Wednesday, June 22, 2005

Help from the Other Side of the Blood-Brain Barrier.....
From the Wall Street Journal, a plan to reduce liability premiums that physicians and lawyers can agree on:Once Seen as Risky, One Group Of Doctors Changes Its Ways
Anesthesiologists pay less for malpractice insurance today, in constant dollars, than they did 20 years ago. That's mainly because some anesthesiologists chose a path many doctors in other specialties did not. Rather than pushing for laws that would protect them against patient lawsuits, these anesthesiologists focused on improving patient safety. Their theory: Less harm to patients would mean fewer lawsuits.
They worked to improve safety and training methods, and it has both helped patients:
Over the past two decades, anesthesiologists have advocated the use of devices that alert doctors to potentially fatal problems in the operating room. They have helped develop computerized mannequins that simulate real-life surgical crises. And they have pressed for procedures that protect unconscious patients from potential carbon-monoxide poisoning.

All this has helped save lives. Over the past two decades, patient deaths due to anesthesia have declined to one death per 200,000 to 300,000 cases from one for every 5,000 cases, according to studies compiled by the Institute of Medicine, an arm of the National Academies, a leading scientific advisory body.

And saved money:
Malpractice payments involving the nation's 30,000 anesthesiologists are down, too, and anesthesiologists typically pay some of the smallest malpractice premiums around. That's a huge change from when they were considered among the riskiest doctors to insure. Nationwide, the average annual premium for anesthesiologists is less than $21,000, according to a survey by the American Society of Anesthesiologists. An obstetrician might pay 10 times that amount, Medical Liability Monitor, an industry newsletter, reports.

In some areas, anesthesiologists can now buy malpractice insurance for as little as $4,300 a year, although premiums ranged as high as more than $56,000, according to the ASA. The ASA survey gave no general explanation for the disparity but did note that premiums were higher for anesthesiologists who had been sued before and for those who perform higher-risk procedures.
Even the IOM likes anesthesia:
A 1999 report by the Institute of Medicine noted that "few professional societies or groups have demonstrated a visible commitment to reducing errors in health care and improving patient safety." It identified one exception: anesthesiologists
The watershed moment came in the early 80's:
In 1982, the ABC news program "20/20" aired a piece on anesthesia-related deaths. "It was a devastating indictment of anesthesia," recalls Ellison C. Pierce Jr., a retired professor of anesthesiology at Harvard Medical School who is considered by many to be the father of the modern anesthesia-safety movement.

Around the same time, anesthesiologists were getting hit by their second wave of big malpractice-insurance premium increases in a decade. The specialty was then considered among the riskiest to insure, and premiums were often two to three times as high as those other doctors paid. Casey Blitt, a 63-year-old Tucson, Ariz., anesthesiologist who has long been active on patient-safety issues, says his insurance soared to $50,000 a year from $20,000 or less. Dr. Pierce says anesthesiologists were "terrified," and anxious to do something.

Dr. Pierce at the time was president of the American Society of Anesthesiologists. In 1985, that group provided $100,000 to launch the Anesthesia Patient Safety Foundation. The new foundation was unusual in medicine: a stand-alone organization solely devoted to patient safety. Working closely with the larger ASA, from which it still receives about $400,000 a year, the foundation galvanized safety research and improvement.
The process started with data collection:
Twenty years ago, little was known about people injured or killed during anesthesia. No U.S. database existed, so anesthesiologists set out to create one. They decided to collect information from insurers on closed malpractice claims, those in which insurers had made a payment or otherwise disposed of the complaint.

Most insurers hesitated to cooperate at first, saying they were worried about patient privacy. One company finally agreed: St. Paul Fire & Marine Insurance Co. in Minnesota said it was concerned about heavy losses it had suffered from anesthesia-related injuries and was eager for anesthesiologists to review claims. Soon, other insurers followed suit.

Anesthesiologists left their practices for days at a time to pore over closed insurance claims. The information they collected was fed into a computer at the University of Washington to create an overall picture of how anesthesia accidents tend to occur. It "was a humbling experience," recalls Russell T. Wall, an anesthesiology professor at Georgetown University School of Medicine in Washington, D.C. To date, more than 6,400 claims have been analyzed.
The American College of Surgeons has also begun to analyze closed claims as part of the Patient Safety and Quality Initiative. They fixed big problems:
In part by analyzing claims, the anesthesiologists were able to document the extent to which patients were dying because of a simple mistake: Anesthesiologists were inserting the patient's breathing tube down the wrong pipe. Rather than putting it down the trachea, which leads to the lungs, they were accidentally inserting it down the esophagus, which leads to the stomach. The problem was, there was no way to determine quickly whether the tube was in the right pipe. Patients often simply turned blue or their blood turned dark. By then, it was usually too late to save them.

The research contributed to two innovations that between them would all but eliminate death and injury from "intubation" errors. One, known as pulse oximetry, measures the oxygen level in the patient's blood stream by means of a device that clips onto the patient's finger. The other, capnography, measures carbon dioxide in a patient's expelled breath, which helps doctors determine at a glance that a patient is breathing properly.
Both of these technologies have spread far beyond anesthesia. They also solved some smaller ones:
That change has been accompanied by other less obvious improvements. During surgery, a patient's body temperature can fall as room-temperature intravenous fluids are infused into the blood. This cooling can cause tissue to die and make the body vulnerable to infection. The safety foundation funded research on the problem in the 1990s, and now care is taken to keep patients warm during surgery, often with specially made blankets that can be heated. Blood and fluid warmers are also used.

Anesthesiologists also have become much better at preventing patient exposure to carbon monoxide. The potentially deadly gas can be an unintended byproduct of the process of cleansing a patient's exhaled breath of carbon dioxide before the air is recycled back to the patient's lungs. One simple way to guard against this problem is to make sure that absorbent material in anesthesia machines that filters the recycled air remains moist.

In 1994, the newsletter of the anesthesiologists foundation documented cases in which patients were exposed to high levels of carbon monoxide during surgery on Mondays, presumably after absorbents had spent the weekend drying out. The organization recommended replacing the absorbent material on Monday mornings and several other changes. These are now standard practice, and rates of carbon-monoxide exposure have fallen dramatically.
Sometimes we as surgeons can be seen as stumbling blocks:
Anesthesiologists are now focused on alarm bells. Modern anesthesia machines come equipped with audible alarms that sound when certain thresholds, such as oxygen levels, are crossed. But the alarms irritate many surgeons, so some anesthesiologists have turned them off. The foundation has documented 26 alarm-related malpractice claims between 1970 and 2002, or a little more than one a year. Of those, more than 20 resulted in either death or brain damage.
I, for one, am not irritated by the alarms. They indicate that something is amiss. My antennae also go up if I see a bunch of movement behind the drapes. More results:
In 1972, according to a recent study by Public Citizen, a consumer-advocacy group in Washington, D.C., anesthesiologists accounted for 7.9% of all medical-malpractice claims, double the proportion of physicians who practiced anesthesiology. Between 1985 and 2001, anesthesiologists accounted for only 3.8% of all claims, roughly comparable to the percentage of doctors who were anesthesiologists.

The size of payments from successful malpractice suits against anesthesiologists also has declined. According to the American Society of Anesthesiologists, the median payment during the 1970s was $332,280. By the 1990s, it had dropped 46%, to $179,010. These amounts are in 2005 dollars and are the most recent figures available.

Claims for serious injuries have become less frequent. In the 1970s, according to the ASA, more than half of anesthesia-malpractice claims involved death or permanent brain injury. In the 1990s, that fell to less than one-third of claims.

Malpractice rates for anesthesiologists have gradually fallen, the ASA says. This year, the average annual premium is $20,572, compared with $32,620 in inflation-adjusted dollars in 1985. That's a decrease of 37% over 20 years. Malpractice rates are generally set at the beginning of the year.
The ASA and anesthesiologists overall deserve a well-earned pat on the back for their efforts. I also applaud the ACS for the safety improvement efforts that are underway. However, I would not be surprised if the efforts by the ACS are more difficult and less successful. The improvements in anesthesia were based on solutions to problems that were, for the lack of a better word, quantifiable. Esophageal intubation is a problem, given the right tools, that can be quickly recognized and corrected. How can one quantify surgical judgment? How many variables such as experience, technique, medical co-morbidity, material, and time of day, for example; affect the outcome of surgery? Yes, safety is compromised when surgical instruments are washed in hydraulic fluid. But the biggest obstacle may be ourselves:
At the University of Utah Hospitals and Clinics, Dr. Kochenour says his institution has tried to emulate the anesthesiologists by concentrating more on identifying systemic errors and less on individual blame. But these efforts run headlong into thinking drummed into physicians since medical school, he says. "I don't think physicians are very good systems thinkers, by and large," he says. Many, especially surgeons, prize their independence, he says, and that makes it hard to achieve the kind of cooperation necessary to reduce errors.
Best of luck.
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