Search for tag: "hospitals"

Interviewer: Going to help you understand hospital rankings, that's coming up next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: When a hospital says they're number one in this ranking or in the top 10 in another ranking, what does ultimately mean for you as a patient? And are there some rankings that are more prestigious than others? All right. Hopefully, we'll get some help understanding this. Dr. Robert Pendleton is a Chief Medical Quality Officer at University of Utah Health Care. And one time, I was listening to you speak and you referred to as these rankings kind of like merit badges because there are so many of them, right? What exactly do you mean by "they're just merit badges"?

Dr. Pendleton: Well, you have to understand my perspective is five years ago, I was just a doc in the hospital who knew nothing about any of this, other than what patients see, right? These banners and everything. And when I took on the role of Chief Quality Officer, it was really eye-opening to me because depending on which ranking you're talking about, every hospital has one, right? Every hospital has a banner or whatever. And pretty quickly, it felt like I was back in Boy Scouts, collecting merit badges. And there are so many rankings that it becomes really confusing for patients to understand, "Well, what actually matters?"

Interviewer: Yeah, how many are there? Do you have any sort of a guess at that?

Dr. Pendleton: Yeah, there are probably a dozen or so very popular ones, but then another 20 or 30 merit badges that are maybe sort of less developed, but still things that people will put up on their or their hospital marquees and that sort of thing.

Interviewer: Yeah, so what are these ratings usually based on? And should we make some differentiation at this point where we talk about, "From now on we're talking about the meaningful ones and we're kind of forgetting about the merit badges"? Or how do you think we should best organize that to help a patient understand?

Dr. Pendleton: Yeah, I think that the most common ones that hospitals talk about, even within that pool, are very different. You have some rankings that are almost entirely on things like reputation or what are called structural measures. So a structural measure may be something like how many intensive care unit doctors does your hospital staff at night.

And although those kinds of things, reputation and structural measures like staffing, on the surface, are important, my belief is that in health care we've moved beyond that where we can start measuring more meaningful things and actually start looking at measures of safety, complications, how likely patients are to survive a severe illness when they get hospitalized, whether their doctors and nurses and health care team communicates effectively in a way that patients can understand what the game plan is. We're now at a point where those objective measures should be used almost entirely in these rankings because I think that reputation, staffing ratios etc. just feels like more merit badges to me.

Interviewer: Sure. So beyond that, just kind of the, "Are you going to go in and have a good outcome," sort of thing, are there things that go into these rankings that measure in terms of patient benefits? You talk about patient benefits a lot.

Dr. Pendleton: Yeah. There are. There are things like how long do you stay in the hospital for a given problem, compared to what we would expect. Most patients don't want to spend any more time in the hospital than they need to. They measure things like, do you get a common complication in health care, which is like a new infection. And again, a whole Interviewer of very patient-oriented things, like you know, how well did your doctor communicate with you? How responsive was the staff if you used your call light to summon for help? Did the pharmacist talk about your medications in a way that you can understand them?

When you were discharged from the hospital, did you understand your follow-up plan? And then measuring, did you actually need to have an unexpected return back to the emergency department or the hospital after you were discharged?

Interviewer: So you talk about kind of which of the metrics matter. How can I determine now which of these merit badges matter? Like, for example, I go to a hospital's website and I see that they have one of these merit badges. How do I know if that's the real deal or if it's just a merit badge?

Dr. Pendleton: I think most of these merit badges are starting to become more publicly available. So if you Googled, for example, "US News and World Report methodology," most patients now can get to a website that still is oriented in a way that patients can get something out of that and click through to see whether there are meaningful, actual measures of care that are part of these scorecards.

Interviewer: So University of Utah Health Care just recently got number one on the Vizient Quality and Accountability Study. Is that a good one?

Dr. Pendleton: Well, of course, it is. We're number one.

Interviewer: But you've been very honest with me up to this point so I know you're going to be honest with me on this.

Dr. Pendleton: Yeah, absolutely. We actually, every year, go through and look at all these merit badges as an organization, and really in great detail, we go through a process to say, "Is this the right thing for us to focus on as an organization where we can help our organization get better?" Vizient is one where we have been particularly enamored by, if you will, over the last seven years or so. And the reason is it is entirely objective measures of better care: survival rates across the entire enterprise, not just one or two areas; a broader range of complication rates, broad range of patient-reported feedback about the experience of their care, costs of care, efficiency of care.

And it allows us to benchmark that each of those measures with our peers so that we know, "Well, how are we doing compared to other really well-known health systems, like Johns Hopkins or the Mayo Clinic?" And for us, that really allows as to understand where our opportunities are to be better.

Interviewer: So it sounds like that the quality of the award or the ranking really has a lot to do with what are they measuring in the first place. And you talked about some meaningful versus not-so-meaningful metrics. Sounds like they also would apply to day-to-day care, in addition to more complicated stuff. Like I guess at one point, I thought, "Well, if I'm getting a knee replacement, then I'm really going to want to pay attention to these ratings." But it sounds like day-to-day stuff's included in these as well.

Dr. Pendleton: It does. And the true day-to-day stuff for healthy people like you or I, who are getting care in clinics and we may never enter the walls of a hospital emergency department in any given year, Vizient also is sort of becoming a leader in how we assess ambulatory-based care, that sort of common care. And it is going to be a very nice companion to the one where we were ranked number one, which is still focused more on acute care. And so I'm excited because I think that the more meaningful measurement that health systems have, the more transparent that is to patients, the more we can engage in actually making things better, which is what we're in the business for.

Interviewer: Are there any other ones that are worth looking at?

Dr. Pendleton: I think one that has gotten a lot of popular press is Medicare. So Medicare has taken data and worked through a whole set of meaningful metrics and come up with their own five-star rating. And currently, I think that for patients, that's another helpful one to look at. But the limitations with that one are sometimes it will compare apples and oranges. So, as an example, a large tertiary care academic medical center, like University of Utah, will get put in the same bucket and has a center in New York who only does hip replacement surgery. And those are two very different missions in how they deliver care. And so, aside from those caveats, it's another one that I think is fairly meaningful.

Interviewer: So, at the end of it all, are these different rankings, you do find that some of them do have value and would have value to a patient?

Dr. Pendleton: Absolutely. I think that as health care embraces how we think about and measure the care that we deliver continues to evolve and get better, these rankings similarly continue to evolve and get more and more meaningful.

Announcer: Want The Scope delivered straight to your inbox? Enter your email address at thescoperadio.com and click "Sign me up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: I think one of the concerns that people have in America now that the first case of Ebola is here in the United States is that we're going to have a situation similar to that of Africa. Dr. Sankar Swaminathan is the Chief of the Infectious Disease Division at the University of Utah and an infectious disease specialist.

Tell me why we shouldn't expect the same thing happening in the United States as, related to Ebola, as we've seen happen in Africa.

Dr. Swaminathan: The situation is dramatically different here in the United States from West Africa. With regards to transmission, there are two places where transmission has occurred, in the community and in the health care setting. The health care setting in West Africa is about as different from the health care setting in the United States as one could imagine. There are mud floors, no gloves, no running water in many places. So we have the capability here to protect our health care workers and our other patients from spread in the hospital. And that does make a huge difference. There has really been no such transmission in Western hospitals, even when cases have been brought here of other viral hemorrhagic fevers as well.

The transmission in the community occurs because of a variety of reasons. But a lot of it has to do with resources, a lack of trust in officials and in the health care system so that people are afraid to seek care. People even chase away workers when people have come to help. This leads to increased transmission in the homes where people don't have the facilities to deal with it. So that's very, very different. So we're not going to have unchecked spread in homes or in hospitals in this country.

The second is the transmission is really not as easy as people seem to think. Many of these studies that have to do with varieties of transmission have been done in a laboratory. But when you've actually looked at outbreaks of Ebola, even people who lived in a home with someone who died of Ebola did not get the infection unless they were directly in physical contact with the patient, or cleaning up their blood, or vomit, or other bodily fluids.

It's all relative risk. And as long as we have good public health facilities, which we do in this country, it should and will be possible to isolate, identify contacts, isolate those contacts and limit the infection so that one person cannot spread the infection to more than another person.

Now while one can't rule out a secondary case, it's very, very unlikely. Given what we know, from all the evidence that we have as to how it's transmitted, as to how long the virus can live on surfaces, as to how infectious people are, it's very unlikely that we would have the kind of transmission that's occurring in West Africa today.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.

Scot: Have you ever seen one of those defibrillation machines on the wall and wondered "huh, I wonder how that works"? We're going to find out next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Scot: So you're starting to see them pop up more and more in public places-defib machines-in case somebody's having a heart attack or heart failure. But have you ever wondered boy, would I know how to use one? We're talking with Dr. Troy Madsen, emergency medicine at University of Utah Hospital. How do you use those machines?

Dr. Troy Madsen: You know, it's one of those things where fortunately they've made them easy enough to use that, you know, I'd like to say they're foolproof. They're probably not quite foolproof but pretty close to it.

Scot: Okay.

Dr. Troy Madsen: So, you know, the big scenario where I would use it would be where someone didn't have a pulse and they weren't breathing. So someone falls down. And you're going to find these machines in lots of different places, lots of different public sort of locations. But if someone falls down, they're not responding to you, they don't have a pulse, number one-start CPR. Call for 911. But meanwhile ask someone to go get one of those machines.

Scot: So can you get them? I thought they were permanently mounted on the wall.

Dr. Troy Madsen: They are, but usually you can just break through that just like, you know, you would break through some sort of thing for a fire extinguisher or something like that or get it open.

Scot: And then carry them?

Dr. Troy Madsen: And just bring it over.

Scot: Oh, they're battery powered?

Dr. Troy Madsen: They are. They are battery powered.

Scot: Oh, I thought they were mounted permanently.

Dr. Troy Madsen: No.

Scot: Oh, okay.

Dr. Troy Madsen: Fortunately you can just pull them right off the wall, bring them to wherever you are and wherever you need help.

Scot: Okay, all right. So somebody goes and gets one. They bring it on over.

Dr. Troy Madsen: Yeah.

Scot: And the only time you'd use it, if somebody doesn't have a pulse, that's the only time?

Dr. Troy Madsen: Yeah, exactly.

Scot: Okay, all right.

Dr. Troy Madsen: This is something for CPR.

Scot: Okay.

Dr. Troy Madsen: You're going to use if you're doing CPR. Ideally, you know, if you're in a situation where someone goes down and you don't have any experience with CPR, just start chest compressions but ask "hey, does anyone here know how to do this?"

Scot: All right.

Dr. Troy Madsen: Get the most experienced person in there, but it's something where you can pull that thing off the wall, get it down there, and start using it. So once you open it up and turn it on, it'll tell you what to do. It'll tell you "place pads," and it'll show you where to place the pads. You're putting them on the person's chest.

Scot: Really? So it's a little video screen?

Dr. Troy Madsen: It'll speak to you. It actually talks to you.

Scot: It talks to you.

Dr. Troy Madsen: It will talk to you.

Scot: Wow.

Dr. Troy Madsen: Yeah, these things are programmed just so they talk to you, and they'll tell you what to do.

Scot: Okay.

Dr. Troy Madsen: And then they'll tell you "Do chest compressions" because that's the most important thing you're going to do in any of these situations. Just do good chest compressions. Keep pushing on that person's chest at 100 beats a minute. Just keep going.

Scot: Staying alive.

Dr. Troy Madsen: Staying alive.

Scot: Bee Gees song.

Dr. Troy Madsen: Yeah, think staying alive.

Scot: Sing it in your head.

Dr. Troy Madsen: Because that is 100 beats a minute. And then it will tell you "Stop compressions" and then it will say that it's analyzing the rhythm, and what that means, it's looking at the person's heart rhythm to decide is this something it can shock or not. And there are certain heart rhythms when a person's heart is not beating, but it still has some electrical activity where it can shock that, and by shocking it, it can put it back in normal rhythm. So that's what the machine's looking for.

Scot: Okay.

Dr. Troy Madsen: And then if it can shock it, it says "shock," and it tells you "push this button," and you push it, and it shocks the person, and that shock might be the thing that saves that person's life.

Scot: So it sounds really easy to use this machine.

Dr. Troy Madsen: It is.

Scot: Just do what it tells you to do.

Dr. Troy Madsen: Exactly.

Scot: Wow.

Dr. Troy Madsen: They've really designed it so it just walks you through the steps. So, you know, if you're in that situation and you don't have any experience or there's just no one there who knows how to use it, that's okay. Just jump in and do it, and it will walk you through the steps. Keep in mind that this person if they don't have a pulse and they're not breathing, for all intents and purposes, they are dead. So you are doing something to try and help them, so just jump in and do it, and it'll tell you what to do.

Scot: In that instance, you're not doing harm.

Dr. Troy Madsen: You are not doing harm. We always tell ourselves "Do no harm." You're not doing harm. Without your help, this person is dead, so just jump in and see what you can do, and the machine will tell you how to do it.

Scot: And then you just keep doing what the machine tells you until when?

Dr. Troy Madsen: Exactly. It'll just keep telling you until the ambulance gets there. That's the most important thing. Until they get a pulse back. It'll tell you to check for a pulse, so you can feel the best places on the neck. Feel for the carotid pulse. It's the big artery there on the neck. If you don't feel a pulse, then it'll just tell you "Keep doing chest compressions." And it'll tell you "Stop chest compressions." And it'll tell you again if it can shock, and you push the shock button. So it'll walk you through the steps very nicely.

Scot: So, to the best of your knowledge, are these machines in a lot of places? Just a few places? Is it publicly owned places?

Dr. Troy Madsen: You're going to find them in most large places where people are congregating, meaning airports, arenas, concert venues, schools, certainly hospitals. You know, all these places are usually going to have a defibrillator or an AED, an automated external defibrillator. So wherever you are, if you're in a public place, look for one if you need it, if you're in that situation . . .

Scot: Sure.

Dr. Troy Madsen: . . . or ask someone "can you go find something?"

Scot: Just be aware that there could be something that could help you.

Dr. Troy Madsen: Exactly.

Scot: Because that would be terrible after the fact to realize that that tool was there and you didn't use it.

Dr. Troy Madsen: It would be, yeah.

Scot: What if you're in a situation where you have to make the choice of doing the chest compressions or going to get the machine because there's nobody else around at that point?

Dr. Troy Madsen: That's a tough situation.

Scot: Would you run and get the machine or should you do the chest compressions?

Dr. Troy Madsen: My number one thing there would be calling 911, and if I didn't have a phone there with me, I would go to a phone and call 911 because they're going to give the most help. But I would do chest compressions. If I were in that situation, chest compressions are going to keep that person alive long enough for the ambulance to get there.

Scot: But first call 911 before you do anything.

Dr. Troy Madsen: Number one-call 911. Yep, that is the first step before you do anything because they're going to get the advanced care and get that person where they need. But you can keep that person alive, keep at least some blood going to their brain and their body by doing chest compressions.

Scot: All right. Any final words of advice on using one of these things?

Dr. Troy Madsen: Final word of advice would be, you know, if you're in this situation, think chest compressions first. Do that. Call for 911. But if you've got access to it, don't be scared of it. Just jump in and use it. It'll walk you through the steps.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on the scope. Interviewer: While antibiotics save lives, over use of antibiotics can put patients at risk for hard to control infections and deadly diarrhea. I'm here with Dr. Matthew Samore an epidemiologist who researches the best strategies for preventing the adverse effects of antibiotics. Dr. Samore, what are some of the infectious bacteria that are causing the worst problems in hospitals?
Dr. Matthew Samore: Yes, that's a very good question. Some of the worst offenders in hospital populations are these resistant bacteria. And one that, I'm sure you've heard of that has gained a lot of press is referred to as MRSA or Methicillin-resistant Staphylococcus aureus. This is a particularly difficult pathogen because it's resistant to many different antibiotics, not just Methicillin, and so the treatment option for this organism are relatively limited. There are actually even worse pathogens than MRSA. There are some gram negative rods that are literally resistant to every drug that we have that's conventionally used to treat infection. And then finally, another type of organism that fits in the same general realm of antibiotic resistance is Clostridium Difficile. And Clostridium Difficile is particularly associated with antibiotic exposure and it causes infection when the normal gut bacteria, what you may have heard of referred to as the microbiome or the microbiota. When that normal gut ecology is disrupted by antibiotics, Clostridium Difficile is then able to take hold into gut. It produces a toxin. This toxin can cause a very severe colitis and at times can be even fatal. Interviewer: You worked at the VA Hospital in Salt Lake City. Have you seen cases of infection here?
Dr. Matthew Samore: Oh, yeah, every hospital. And I'm also at the University of Utah Hospital. By many estimates, Clostridium Difficile diarrhea is the most common healthcare associated infection in U.S. hospitals. It's extraordinarily common and no hospital has succeeded in eradicating this organism. It's simply too prevalent in nature and there is probably no good way at the present to prevent its occurrence completely. Interviewer: You led a study that was incorporated into a report issued by the Center for Disease Control about proper use of antibiotics . . .
Dr. Matthew Samore: Indeed. Interviewer: . . . in combating Clostridium Difficile. Dr. Matthew Samore: Yes, that's the name. Interviewer: Hard to get that out. So what questions were you trying to address in this study?
Dr. Matthew Samore: The CDC has embarked on a series of studies to look at overuse of antibiotics, to look epidemiologically at the relationship between antibiotic use and these adverse consequences like Clostridium Difficile diarrhea. And we had a paper that was published last November in class, one that described a very sophisticated, what we would call a high fidelity model of Clostridium Difficile in hospital populations. And we use that model to examine different kinds of infection control measures to prevent spread of C. Difficile. And that paper caught the attention of CDC. They wondered whether we could apply some similar kinds of modeling techniques to address this question that was raised and their analysis of epidemiological data which was what would happen in a hospital if you reduced high-risk antibiotics. Interviewer: Well, so, you used simulations, you've used models to predict these outcomes. Dr. Matthew Samore: Right. Interviewer: What's the advantage of doing it that way rather than like you talked about before, looking at records, or even I don't know if it's ethical to do the experiment on people. Dr. Matthew Samore: Right. Well, experimentation in people is something that requires an Institutional Review Board approval. Interviewer: Sure. Dr. Matthew Samore: It's obviously a very important part of the advancement of biomedical science and it's something that is vital to ultimately achieve solutions that can actually make a difference. The problem is experiments that are done are often actually not even clear cut in their answers and you can't really examine every possible type of intervention in experiments. And the other challenge that has been particularly pervasive for antibiotic resistance is that most hospitals tackle these problems one at a time or one institution at a time, so often the interventions that are done are not controlled. They're often ambiguous in interpretation and so it actually has been very difficult to get a deep understanding about the consequences of reducing high-risk antibiotic use from just doing the study in hospitals. And one of the things that's interesting and attractive from the scientific perspective is the complexity of spread of infectious diseases and that's where these more sophisticated modeling and simulation methods come into play. Interviewer: So in your simulations, what were some of the parameters that gave you the worse rates of infection?
Dr. Matthew Samore: The effects on transmission have a big impact on disease raids and to the extent that antibiotics increased transmission there is a correspondingly greater reduction in Clostridium Difficile if you reduce antibiotics. So that's an interesting aspect to it I would say. Interviewer: So you mean if physicians administer more antibiotics, you get more infection. Dr. Matthew Samore: That's right. It's a paradoxical thing. Interviewer: Yeah. Dr. Matthew Samore: Right? Antibiotics treat infection, but when it comes to Clostridium Difficile the more antibiotics the wor- . . . The better for Clostridium Difficile, the worst for us. The basic finding was that the predicted fact of reducing high-risk antibiotics by 30% was a 26% reduction in Clostridium Difficile diarrhea. Interviewer: Based on your work and other people's work as well. Right?
Dr. Matthew Samore: Yes. Interviewer: The CDC actually came up with some guidelines for physicians and hospitals. Dr. Matthew Samore: Right. We think and the CDC thinks that achieving a 30% reduction in high-risk antibiotics is possible. Now we think that in general antibiotics should be used smartly. Rather than always choosing the broader spectrum drug, choose a narrow spectrum drug. Stop the drug if it's not needed. If the tests are negative, then stop the drug or maybe wait on empirical use of antibiotics until the tests come back. So there are a lot of ways that antibiotic use can be done more wisely. And believe me a whole other question and we can talk about this in another interview is, how do you change practice?
Interviewer: Yeah, well, I was going to ask that actually. Dr. Matthew Samore: Yeah, it's huge because these patterns get ingrained and they're not the same in the U.S. as they are in other countries. The U.S. is not the worst, but we're nowhere near the best when it comes to appropriate antibiotic use. So the reality is in U.S. hospitals, about half of all patients get antibiotics. And the frequent lament, this goes back a long time, is that antibiotics are used as antipyretics. They're used like Tylenol. Someone has a fever, let's give them an antibiotic. Again, it's because hospitalized patients are vulnerable. They're sick and you probably have heard the adage, hospitals are no place for sick people. The patients are vulnerable. Doctors go on and miss something. To some extent it's a bit of defensive medicine to treat and to sometimes over treat, but the consequences are hazard, exposing hazardous, exposing individuals or patients to these complications like Clostridium Difficile diarrhea. So what we're trying to achieve is an appropriate balance. The adage that we use, what we call antibiotic stewardship is the right drug at the right time, at the right dose, for the right patient. Interviewer: So if hospitals don't abide by these new guidelines, what are you afraid might happen?
Dr. Matthew Samore: The worse case scenario is indiscriminate use of antibiotics leads to a proliferation of antibiotic resistant organism and we just achieve much worse control of infectious disease, and we get into a situation where people are dying from infectious diseases and not being able to be effectively treated. There is not an inexhaustible supply of antibiotics. This is a resource that we share that we should preserve. People think they're safe, you just add them to your water, or just pop a few pills that I left over in my cabinet, but that is not the case. Antibiotics have potentially serious consequences, so they should be used wisely. Announcer: Interesting, informative, and all in the name of better health. This is the Scope Health Scientist Radio.