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Wednesday, October 08, 2003• Potentially deadly infections of the bloodstream that can crop up after surgery, the No. 1 problem the researchers found. The team found that people who got such infections had a 22% higher risk of dying. Survivors had to stay an extra 11 days and had a hospital bill that was $58,000 higher than people who didn't get an infection. • Reopening of a wound after surgery, often because of an infection. That injury means patients often spend 10 extra days in the hospital and have hospital charges that are $40,000 higher. • Leaving a medical instrument or sponge in a patient's body, a mistake that rarely kills but often leads to two extra hospital days and $13,000 in additional charges. Other “medical injuries” the paper documents are accidental puncture or laceration, birth trauma, complications of anesthesia, bed sores, collapsed lungs caused by a medical procedure, trauma to a mother after delivering a baby (lacerations caused by passing a baby, etc.), hemorrhage after surgery, falls that result in broken hips after surgery, metabolic derangements after surgery, transfusion reactions, and “selected infection due to medical care,” whatever that is. With the exception of foreign bodies left behind after surgery and accidental punctures, these “injuries” aren’t so much a matter of neglect as they are known risks of the procedures involved. Any time the skin is incised or broken, you’re at risk for infection. Surgeons try to minimize the risk by using antiseptic preps and sterile techniques, but they aren’t gods. They can’t elminate every microbe in the vicinity of the wound before, during, and after the procedure. Sometimes, despite their best efforts, a wound gets infected. Babies enter this world through a narrow anatomical passage. They stretch the skin that makes up that passage in the process and sometimes they tear it badly. Obstetricians try to minimize the damage by making controlled tears instead. They’re called episiotomies. But sometimes, they have to use forceps or vacuum extractors to help a baby out, and sometimes that results in more damage to the mother. And sometimes it causes an injury to the baby. But given the choice between a torn labia or vagina and a dead baby, most people would chose the torn tissue. Everyone in medicine knows that there’s no such thing as a risk-free procedure, and yet organized medicine does little to counter the exaggerated claims of papers like this. This particular paper passed peer review and editorial review to get published in the AMA’s own journal, thereby guaranteeing it national media play. And even then, the editors can’t bring themselves to point out the obvious - that these aren’t errors or injuries, but the risks of modern medicine. That’s not to say that we shouldn’t minimize risk as much as possible. We should. But this sort of data doesn’t tell us how many of these complications were due to dirty hands or clumsy obstetricians and how many were simply unavoidable. The data comes entirely from discharge diagnoses with no assessment of the nuances behind those diagnoses. So one post-op wound infection is the same as another in the eyes of the paper. To their credit, the editors of JAMA point this out. (Unfortunately it’s only available online for a hefty fee.) They cite studies that have looked at the reliability of discharge diagnoses in determining quality of care: The results of the CSP (Complications Screening Program) validation study...suggest that administrative data-based algorithms provide questionable insight into substandard hospital care. Briefly, the study failed to find objective clinical evidence in the medical record to support hospital-assigned discharge diagnosis codes used to identify complications for 19% of surgical and 30% of medical admissions. Discharge diagnoses used by the CSP to flag complications represented conditions that were present on admission for 13% of surgical and 58% of medical cases (ie, these conditions had not occurred during the hospitalization...). Although physician reviewers confirmed the presence of CSP-flagged complications among 68% of surgical and 27% of medical patients, they found quality problems in only 30% of surgical and 16% of medical cases. ...Indeed, an expert panel found it extraordinarily difficult to construct review instruments to identify specific process-of-care problems (ie actions by clinicians) that might contribute to the occurrence of many complications. Unfortunately, it’s a very dry and uninteresting defense, so it hasn’t gotten the media’s attention. That’s unfortunate, because these things matter. Thanks to the media coverage that papers like this get, the average layperson - and that includes trial lawyers and juries - become ingrained with the idea that any complication from a medical procedure is a result of negligence. It sets an expectation for perfection that just isn’t attainable in the real world. posted by Sydney on 10/08/2003 08:35:00 AM 0 comments 0 Comments: |
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