn’t cover new tires, oil changes, and the like. It covers accidents, liability, theft, and damages we might not be able to afford without it. Same with insurance on our homes, our lives, our possessions. . . but not our health. Of course, we’ve been in this system for so  long that most of us could not pay out of pocket for the majority of our health expenses, but the author argues, and correctly, I believe, that the cost of health care as billed to insurance companies and the cost of health care as incurred by providers and facilities is astronomical, and much of that cost is due to administrative nonsense and lack of decent competition and incentives to perform. Interesting, no?