A cardiologist wrote to me about my post concerning the nurses fired for administering drugs without physician approval. The response suggests that there should have been standing orders, which sounds logical to me:

In regards to intubated patients, 1) almost all ventilated patients have standing orders for either Diprivan, Versed, or Ativan; 2) these sedating medications are held prior to extubating patients; 3) in my experience, (for what it’s worth), patients who extubate themselves usually stay off the vent, either because they were ready to be extubated, or because they would rather die than be re-intubated. I don’t know why those nurses were disciplined. If they willfully ignored the MD’s order, they should be fired (unless the MD was grossly incompetent). If said MD did not given standing orders for Diprivan, etc, s/he deserves to be paged throughout the night.  . . . One other possibility:  the physicians were so incompetent, the nurses took it upon themselves to initiate sedation orders. But again, if standing orders were present, this would not be a violation..

I am deeply puzzled by this one.  Apparently patients on respirators sometimes try to pull their tubes out of their throats in a panic, and administering such patients Diprivan immediately calms them and potentially saves their lives. A hospital in Louisville, Kentucky has  fired 14 nurses for giving the sedative to patients on respirators without a doctor’s order.  Now I am not an expert on clinical procedures so take everything I say as opinions held very gently, but…..

a) Wouldn’t there or shouldn’t there typically be a standing order from the doctor as to what a nurse should do if a patient starts trying to pull their respirator out?
b) If (at least) 14 nurses were routinely doing this, it is definitely a system problem.  Should not the hospital have been educating the nurses about the rules before they fired them, as they apparently are doing now for those not fired? Has anyone in the hospital management been fired for allowing so much to go wrong on their watch?
c) Is it realistic for nurses to know these rules? On Saturday I watched a baseball play-off game where a hitter being paid over $4 million a year failed to score the winning run because he mis-interpreted a rule.  Yet he’s in the game I’m watching as I type this on Monday night!
d) A nurses’ association is trying to unionize this hospital.  Were those nurses fired purely for the sedative offence or were they involved in union activities?
e) Who creates the Kentucky Board of Nursing standards? Am I suspicious, or might a core of doctors be involved here. Don’t forget that several states restrict midwives from delivering babies, and even prosecute them, when in most other countries they are a core part of the labor and delivery system*, and there is very credible evidence that using midwives for routine births is safer than using OBGYNs.  Those rules came from the political power of organized medicine. Is something similar going on here regarding the ability of nurses to encroach on anesthetists turf?

I don’t know the answers to this issue.  But this mass firing looks like a symptom of a wider disease at this and probably other hospitals.  If you have comments, please email me and I’ll follow up later.

*For example, while the United States has 35,000 obstetricians and about 5,000 midwives, Great Britain has 32,000 midwives and fewer than 1,000 consultant obstetricians.

While the managed care industry generally has more or less given up the concept of trying to manage the way physicians practice, it’s not quite so in California. The CCHRI, a mostly payer/provider funded group, albeit with representation from organized medicine, reported late last week that both clinical performance indicators and member satisfaction are getting better.

How come the connection between managed care and quality is still alive in California, after a combination of physician and consumer outrage beat managed care to death with a stick in the rest of the USA? Well, like everything else it’s mostly an accident of history.  California has big medical groups.  They tend to have the management structures in place that allow them (even if they haven’t always) to both measure their physicians’ clinical performance and work to actively change their behavior.  Outside the left coast physicians still tend to practice in smaller groups and the groups that do exist tend to be smaller, looser or affiliated with a clinical teaching practice (and therefore be unmanageable!).

So how did California get that way?  Well, by dint of historical accident, it had the Kaiser Permanente organization. Because of the inherent price advantage Kaiser’s pre-paid (or capitated) plan had over the traditional insurance companies, in the late 1970s and early 1980s Blue Cross went actively looking for physician organizations that looked something like the Permanente Group on which to base their incipient HMO, the forerunner of HealthNet.  They found several groups mostly in southern California.  Of course they were historical accidents too.  One, Friendly Hills, was a group of family docs who’d covered for each other on call and gradually developed closer business links.  Another, Mullikin, was (I was once told) a haven for gay doctors who couldn’t find other places to practice. By the mid-1990s these groups and their ability to deliver high quality population-based care in a heavily internally-managed environment was well known in the industry. I spent many a session frightening East Coast hospital management teams with the specter of what would happen to their  occupancy rates if those crazy Californians brought their "bed-days per thousand" rates to their town. It even got the attention of the east coast medical intelligensia. Unfortunately both the greed aggressive business tactics of the health plans and the greed incompetence of the Medpartners organization which bought the vast majority of these groups had driven them into chaos and bankruptcy by the late 1990s.

It appears that the medical groups are recovering from that era of chaos and are now getting back onto the "good" managed care track.  With employers paying more and health plans not being under the financial gun they were in the mid-1990s, the CCHRI report shows that there’s potential within California for real improvement in those population clinical improvement measures that we were all talking about 10 years ago.

Researchers in John Wennberg’s shop at Dartmouth have come out with another stunning analysis of practice variation published in the new England Journal of Medicine (NEJM). This time it’s not region that makes a difference, but race of the patient. Essentially the article says that you are much less likely to receive a common type of knee surgery if you are black or hispanic than if you are white.

We’ve know for a long time that outcomes and health status are impacted by race and socio-economic status (SES).  For instance black males in Harlem have much lower life expectancy than average.  Similarly, despite the 50 years of Universal Health Insurance and care from the National Health Service in the UK, SES or "class" level there has a marked impact on health status and outcomes. In fact variation in employment status within the same SES, also has a large impact (and not surprisingly it’s better to be at the top than the bottom), as shown in the classic British Whitehall Study. And of course we also know that access to care for those without insurance is worse in the US than for those with insurance.

However, I believe that this is the first example in the US showing that access to a specific type of care for those in the same insurance category is very different.  I don’t know why black seniors in the US have knee surgery at half the rate of white seniors.  I suspect both patient demand, and physician culture have something to do with it.  I also don’t know which rate of knee surgery is better.–especially as last year the NEJM published a study that said that in the case of osteoarthritis, knee arthoscopy was no better than placebo. But it is clear that race and presumably other social factors influence the treatment that is given to patients with similar conditions for no good reason.

(Alerted to this by California Healthline)