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Tag Archives: Joint Commission

Redefining the Pain Scale

The smiley faces just don’t seem to cut it any more. The Wong Baker pain scale was originally created for children. Now it is used by medical providers to precisely gauge pain in adults all over the United States because of the concept pushed on medical providers that “Pain is the Fifth Vital Sign.” Although this phrase was originally created by the Department of Veterans Affairs, The Joint Commission adopted it and ran with it, rolling out Pain Management Standards declaring in 2000 that “the pain management paradigm is about to shift,” that pain control was a “patient rights issue” and that providers would be required to measure pain on a 1-10 scale. See JAMA article here. PDF here. Skeptical Scalpel weighed in on the “Pain as a Fifth Vital Sign” issue in 2013. Of course now that the US is in the throes of an opiate epidemic because of the Joint Commission’s actions, the Joint Commission walked back its demands, stating that it only required providers to measure pain, not to use drugs and that it didn’t require the patient’s pain scale to reach “zero.” Then it put out a propaganda bulletin (.pdf) describing “Myths About The Joint Commission pain standards” … but that’s fodder for another post. So when I get to the whole pain rating thing and someone says his or her pain is a “10” while simultaneously munching on Cheetos and playing Flappy Bird on his or her TracFone, I have cause for concern. Either the patient is dissociated from reality, has some ulterior motive for overestimating his or her pain, or the patient doesn’t understand the pain scale. No matter how many times you shove the smiley faces in front of the patient’s smiley face, the patient just doesn’t get it. So sometimes I call them out. “Consider ’10’ as pain that is so bad that you are rolling around on the floor in agony and asking for someone to put you out of your misery.” [flap flap flap] “Oh, yeah,” [crunch chew chew chew] “it’s definitely a TEN” “Oh, but my unfortunate patient in distress, you’re not rolling around on the floor.” [Looking up from the screen momentarily] “OK, then it’s a 9 and a half” Brilliant. If only everyone could be so mathematically adept. There have been many memorable attempts to describe the pain scale. Brian Regan described his experiences trying to outmoan the patient in the next room, then discusses how he decided to describe his pain scale to the nurse. If you’re at work, don’t drink coffee while watching. If you’re at home, pop a beer and fire up the link. It’s worth 8 minutes of your time. Then there’s xkcd’s take on the pain scale – which piggybacks off of Brian Regan’s stand up routine. How would you rate your pain if 10 is the worst pain you could imagine … ? Allie from Hyperbole and a Half did an admirable job of it when she took her boyfriend to the hospital for vomiting Crasins and needing to be checked for Ebola. You really need to read that post for some good chuckles. So then I happened to come across an Improved Pain Scale picture on Reddit that does a reasonably good job at describing pain. View post on imgur.com Personally, I still like the Hyperbole and a Half scale better, but this Reddit one isn’t bad. And before someone out there tries to call me out for all of the links being in the Reddit post, the only one that I hadn’t seen before was the xkcd scale. I’ve passed around the links ...

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Should JCAHO Regulate Family Visitation?

I had a whole story ready to post about another very sick child that we treated, but decided to leave a more general issue instead. When there are critically ill patients, the staff has to think quickly and act quickly. Interruptions are counterproductive to our job during those times. Think about trying to concentrate on something – whether it be driving and trying to find a street address, talking on the phone, or trying to figure out a crossword puzzle – and being interrupted by your kids. The interruptions knock you off track from the task at hand. There was a 6 month old who was critically ill in our department. With children, tasks such as starting IVs and intubating them are more difficult, and you also need to check the dosages of medications that they’re being given since pretty much all medications for children are weight-based. All the medical providers really need to focus. So how do we manage a situation in which the parents are interrupting the care of their infant child? I understand that seeing all of these things happen to your child is a scary experience. I understand that parents want to be there with their sick children. I’m a parent. I’ve seen it with my children. Should the physician trying to save a child’s life stop what he or she is doing to explain to the parents what is happening – which may affect the survival of the child – or should the physician get done what needs to be done and talk to the parents later? Some parents are very good about staying out of the way and just watching what is happening. But some parents will push you out of the way to stand next to the child, holding the child’s arm and caressing the child’s head when you really need access to the arm and the head. If the family’s expectations are not met while you’re trying to save the child’s life – whether it is because you didn’t answer questions to the family’s satisfaction, whether you asked them to do something they didn’t want to do, or whether you said something to the staff that the family took the wrong way, then you may find yourself at the end of a complaint to hospital administration. If you everything necessary to meet the family’s expectations, but doing so causes delays in caring for the child and the child suffers a bad outcome, then you may find yourself at the end of a malpractice lawsuit. I know that some people will suggest “meeting in the middle.” That is fine and usually works well in most situations. However, there are times when “meeting in the middle” doesn’t work, and those times may cost a child his or her life. Should we excuse all family members from the room during critical care moments to decrease the likelihood of medical errors related to interruptions? If we’re talking about “patient safety issues,” situations like this occur a lot more frequently than some of the other things that JCAHO tries to regulate. Does JCAHO need to regulate family visitation?

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Safety of Medical Care in US

Remember that statistic from the 1999 Institute of Medicine report that trial lawyers like to throw in everyone’s face about how “up to 98,000 people in the US die each year due to medical mistakes”? It’s like TWO 737 jetliners crashing every day … and we’re doing nothing about it. So today a news story was sent to my inbox that included Saudi Arabian Ministry of Health statistics on medical malpractice. The report shows that there were 1,356 cases of malpractice in Saudi Arabia in 2009 and that “129 people died from medical mistakes in 2009.” Of course, the 129 number seemed quite low to me given the 98,000 number that is constantly cited in the press. Maybe Saudi Arabia’s population is just smaller than I thought. Nope. Saudi Arabia has a population of roughly 26 million – about 1/12 of the 310 million people in the United States.  Multiply those 129 Saudi Arabian deaths by 12 and the population adjusted death rate from medical mistakes in Saudi Arabia is 1,548 — versus 98,000 for the United States. Look at it another way. Divide 98,000 deaths from medical mistakes in the United States by a population of 310 million and you get about 316 deaths per million population in the United States due to medical mistakes. Divide 129 deaths from medical mistakes in Saudi Arabia by 26 million population and you get about 5 deaths per million population in Saudia Arabia from medical mistakes. 316 deaths per million in the US versus 5 deaths per million in Saudi Arabia. Is medical care in the United States that much worse than in Saudi Arabia — even without the benefit of safety agencies such as the Joint Commission and HospitalCompare.gov? Or do unrealistic requirements from “safety” organizations such as the Joint Commission and “quality measures” from our government actually cause more deaths from medical mistakes? Or are the Institute of Medicine’s numbers so far off that they shouldn’t be believed? I did a little more searching. This parliamentary paper from the United Kingdom pegs deaths due to medical “incidents” at about 3,500 per year in England. In a country of 52 million people, that averages out to about 67 deaths per million population – still about one fifth of the alleged United States numbers. Then I found a Canadian study showing that the range of deaths from “medical misadventures” in various industrialized countries ranges from 1 per million population to 10 per million population. The US is in the middle of the pack at about 6 deaths per million population per year – which equates to about 1,860 deaths per year from “medical misadventures” in the United States. 1,860 deaths versus 98,000 deaths Why are the numbers in that IOM paper such outliers? And why do the trial attorneys keep citing it as gospel?

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Is Protecting Yourself a Joint Commission Violation?

There are a lot of bonehead stories about the Joint Commission in the news lately. I just had to post this one. CMS and JCAHO are now investigating Lehigh Valley Hospital in Pennsylvania for using stun guns on unruly patients. In one instance, a patient was using an IV pole as a pugil stick before security guards used a TASER to put him to the ground. In two other instances, patients were beating on security guards when they were “tazed.” Protecting yourself is apparently a “violation of state and federal health rules.” As a result of the stun gun incidents, the hospital was ordered to retrain certain staffers in responding to behavioral emergencies. Security and emergency department staff had to be trained in comprehensive crisis management. The hospitals also had to establish a task force to track “incidents” and ensure that staffers had used the “least restrictive measures” when restraining a patient. When are you guys going to learn? When a patient is choking the life out of you, you HAVE to offer them milk and cookies then tell them to go to a secluded room before you try to defend yourself. Those are the rules. If they have their hands around your windpipe and you can’t breathe, then just point emphatically to the secluded area. Wouldn’t it be … interesting … to watch an “unruly patient” attack a CMS investigator and then watch hospital staff utilize mandatory CMS protocols to intervene? Sir. SIR! How about you stop disarticulating that man’s elbow. Really now. Would you like some juice instead? We have apple, grape, and cranberry. Maybe some nice Saltines and peanut butter? No? Hey! Now if you don’t stop poking your fingers in that man’s eyes, we’re going to have to bring you to a secluded area. I’m not kidding, Mister. And you, Mr. Investigator – stop trying to fend off his attack with your clipboard. Don’t you know the patient could injure his knuckles if he hits that clipboard instead of your face? OK, Mister. I see the Investigator’s blood dripping all over the place. Someone might slip and get hurt. You are officially creating a patient safety hazard. NOW you’re getting CITED! SECURITY! That should calm those unruly patients.

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