CT Center for Patient Safety
CT Center for Patient Safety Newsletter

April 2017
In This Issue
New Guideline Will Allow First-Year Doctors 
to Work 24-Hour Shifts

The Accreditation Council for Graduate Medical Education has put into place new regulations
effective July 1st allowing first year residents to work up to 24 hours in a shift.  Picture this:  You enter a hospital this coming July 3rd.  Not only is it the day before a holiday, but your doctor may be a resident who has just completed medical school and has just worked for the preceding 22 hours.  How safe do you feel?

Until this change, the shift limit was 16 hours with no more than 80 hours per week, and even at that, patients were often concerned that fatigue might be playing into their quality of care.  Prior studies have not supported this theory.  This new standard was put into place because the Council felt that it would enhance patient safety by creating fewer handoffs.  They also felt that it would "improve the new doctors' training by allowing them to follow their patients for more extended periods, especially in the critical hours after admission."  More details can be found in the complete article in the New York Times.
March was National Nutrition Month - better late than never!
Here's how it works: Try one tip each day, starting today. (You can change the order, but be sure you try each one.) Then, repeat.

1.  Cut portions.
If you think leaving just a little something on your plate won't matter, think again. It will. Small amounts of uneaten food add up to calories that stay on the plate - not on you.
2. Sip while you sit. 
Bring a cup or bottle of water with you whenever you sit (at your desk, in the car or in front of the TV, for example). Although moving is better than sitting, at least you'll be performing a healthy habit when at rest.
3. Make a move. 
Take the stairs, park a few blocks away or otherwise become inefficient and take extra steps to get where you need to go.
4. Have a vegetable at breakfast. 
Most people save their veggies for dinner, but it's healthful to think outside the cereal bowl and veg out at breakfast. For example, add a sliced tomato to your cheese sandwich or some mushrooms to your eggs.
5. Find fiber. 
Whether it's a bran cereal, nuts, oatmeal or an array of other fiber-filled foods, added fiber can make you feel fuller longer and provide a, well, moving experience.
6. Flip the package over. 
Read nutrition labels to see what's really in your food. Don't be fooled by a flashy front-of-package claim.
7. Don't fear fat - but don't go overboard.
Fat has more calories than other nutrients, but it has multiple benefits. If you watch your portions, you can enjoy its decadence.
8. Don't have guilt as a side dish.
If you overindulge at a meal, move on.
9. Be mindful. 
Unless you're driving, close your eyes when you eat. Notice the food's texture, temperature and flavor.
10. Pick plants
Protein derived from plant sources such as seeds, nuts, tofu and tempeh, as well as from grains, can help lower cholesterol, improve your heart health and add a satiating blend of flavors to extend Meatless Monday to the rest of the week.
11. Tap into your dark side.
Dark chocolate has been shown to have heart-healthy benefits and it can certainly boost your mood. Be mindful of portions, though, to help keep yourself feeling happy.
12. Eat something fishy. 
Enjoy fish as a dish at least three times a week. It's heart-healthy, low in fat and contains beneficial omega-3 fatty acids.
13. Take time for tea. 
Tea contains polyphenols, it's good for your bones and it provides a soothing cup of comfort in any season.
Don't think of this interaction as cooking lessons. Rather, realize that teaching your kids to put together a meal is a lesson they can use for the rest of their lives. 
Replace salt with lemon, herbs and spices.
16. Eat when you eat. 
Try not to do simultaneous activities such as typing, watching TV or driving when you eat. You'll appreciate each bite even more.
The more hours you're awake, the more time you have to nosh. Lack of zzz's can also mess with your hormone levels.
18. Be good to your gut. 
Include Greek yogurt, sauerkraut, kefir or foods high in fiber in your diet.
19. Make healthy swaps. 
For instance, try mashed avocado instead of butter or use whole-wheat pastry flour in place of white, refined types.
20. Go nuts.  
Nuts add crunch and decadent flavor to salads, veggie dishes, yogurt and even sandwiches via nut butters. Nuts can help reduce cholesterol levels and stabilize blood glucose levels.
21. Indulge without bulge. 
Comfort foods in the right amounts and at the right times will provide what you're looking for - comfort. Excessive amounts could lead to discomfort and unnecessary weight gain. Avoid portion distortion.
22. Chill out. 
Frozen foods, particularly fruits and veggies, can be just as nutritious as fresh produce and, in some cases, they may be even better.
23. Have a superfood
Most superfoods can be found in the produce aisle - they're not fancy and they don't even wear food labels. Add a fruit or veggie to each meal.
24. Share a meal. 
Try ordering your own appetizer but split the main dish with a friend.
25. Get big on beans. 
Beans are the most undervalued food in the supermarket. They are inexpensive, easy to store, rich in protein and fiber, and taste so good. Add some to your soup tonight.
26. Do something. 
Don't call it exercise - call it fun. Dance, ride a bike, take the dog for a long walk or just climb the steps in your home or apartment.
27. Cook someone a meal. 
There's no better way to show you care than to make the effort to cook for somebody you care about.
28. Keep a food diary. 
Most people don't realize how much they really consume in a day. If you write it down, the amount you eat may surprise you.
Be sure your snack consists of protein, whole grains and healthy fat for the trifecta that will keep you feeling fuller longer.
30. Be kind to yourself. 
If you're not having a great day, don't "reward" yourself with food - the wrong foods in the wrong amounts may become punishments instead of rewards. Take a bath, write a letter, surround yourself with true friends or buy yourself something that will make you smile. You deserve to have a wonderful month - and a fabulous rest of the year.

From US News & World Report  http://bit.ly/1OQZt9j

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Dear Members, 
Spring is here??  As we look ahead towards warmer weather with flowers blooming, leaves on trees and pollen in the air, I want to remind you that it is important to treat allergies, colds and bacterial sinus infections appropriately.  We continue to work with and to promote Choosing Wisely's, Antibiotics: When You Need Them & When You Don't in an effort to reduce the overuse of antibiotics and the consequential rampant antibiotic resistance that we are seeing.  If you are sick, we encourage you to seek advice from your  doctor.
  1. Don't push for antibiotics with your doctor. If you don't have a bacterial infection, ask how to relieve symptoms.
  2. Fight it off. ...
  3. Get recommended vaccines and flu shots. ...
  4. Take antibiotics only as prescribed. ...
  5. Don't use leftover antibiotics to treat an infection.
On another subject, I want to share that the concept of Person-Centered Care is alive, thriving and growing.  I just returned from a PCORI (Patient-Centered Outcomes Research Institute) meeting. Their mission is "promoting high integrity, evidence-based information that comes from research guided by patients, caregivers and the broader health care community."  Our conversations included the involvement of patients at all points in their research projects, input on additional ways to use various research results that are meaningful to patients, and on more ways to disseminate the research results so that larger numbers of patients will be aware of them.

Another notable event was the publication of a discussion paper by the National Academy of Medicine's (NAM's) Leadership Consortium for a Value & Science-Driven Health System.  They convened a Scientific Advisory Panel (SAP) to compile and disseminate important insights on culture change strategies.  The product of this Panel's work is titled, "Harnessing Evidence and Experience to Change Culture: A Guiding Framework for Patient and Family Engaged Care."  In this guide are evidence-based strategies to facilitate patient and family engaged care (PFEC).  The evidence is drawn from both  scientific evidence and lived experiences and is put together in the paper to provide a basis for infusing a culture of person Centered Care into our healthcare systems.
Lisa Freeman
Executive Director
Volunteers wanted for a Research Study

Researchers at the University of Connecticut are looking for volunteers to participate in a  focus group exploring community opinions on services offered in community pharmacies.   For more details and to view the Flyer, click here.
The Puzzling Popularity of Back Surgery in Certain Regions
Did you know that depending on where someone lives may be somewhat predictive of whether or not they will have back surgery to relieve back pain, even if the evidence does not support the benefit of the surgery?  It seems that, much like many things, once people think that there is a solution to a problem, even when it is shown not to be as effective as alternatives, it is hard to retract behaviors.  

In the early 1990's back surgery was done infrequently.  Its frequency, as a treatment for back pain, rose in certain parts of the country, yet a 2006 study showed that after one year, there was almost no difference between subjects who had surgery and those who didn't. Increase in surgeries in hospitals flattened, but growth continued in outpatient facilities and the relative regional variations didn't really change.

An article in the New York Times goes into this phenomenon as it discusses the regionalization of different types of healthcare surgeries with a focus on back surgeries.  Interestingly, the authors referred to a study on cardiac treatments to better understand the variation in regional popularity of back surgeries.  Summarizing their theories, they found that, " regional variation in Medicare spending is associated with variation in physician preferences for intensity of cardiac treatments, and to a greater degree when the evidence is ambiguous.
 Patient preferences exerted almost no influence. It's likely that the pattern holds for back surgery, too, though it has not been studied in the United States."  

They further stated how they were able to eliminate a few explanations that might have seemed logical. So it appears that the option of certain surgeries may not be how evidence supports the results that will be obtained, but in some cases, simply what the surgeon prefers to do. 

A major take-away here is: consumer beware.  Do your homework and verify the evidence-based research available regarding the surgical procedure that you are considering.   Read the article here for more information.
Those Indecipherable  Medical Bills

The New York Times recently published an article following a woman named Wanda Wickizer.  She was a 51-year-old, who suddenly found herself vomiting and racked with debilitating headaches. After a delay in treatment due to a missed diagnosis, it was found that she was suffering from a subarachnoid hemorrhage which can lead to death.  At that point, the patient was taken by helicopter to a larger hospital for the needed medical care.  Three weeks later, having  survived the hemorrhage, she was able to go home.  Her husband was deceased and due to various circumstances, she did not have medical insurance.

Shortly after returning home, she received a $16,000 bill from the local hospital, $50,000 from the air ambulance, $24,000 from the larger hospital's Physicians' Group followed by another bill from them for $54,000.  Finally, she received a $356,884.42 bill from the large academic hospital. Instead of focusing on recovering, she was dealing with this stress at the same time.

What came through in the article is how complex our medical billing has become. It also has a very interesting history.  It was first established i n the 1890s when Jacques Bertillon, a physician and statistician created a system of codes to classify causes of death,  the Bertillon Classification of Causes of Death.  It was adopted in many countries and over time was expanded to include diseases also.  In the 1940's the World Health Organization created the  International Statistical Classification of Diseases, Injuries and Causes of Death (ICD) with the current version being the ICD-10-CM.  Today, there are many different coding systems in use and coding has become a highly specialized profession.  The difference of using one code rather than another, as long as it is supported by the medical record, can mean a significant difference in the reimbursement amount.

Wanda Wickizer wanted to show good faith and expected that the bills would be significantly reduced, but she was only asked to pay them.  So, she asked for an explanation of the charges - as any consumer would do.  After a month, she finally received a list of charges that was difficult to understand and seemed incomplete.  She also got a one-page bill for the hospital portion of her care, broken down only into broad categories.  She was offered a 20% uninsured discount on the big hospital bill leaving a balance owed of $285,507.58.

When she tried to learn what codes the hospital used to calculate her bill, so that she would be able to compare what others pay for the same services and put herself in a better negotiating position, she was unable to.  According to the article, " Hospitals tend to treat their billing strategies - codes and their master price list, called a charge master - as trade secrets vital to their business. State laws and judges tend to respect that as proprietary information."  

Ultimately, the hospital sued Wickizer.  She responded by approaching the media and her journey is further described in the New York Times article.  

Billing, coding, dunning, and collections are a complicated part of healthcare.  From this article, it can be surmised  that if these billing practices were more transparent and if hospitals had to account to their patients and the public about what they are being charged for and how much health care actually costs the "hidden costs" in health care would be addressed and the overall costs of health care might come down significantly.
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If you are interested in a patient safety topic and would like to write about it, please send an email with a brief description of what you would like to write about to:  Lisa.Freeman@CTCPS.org