tag:blogger.com,1999:blog-76600686378081516822024-03-14T04:57:49.253-07:00Total Health EnvironmentIdeas about systemic quality improvement in health care.Abigail Barneshttp://www.blogger.com/profile/14341928100396702997noreply@blogger.comBlogger4125tag:blogger.com,1999:blog-7660068637808151682.post-16556256395572453812011-08-27T19:15:00.000-07:002011-09-12T14:28:18.251-07:00Pressure Redistribution Mattresses Save Money - Even in the ERBedsore is an old fashioned word and the idea that it’s only a problem for long term care facilities and ICUs is an old fashioned idea. A study to be released in the <a href="http://www.annemergmed.com/article/S0196-0644(11)00464-1/fulltext"><i>Annals of Emergency Medicine</i></a> highlights the fact that pressure ulcers can start even in the ER. Pham et al. found that pressure redistribution foam mattresses are a highly cost effective means of preventing pressure sores for elderly patients treated in the Emergency Department. The focus on elderly patients is germane because they are at higher risk, especially if they suffer from poor nutrition, and or, incontinence. Putting these patients on the pressure redistribution mattresses cost as little as 30 cents per patient and saved the hospital much more. The finding is surprising since patients aren’t expected to stay long in ERs. But as little as one hour on an unyielding mattress or stretcher can damage the skin of some patients. <br />
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Like most people, I hadn't spent a lot of time thinking about pressure sores. They aren't mentioned much by researchers or by the press. I've learned this week that they cause much more suffering than their under-the-radar status would suggest. For patients and their loved ones ulcers are painful. Some of that suffering, it seems to me though, comes from the general belief that pressure sores are entirely unnecessary. And the public doesn't get that idea out of the blue. The Center for Medicare and Medicaid Services considers pressure sores to be HACs (hospital acquired conditions) <a ef="http://www.nejm.org/doi/full/10.1056/NEJMp078184"> that is, entirely preventable</a> and has refused to reimburse for treating them since 2008. And "pressure" to prevent them has climbed even further since New Jersey passed a <a href="http://www.njleg.state.nj.us/2008/Bills/S2500/2471_R2.HTM">law</a> in 2009 allowing the state to release hospital specific data on fourteen medical mistakes. It includes pressure ulcers on that list. But is this really fair? Is every pressure sore avoidable? The research just doesn't support that conclusion. <br />
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Now don't get me wrong. I'm not suggesting that high rates of sores aren't a sign of poor care, obviously they are. And I'm not saying that there's not room for improvement, there is, plenty of room. The<a href="http://www.o-wm.com/files/owm/pdfs/VanGilder_Nov.pdf"> 2008-2009 International Pressure Ulcer Prevalence Survey</a> gives a good general overview of the problem. In the US they found that 5 percent of all patients in acute care facilities acquired ulcers. Long-term care, had higher rates. The National Pressure Ulcer Long-term Care Study (NPULS) reported that in 2002 an average of 9.8 percent of residents had them. But the idea that pressure sores are "never events" things that wouldn't occur without someone making a mistake, is cruel. It makes patients feel worse and puts the blame on the care institution, (essentially the nurses) when the real culprit is the illness itself. <br />
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Even the best regimen can't fully prevent sores. At least one Egyptian mummy has been found with pressure ulcers,even though one presumes the person was tended by slaves. Added to the general stress that being bed bound puts on skin is the fact that contemporary medicine requires so many patients be hooked up to lines and tubes, especially in intensive care. Ten percent of ulcers are associated with such devices. And even for patients in less intensive settings, being bed bound is associated with some risk. Tom DeFloor, Head of the Ghent University Nursing Science Unit, did a series of randomized, controlled studies looking for the optimal way to manage immobile patients and prevent pressure sores. In 2007 he compared 237 nursing home residents who were repositioned every four, three or two hours. The best outcome came when patients were turned every four hours. Moving them twice as often didn't actually improve results. (International Journal of Nursing Studies 48 (2011) 787–79).<br />
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The most striking thing about this study was that even the best routine didn't take the number of pressure sores to zero. The best they could manage was about 3 percent prevalence rate. In another randomized, controlled study Professor DeFloor found that foam pressure redistribution mattresses were just as effective at preventing sores as alternating pressure mattresses. This is excellent news because alternating pressure mattresses are much more expensive. (IBID.)<br />
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If every patient who needs it is put on a foam pressure distribution mattress the financial savings is likely to be considerable. In its <a href="http://www.healthgrades.com/media/DMS/pdf/PatientSafetyInAmericanHospitalsStudy2010.pdf">2010 Patient Safety in American Hospitals Study</a> Healthgrades estimated that pressure ulcers alone added 2.6 billion in added costs between 2006 and 2008. The British National Health Service estimated that a single severe sore can take three months to heal and <a href="http://www.sciencedirect.com/science?_ob=ArticleListURL&_method=list&_ArticleListID=1804533575&_sort=r&_st=13&view=c&_acct=C000228598&_version=1&_urlVersion=0&_userid=10&md5=2493479cfcc19431bcb20b5a1a7abd96&searchtype=a">cost 40,000 pounds (64,859 dollars)</a>. The mattresses that patients lie on are the most direct experience of the therapeutic environment that they have. Luckily they are a simple and relatively inexpensive element to change for the better.<br />
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Web Links<br />
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The National Pressure Ulcer Advisory Panel has a<a href="http://www.npuap.org/PDF/preventionpoints.pdf"> prevention tip sheet</a>.<br />
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Hospital Compare, the US Department of Health & Human Services site has a <a href="http://www.cms.gov/HospitalQualityInits/06_HACPost.asp">database of hospital acquired condition (HAC) rates </a>that it lists by hospital. <br />
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HealthGrades, Inc. <a href="http://www.healthgrades.com/?ck=1">The Seventh Annual HealthGrades Patient Safety in American Hospitals Study</a>.Abigail Barneshttp://www.blogger.com/profile/14341928100396702997noreply@blogger.com14tag:blogger.com,1999:blog-7660068637808151682.post-33687690682348751512011-08-16T18:45:00.000-07:002011-08-20T13:05:53.826-07:00Microbiomes: Each of Us is an Ecological System<i>In the future we'll manage our microbiomes that way organic farmers grow crops, helping good species to flourish while making life harder for the undesirable ones.</i><br />
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Kellyn Betts has an article in <i>Environmental Health Perspectives</i> this month about something that hasn't recieved a lot attention in the health policy and health delivery sectors yet, but certainly will do soon. It's the microbiome. Her article<a href="http://ehp03.niehs.nih.gov/article/fetchArticle.action;jsessionid=81F4F564E83513266467CA972F2BEACA?articleURI=info%3Adoi%2F10.1289%2Fehp.119-a340"> A Study in Balance: How Microbiomes Are Changing the Shape of Environmental Health</a> shows why this is an emerging field of research that has so many people excited. <br />
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For those not familiar with the term, microbiomes are the tiny ecosystems of microbes and other little critters that live on and in each of us. There are an estimated 100 trillion microbes now going about their business in four major biomes: the mouth and gastrointestinal tracts, the respiratory system, the urogenital systems and the skin. Microbes are so important to our ability to function that microbiologists are proposing to call us all "superorganisms," that is, symbiants of us and our bacteria. There has been so much interest in the microbiome that the <a href="http://www.nih.gov/">National Institute of Health</a> has set up the <a href="http://commonfund.nih.gov/hmp/">Human Microbiome Project</a> to study them. We all learned in high school that microorganisms break down complex carbohydrates and help us to digest our Cheerios, but systems biologists are just now starting to unwind the much more complex ways that these organisms keep us going. Early<a href="http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=Search&doptcmdl=Citation&defaultField=Title%20Word&term=Liebert%5Bauthor%5D%20AND%20Phylogeny%20of%20mercury%20resistance%20%28mer%29%20operons%20of%20Gram-negative%20bacteria%20isolated%20from%20the%20fecal%20flora%20of%20primates.%20AND%20Appl%20Environ%20Microbiol%5BJournal%5D%20AND%201997%5BPublication%20Date%5D%20AND%201066%5BPagination%5D"> results</a> indicate that bacteria affect the way some toxins are introduced into our systems. Other <a href="http://www.hmpdacc.org/impacts_health/impact_health.php">studies</a> now in the pipeline are looking at how disturbances in our intestinal biomes may be implicated in diseases such as acne, Crohn's disease, and obesity.<br />
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So how will an understanding of microbiomes change the way medical care is delivered? Well, they say guessing about the future is hazardous but the most immediate implication is that it we will change the way we think about antibiotics. Killing the harmful bacteria will only be half the battle. To get patients back to full health we will need to restore their microbiomes to functioning order. In the future we'll manage our microbiomes that way organic farmers grow crops, helping good species to flourish while making life harder for the undesirable ones. To understand why, it is helpful to bring in some insights from the macro-environmental sciences.<br />
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<u><a href="http://www.scribd.com/doc/10938576/Connell-1978-Diversity-in-Tropical-Rain-Forests-and-Coral-Reefs">Disturbance theory</a></u> was developed to describe how large-scale environmental systems like forests and coral reefs respond to events such as fires or hurricanes. A healthy ecosystem with plenty of diversity among its species will regenerate after a disturbance and all will be well. The problems start when disturbances get compounded, dynamite fishing on the reef in addition to a hurricane, for instance. The natural process of renewal becomes degraded and the system becomes vulnerable to invasive species. Invasive species are opportunists that can thrive on undefended real estate. If we are lucky the invaders will be fairly benign but sometimes they are not. Ciguatera poisoning is caused by one such opportunist, <i>Gambiadiscus toxicus. </i>Like a number of algae species it has the ability to produce a potent neurotoxin. Disturbed coral reefs provide <i>G. toxicus</i> with havens in which to multiply and be eaten by the local fish. When humans fish the contaminated reefs they too consume the toxin. For the unlucky diner Ciguatera poisoning can result in nerve damage and even death.<br />
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Knowledge of how such large-scale ecological systems work can only aid us to better manage our internal ecosystems, but it requires a new way of thinking in medicine. Researchers are already beginning to think about us as environments on legs. That mental shift, seeing ourselves not as discrete units but as beings in constant interaction with our surroundings will continue to be the focus of Total Health Environment. Abigail Barneshttp://www.blogger.com/profile/14341928100396702997noreply@blogger.com1tag:blogger.com,1999:blog-7660068637808151682.post-24736776336734485092011-08-08T09:39:00.000-07:002012-12-12T11:20:38.275-08:00Some Philosophical MusingsIn this post I thought I’d take a detour from the usual practical focus of this blog and discuss some of the deep background thinking that social scientists draw on when they study the built environment. The idea that health care delivery takes place within the built environment is the starting place for this blog's project, which is to bring insights from research in the social sciences to health improvement. Why the social sciences? Because fields like architecture, geography, history and anthropology have been studying the way we interact with our environment for at least a century now. And the same tools they've developed for looking at the macro-environment (cities, regions, and nations) can also be used to study the micro-environment (hospitals, clinics, and offices).<br />
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It is an obvious truth that just as we affect our environment, it also affects us. Yet, for much of the western intellectual tradition we have preferred to focus on our power to change the world, less on what it is doing to us. As far back as to Plato’s musings on the “just city,” the focus has been on the best way to <i>do</i> things. In <i>The Republic</i>, Plato wrote about creating an environment with good laws and law-abiding citizens. He didn’t dwell much on the physical aspects of the city. He hardly touched on the fact that city life changes its inhabitants. So even going as far back as the Socratic tradition we have been fascinated with what we can to our surroundings, less interested in what they do to us. <br />
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I picked up a slim little book I’ve had since grad school the other day, Manfredo Tafuri’s <a href="http://books.google.com/books/about/Architecture_and_utopia.html?id=pOp6J7f3i64C">Architecture and Utopia</a>, and it got me thinking about this topic. While Tafuri was trying to explain his theories of modern architecture I was struck by something else. Since the Renaissance there have been great treatises on how to arrange and design cities, but cities’ component parts, the buildings, roads, squares and gardens were thought of as a backdrop, a stage, as we all remember Shakespeare saying . And as you thumb through the pages and get to Enlightenment thinkers like Thomas Jefferson, you see them carrying on the same way of thinking. Jefferson believed that the Palladian-inspired architecture of Monticello (begun in 1769) promoted democratic values. But the buildings did their job by being symbols of democracy, not by exerting any direct effect on the Virginians who might pass by. Even when you come to a modernist like Baudelaire who recognized “the shock of the city,” and who wrote about nineteenth-century Europeans’ angst at being thrust into the fast-paced world of the machine-aged metropolis, he tended to focus on the way it stimulated inhabitants to action rather than the way they themselves physically changed.<br />
If you are thinking now that there is one area that I am skipping over here you are right. There is one obvious sense in which people have been very concerned about the way the city affects us and that is in the realm of health or disease.Abigail Barneshttp://www.blogger.com/profile/14341928100396702997noreply@blogger.com0tag:blogger.com,1999:blog-7660068637808151682.post-599528066506164702011-08-08T08:49:00.000-07:002011-08-29T11:24:23.750-07:00Psychosocial and Physical Environment Interactions<div class="MsoNormal">The Total Health Environment</div><div class="MsoNormal"><br />
</div><div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -.25in;"><span style="font-family: Symbol;">·<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span></span>Making the health care settings safer for patients.</div><div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;"><span style="font-family: Symbol;">·<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span></span>Decreasing workplace stress for healthcare providers</div><div class="MsoListParagraphCxSpLast" style="mso-list: l0 level1 lfo1; text-indent: -.25in;"><span style="font-family: Symbol;">·<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> <span class="Apple-style-span" style="font-size: small;"> Improving </span></span></span> health care delivery </div><div class="MsoNormal"><br />
</div><div class="MsoNormal">An article in the most recent issue of the <a href="http://sjp.sagepub.com/content/39/7_suppl/147.full.pdf+html">Scandinavian Journal of Public Health,</a> [ 2011; 39(Suppl 7): 147–152.] highlighted the fact that the physical and psychosocial elements of the work environment both contribute to employees taking long-term leave due to disability and injury. My reading of this study is that although it is set in Denmark and doesn’t look at health care settings specifically, it has useful information that can be applied to health care settings. The things that injured workers and made them sick were made worse by management styles that made them uncomfortable. Conversely, workers coped better with difficult physical challenges when they felt better about the emotional surroundings they were in. </div><div class="MsoNormal"><br />
</div><div class="MsoNormal">The obvious point here is that if changing health care environments is to become part of the way we improve health care delivery, then we have to consider both the physical environment and the psychosocial environment. This study provides some evidence that they are elements in interaction with each other.</div><div class="MsoNormal"><br />
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</div><div class="MsoNormal"><a href="http://blogs.cdc.gov/safehealthcare/">http://blogs.cdc.gov/safehealthcare/</a></div>Abigail Barneshttp://www.blogger.com/profile/14341928100396702997noreply@blogger.com0