Tuesday, March 25, 2014

LA doctors practice speeding up trauma care

WEST HOLLYWOOD, Calif. (AP) - Before the car-wreck victim reached the emergency room, doctors, residents and nurses at Cedars-Sinai Medical Center knew what to expect by glancing at their smartphones.
The details came in the staccato of text messages: A 35-year-old man had driven head-on into a bus. He suffered major chest injuries. His vital signs were crashing.
This was not just another day in the hospital. It was a laboratory billed as the "OR of the future," an ongoing experiment aimed at breaking down barriers that bog down care through open communication, better use of technology and teamwork.
In reality, trauma care is rarely this organized. But those who are prized for individual skills are increasingly learning that when it comes to treating trauma patients from accidents, natural disasters or terrorist bombings, communication and coordination can determine whether someone lives or dies.
At an office building less than a mile from the main Cedars-Sinai campus, doctors are guinea pigs in simulations designed to test such skills.
There's a "mission control" room filled with video screens where trainers keep track of the action. The walls are see-through. Open workspaces are favored over cubicles.
At the heart of the lab is a room that could be outfitted as the ER, operating room or intensive care unit - depending on the practice of the day. Medical simulation labs have evolved over the years, from simple lifelike models of body parts that doctors train on to full-blown replications of hospital rooms where trainees can practice different situations. The Cedars-Sinai space strives to speed up trauma care by eliminating workflow disruptions and honing communication skills.
"Health care today is delivered more by teams rather than by individuals. We have to educate folks in teamwork skills," said William McGaghie, who heads a professional training institute at Loyola University Chicago Health Sciences Division.
Registered nurse Anna Doyle is used to working with doctors who parachute into the latest crisis, whether it's tending to the victim of a gunshot wound or rollover accident. It's often a chaotic scene, and not everyone takes the time to get to know one another.
During a recent rehearsal, a resident piped up and asked for everyone's names. For a second, it felt like the first day of school as introductions were made.
Doyle said she found the introductions calming - even if it was just practice.
"We had a personal moment ... that never happens," said Doyle, acknowledging that there's always a line of walking wounded in an emergency.
Armed with a $4 million grant from the Defense Department, doctors and nurses at Cedars-Sinai have been testing ways to improve trauma care by running simulations at the newly opened lab that oozes tech startup.
"This is a place for experimentation," surgeon-in-chief Dr. Bruce Gewertz said.
Before the lab opened, Gewertz and his colleagues followed real trauma patients from the moment they were unloaded from the ambulance to their transfer to the ICU. Along the way, the team documented obstacles that slowed down care: Too many people spoke at the same time, prompting a nurse to ask a resident to speak up. A patient went for a CT scan only to find another patient already in the scanner. A resident's cellphone rang while scrubbing in.
Most of the time, researchers found, delays in care were caused by a lack of communication and logistical hurdles.
The goal is to get everyone on the same page during the "golden hour," a concept borrowed from military medicine when time is of the essence.
The team recently partnered with a consulting firm to develop an in-house iPhone app that displays a patient's vitals and blasts out the information to the trauma team as members are assembling. There's also a text-messaging feature that allows doctors and nurses swarming in from various parts of the hospital to communicate with one another before the patient arrives.
It's too early to determine how much it would cost if the app was part of routine care, but Gewertz said it'll be relatively inexpensive, involving the cost of the phones and a monthly license fee for protected data storage.
On a recent weekday, the team's cellphones buzzed with the condition of the first "patient" of the day, the bus-crash victim.
Typically, doctors don't know vitals until a nurse scrawls them on a whiteboard.
Apps can be helpful, allowing medical teams to "know the information en route so they're not coming in cold," said Pam Jeffries, president of the Society for Simulation in Healthcare and a professor at the Johns Hopkins University School of Nursing. Jeffries is not involved in the Cedars-Sinai effort.
The patient - a high-tech dummy - was wheeled in, moaning and complaining. Doctors and nurses sprang into action, ripping off the dummy's clothes and placing a breathing tube before transferring him.
Despite the quick response, there were hiccups, mainly because of a lack of experience. Residents had trouble inserting the tube, and it took several tries to get it right.
For the second scenario, the team was not given advance information about the patient and kept going in circles asking for any details. A doctor said he heard it was a case of a pedestrian hit by a car.
"Do we know if it's male or female?" another asked.
"I don't know much more than auto versus" pedestrian, the doctor said.
The chief resident said there's worry about internal injuries and to make sure blood supply and other essentials were ready.
As if that weren't enough, they also had to deal with a fire - simulated smoke from dry ice was pumped into the room. One called out for the fire alarm to be shut off while the rest prepared to move the patient to a gurney.
In the chaos, doctors didn't realize the wheel on the gurney was locked and wasted time fiddling.
Despite the hiccups, the patients survived in both cases.

Medical advice without visit to a doctor

E-visit a doctor
E-visit a doctor: A new service allows patients to send an electronic message to Sanford Clinic, hear back from a doctor and have a prescription sent to a pharmacy. Reporter Jon Walker interviews a Sanford official and a patient 
A visit to the doctor now comes without the visit.
Sanford Health has begun offering an electronic option in clinical care. A patient with a health problem can sit at a computer, type a summary of symptoms, attach a credit card number and hit the send key. A response from a Sanford provider with a prescription or medical advice comes back in four hours or less. It costs the patient $55.
The format depends on a patient’s skills in self-diagnosis and the medical system’s ability to respond without any conversation or face-to-face interaction, but it’s mostly a bow to consumer convenience in the computer age.
“It’s so a patient can receive information they can trust as opposed to just Googling,” said Louise Papka, a physician assistant in acute care for Sanford.
Michele Kleinwolterink, 44, said it helped her. She could feel a sinus headache developing two weeks ago as she drove to her job as executive assistant at Bluestem, a private equity company in downtown Sioux Falls.
“I knew I needed to go to the doctor but it was a busy day,” she said. “Sinus headaches don’t just go away. You need meds as soon as possible.”
From her desk, she logged on to her account at My Sanford Chart, the health system’s online records platform. A prompt directed her to an e-visit page, where she answered questions and described her condition in a box allowing a narrative up to 250 characters.
“You answer the same questions you would in the doctor’s office and tell them about your pain,” she said.
It took her 10 minutes. She filed her request and waited.
Sanford pledges a response within four hours but says the average is half that time. It was shorter for Kleinwolterink.
“It only took 10 minutes ... to get an email back from a doctor and they said, ‘You have a prescription waiting for you at your pharmacy that you selected,’” she said.
Sanford has been doing a trial run with the program and last week began offering it to all patients in South Dakota, Iowa and Minnesota. It hopes to add North Dakota this summer. Patients filing an e-visit likely are not communicating with their own doctor but with someone in Sioux Falls who is either a physician or an advanced practice provider such as a physician assistant or nurse practitioner. Sanford has been receiving 20 to 30 requests a week.

7 nonemergency conditions covered

It’s only for adults, only for patients enrolled in the My Chart program and only for seven conditions that are not emergencies. The seven are sinus headache, pink eye, urinary tract infection, vaginal discharge, diarrhea, cough and back pain.

Helping patients control their health

Self-diagnosis plays to a Sanford goal of having patients take ownership of their own welfare, which is one pillar of the national health reform movement. Patients still will visit clinics to see doctors, and they still can call for what still is free advice over the telephone. The e-visit is an option for those with relatively minor problems, who prefer texting and don’t want to sit in a waiting room.
“A lot of problems, a patient is looking for confirmation,” said Dr. Dan Heinemann, chief medical officer at Sanford Clinic. “They don’t have anything serious that they can’t continue to manage at home. ... If I have chest pain, this is not going to do it. But if I have a cough, it’s relatively easy.”
Medicare doesn’t cover an e-visit, but some insurers do. Kleinwolterink said she paid $25 of the $55 fee with a credit card and that Blue Cross Blue Shield covered the rest.
The health charts are a secured format requiring membership and a password entry to ensure privacy. Identity fraud is always a concern in health care, with the intent usually to misuse insurance. The e-visit, though remote, is reliable communication, said Terri Carlson, vice president at Sanford Clinic.
“Our risk folks prefer this over telephone calls. We have objective data in the questions patients have answered,” Carlson said.

Sometimes intimate details in writing

Still, the e-visit marks a cultural shift for patients to commit to writing private details about their health in order to communicate with a website. Some of the seven conditions, such as sinus headaches and back pain, are generic problems, while the others are more intimate.
“It’s a sign of the times to be using technology ... to be making that connection between the consumer and the health care market,” said Lorna Saboe-Wounded Head, assistant professor of consumer affairs at South Dakota State University. “With the social networks, maybe people are more willing to explain the problems they have, even if it’s very personal.”

Safeguards for prescriptions

Randy Jones, executive director of the South Dakota Board of Pharmacy, said health providers are allowed to prescribe drugs by electronic format without seeing a patient. It should be an established patient-doctor relationship that includes safeguards to prevent prescriptions that are improper or premature, he said.
“If they say I’ve got this hacking cough, do they know if it’s viral or bacterial without a lab exam? The answer is no. I would have some concerns,” Jones said. “If the prescriber has valid concerns, they should require that patient to come in for a physical exam and potential lab tests.”
Sanford says it has those safeguards in place. Under those circumstances, “it can be done with care,” Jones said.
Heinemann said the questions a patient must answer serve as a filter.
“If a patient says in an e-visit, ‘I’m really short of breath, I have pain when I breathe,’ those are red flags and probably the individual needs to get in to see a doctor,” Heinemann said. “Most of the time ... I think we can do a pretty good job without seeing the patient.”