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Saturday, January 19, 2013

More on fecal transplants: a less icky alternative, but why?

The bacteria that live in our healthy guts are a garden of cooperating and competing species that help to determine our intestinal health. When we take antibiotics, we kill countless bystander bacteria in our guts and sometimes develop changes in our digestion which can be severe. Clostridium Difficile infection is one of these conditions, a superinfection with a bacterium which is pretty resistant to antibiotics and causes infection of the colon with diarrhea, sometimes fever, nausea and vomiting and occasionally death. We treat Clostridium Difficile (C. Diff) diarrhea with a couple of antibiotics to which it is sensitive, but they don't work very well and some patients become chronically infected.

What does work for C. Diff, when all else fails, is a fecal transplant, that is to say taking stool from a healthy person and putting it into the gut of a person who has the infection. This is a stinky procedure in which genuine human poop, from a human who has been tested for diseases like HIV that can cause their own problems, is diluted with saline and instilled into the gut either with a colonoscopy, a naso-enteric tube or a simple enema. It works quickly, like in one or two days and the patient, once cured, usually stays cured. It doesn't work on every single person, but very nearly.

Various physicians around the country do real fecal transplants, but it is surprisingly difficult to find a doctor who will. I saw a successful fecal transplant at our office a few years ago which was, in fact, very easy and instantly rendered the recipient well. The poop was mixed to a liquid consistency in a blender with saline and instilled by enema into the patient with the chronic C diff.

Researchers from Canada recently reported the successful treatment of two patients with Clostridium Difficile diarrhea with a combination of 33 bacteria isolated from the stool of a single healthy woman.  They tested an original group of over 60 bacteria for antibiotic resistance and chose the bacteria that did not appear to have any significant levels of resistance. The bacteria colonized the recipients' guts after being introduced by a tube into the duodenum from the nose, and the two patients, who had recurrent severe C. Diff infections, were symptom free 24 and 26 weeks after the procedure, despite being treated with antibiotics for other infections (which often leads to relapse in conventionally treated patients.) It sounds like these researchers have created an excellent human derived probiotic, but I'm thinking that if fecal transplant is actually successful, it makes sense to consider doing real fecal transplants with real feces, which will never cost very much and are much more diverse as far as bacterial species are concerned. The artificial poo extract is more likely to be adopted as standard of care, though, because it is not brown and stinky and will eventually be backed by a major pharmaceutical company.

Patients die frequently in the hospital as a result of C. Diff infection. Because fecal transplants are so yucky that nobody wants to even discuss them, much less perform them, we allow many people to die every year of colitis due to C. Diff. It is difficult to imagine that our cultural aversion to the products of our lower intestines regularly results in patients actually dying. A study in the New England Journal of Medicine reported this month was stopped early by the institutional review board in the Netherlands because fecal transplant was so much more effective than antibiotic therapy that continuing to offer patients the inferior option was considered unethical. For a good long while it will continue to be ethical to offer only antibiotic therapy for C. Diff at American hospitals, and to not even discuss fecal transplants except perhaps as a way to make physicians and nurses squirm.

It is clear that intestinal bacteria populations are responsible for more than making us poop regularly. Fecal diversity is related to weight gain in mice, for instance. Fecal transplants have been used successfully to treat inflammatory bowel disease such as ulcerative colitis. I've wondered if the spreading epidemic of gluten intolerance has to do with the huge amounts of antibiotics that humans in the US are prescribed and if that, too, might be treated with repopulation of the gut with the diverse collection of bacteria that make up the feces of healthy and ideally antibiotic naive people (if there are any of those left.) It seems to me that widespread antibiotic use in our communities in general has probably significantly affected the bacteria in all of our guts, even those of us who rarely or never take them. Antibiotic use in food animals probably contributes as well to a shift in our normal flora. Perhaps some of this recent research will push us to begin to venerate our bacterial symbionts and strongly consider their well being when considering taking or prescribing antibiotics.

Thursday, January 17, 2013

Hospitals are still awful: movement toward patient centered care and Eric Topol's idea

First a disclaimer: People often receive compassionate, considerate and effective care at hospitals. They have countless interactions which impart the miracle of human caring and enrich their lives. It is also institutionally prevalent to have haphazard care with poor communication, near misses and avoidable misery.

I have been working at a university hospital emergency room as part of a mini-fellowship in bedside ultrasound.  It is the first time I have spent significant time entirely dedicated to an emergency room since I was a medical resident about a quarter of a century ago. As an internal medicine physician who works in hospitals, I have spent one or two hours at a time relatively often in emergency rooms taking care of patients who were admitted to me on their way to the medical floor, but that is not the same as staying there, seeing the more and the less ill, the folks who may go home and may get admitted, watching the rhythm of the department over time.

People come to emergency rooms for many reasons. Often they come because they need to see a doctor, but can't get in to one in an office because the doctor is busy or doesn't accept their insurance, or they don't have any way to pay, no money and no insurance. They come in because there is something wrong that they have decided needs to be dealt with now. The problem may be a true emergency, something that if left another day will lead to death or disability, or just something that has become intolerable and appears, from the patient's view, to have reached a level where any delay in treatment is unthinkable. They also come in, brought by ambulances or police or concerned family or friends, for drug overdoses, stab wounds, car and motorcycle accidents, assaults. They come in with no regard to whether the doctors in the emergency room are already busy, and they do not pace themselves. Three patients with stab wounds may arrive in 15 minutes, topped by a cardiac arrest. Usually the universe doesn't do this to us, but milder versions happen all the time. The acute treatment of the critically ill patient is often beautifully choreographed, efficient and successful. Treatment of the less critical patient, not so much.

Patients are brought back to the actual department where, in this ER, they are evaluated in curtained bays, with privacy of their stories ensured only by the ambient noises of crashing and yelling and beeping. Some newer emergency departments actually have rooms with doors, but not the one I'm hanging out in now. They are evaluated by resident physicians, attending emergency room doctors and sometimes students. They are cared for by nurses whose attention is constantly pulled in many directions by a constant flow of patients with varying urgency of need. After a patient is evaluated and an initial treatment plan is developed, they get IV's, usually, medications, sometimes, lab tests usually, radiological procedures frequently, and often a bedside ultrasound by someone like me, in training. Then they wait. And wait. And their relatives, who have to go to work in the morning, which is now only a few hours away, sit and wait. Occasionally someone comes by to tell them what they are waiting for, but not very often. Their labs are completed, and if there is nobody else more critically ill, some doctor in the team checks them and thinks again about what should be their ultimate outcome. And they wait, not knowing what is happening. They wait, lying on plastic covered gurneys which are covered with sheets that slide down and bunch up underneath them. Sometimes, but not often, primary doctors or consultants who are familiar with them are contacted. If they are admitted to the hospital they are moved to a more comfortable room in a new building (which must seem like heaven in contrast with the ER) but they have to wait hours to be seen by the admitting physician and moved to said room.

After 25 years in internal medicine practice, I am much more familiar with what happens to patients when they do reach the hospital wards. They tell their story, which they have told at least 5 times already, with multiple interruptions, to a new crew of people, nurses, specialists, new doctors from a different shift. They worry that the whole story that they told before has not been communicated and that what is being done to them may be wrong or unnecessary because of miscommunication. They hear about planned tests, have tests, wait for hours for results, or days, or never hear the results at all. They get treatments delivered by nurses along with explanations given by the nurses, which only occasionally bear any resemblance to what they doctor was thinking when the treatment was ordered. (This is not the fault of the nurse, but due to the system in which nurses and doctors rarely discuss treatment plans in any meaningful way.) They also get explanations from specialists which differ from those given by hospitalists, and maybe get to spend a little more time talking to social workers or discharge planners who sometimes have a better idea of the big picture than anyone else on the team.

The inevitable result of all of this is that patients, except those who are unusually generous of spirit, are frustrated and often grouchy, occasionally spitting mad. They are also not made well in the most expedient of manners, and often are made sick on the way to being made well, or instead of being made well.

Eric Topol, a renowned cardiologist and inventor of novel medications, and more recently a questioner of tradition, employed by the Scripps  Research Institute studying innovative medicine, has given a brief video talk about ways in which hospital stays and doctor visits might be replaced by video chats and remote transmission of physiological data. I think that he is being short sighted and has forgotten that many people who end up in hospitals do so because there is no unpaid human who will or can care for them outside of a hospital, either because they have become so darn sick they can't even make it to the bathroom, or because they are homeless or marginally housed, and that 3 dimensional health care is fundamentally what humans do for each other. Still, I love the fact that he is talking about ways to radically change medicine.

Many organizations are developing systems to make medical care more "patient centered." This term was initially coined in the 1960s and was defined as systems that "“take into account the patient, the social context in which he lives, and the complementary system devised by society to deal with the disruptive effects of illness” We physicians sometimes think of this kind of thing as fluff, and unworthy of our skills in fighting off death and disease in their myriad forms. Movement in the direction of patient centeredness, with attention to the systems which make medical care unkind, is vitally important, and should legitimately absorb a significant portion of physicians' considerable problem solving skills.

Thursday, January 10, 2013

Addendum to patient safety: the "Post Hospital Syndrome"

Harlan Krumholz, a Yale University professor of cardiology and public health, just published an article in the New England Journal of Medicine entititled "The Post-Hospital Syndrome--An Acquired, Transient Condition of Increased Risk." In it he points out that, not only are there many under-recognized complications of hospitalizations, mostly the same things I mentioned in my previous post, but these things lead to a very vulnerable period for patients after they are released from the hospital. Patients, especially elderly ones, often come back, sick, to the hospital with a new condition that was not directly related to what got them in trouble in the first place. Instead they come back with new issues, related to the fact that they were in the hospital, being unfed, un-exercised, treated with medications, and stressed in a myriad of ways which have consequences later on.

I notice a few things that relate to this, in my job as a hospitalist and primary care internist. First is the fact that emergency physicians often want to admit patients to the hospital and come into conflict with hospitalists or primary care doctors who want the patient to stay at home, out of the hospital. The emergency doctors have seen dramatic instances in which patients sent home from the emergency department come back later with much worse symptoms. They also have oodles of successes, in which patients are successfully treated and go home to recover. Since these patients don't come back to the ER, the ER doctors don't know about the successes, usually. We, as primary care doctors or hospitalists, see patients admitted to hospitals who get the usual complications, stay far too long and have trouble becoming re-established in whatever their previous situation was.

Patients and families often lose their nerve after a hospitalization and think that the patient is less capable of independence than they truly are. Patients then end up staying still longer in the hospital and being discharged either to nursing homes or with home health nurses or physical therapists, which sometimes are fabulously helpful but mostly are not.

When I visited the Republic of Georgia, where medical care is not great, but there are also no nursing homes to speak of, and less tendency to use hospitals, I visited a woman who was supposed to have been our hostess (Nana 1, we called her--having found lodging with Nana 2.) She was unable to have us stay because she was recovering from pneumonia. She was still feeling pretty puny, not getting out of bed much and cared for by her neighbor. At her bedside were the packaging for an antibiotic which I would have chosen for a hospitalized patient with pneumonia and pills which I would also have used. The doctor, apparently, came to her house every day and gave her an injection of the first, and made sure she was doing better. In the US we are trying to introduce programs that bring doctors into peoples' homes in situations where home care would be most appropriate, but the patient is not well enough to come back and forth to the office. This will be a good way of avoiding some in-hospital complications and thus the "post-hospital syndrome." At this point there is no financial incentive to do things this way, since we make much more for seeing patients in the hospital and we can save time by not going to and from patients' homes. Ideally, though, the way we treat patients would optimize their health, not our convenience.

Monday, January 7, 2013

Patient safety: How might we avoid killing or hurting people in our care

Hospitals are very focused on avoiding harming patients lately. They have been moving in that direction for a long time, but with health care reform legislation, payments are on the line, which makes something that was a very good idea into an imperative. In the year 2000, the Institute of Medicine, a non-profit organization that monitors various aspects of medical care, reported that 44,000-98,000 people died each year due to medical errors. This began a nationwide focus on patient safety that has had some, but not enough, impact on outcomes. Hospitals already do not get paid for care of a patient who gets a blood stream infection from their central venous catheter or a urinary tract infection from their bladder catheter, so they have to eat the costs associated with these things. When a hospital is paid a lump sum for a diagnosis (say a patient is admitted with appendicitis) and the patient gets some complication that makes their care longer or more expensive, the amount of money the hospital makes on the whole episode is less. But at some point in the not too distant future all payment will be based on good outcomes and having some event in the hospital that makes things more complicated (and the patient sicker) will hurt the hospital almost as much as it does the patient.

We call the bad things that happen to patients "adverse events" and we try to eliminate all "preventable adverse events."

Some of these adverse events are really obviously our fault, and others are so preventable that we consider not preventing them to be unconscionable. Our fault would be doing the wrong procedure or the right procedure to the wrong patient or body part, leaving a sponge in a patient's wound, causing infection of a procedural site by not using sterile technique, giving the wrong medication or the wrong dose, or a medication to which a patient has an allergy. MRI machines have powerful magnets and occasionally make metal objects brought into the room into deadly or injurious projectiles. We have foul evil bacteria in hospitals and if we don't wash our hands between patients we will transmit bugs such as methicillin resistant staph (MRSA) and Clostridium Difficile from patient to patient. We know that patients who are bedridden or have had orthopedic procedures get blood clots in their legs that can go to their lungs and kill them, so we give them medications that prevent clotting and sometimes contraptions that massage the blood in their legs. We know that patients on ventilators with tubes in their tracheas will develop pneumonia if kept lying flat, so we elevate the heads of their beds. We know that delirious and elderly folks who are weak are liable to fall and break bones so we watch them very carefully. We know that fragile skin on the bottom can break down and cause pressure ulcers if we don't turn a bedridden patient regularly.

Hospitals are carefully monitored and soundly disciplined if they have too many of these bad things happen, so we really do pay good, and progressively better attention to this sort of thing.

What we don't necessarily recognize is the huge burden of adverse events that happen in hospitals just because patients are in hospitals, despite or because of the fact that they are being treated by our best and brightest physicians with our best evidence based medicine and fancy technology.

Patients are usually admitted to the hospital because they have something wrong enough that they can't safely stay home. Sometimes they are admitted because we aren't sure whether this is true, but want to be on the safe side. When we make the decision to hospitalize a patient, we take on a huge responsibility and expose the patient to very significant risks.

We almost always put an IV in the patient. This is a small sterile tube that goes into a vein and is held in place by something sticky. We then hook the IV up to some sort of fluid with a pump which goes "beep beep beep beep..." when the little tube gets kinked or displaced. We sometimes give the patient various medications through the IV, maybe diuretics to take off some fluids, sedatives to calm them down, antibiotics to kill real or imagined infections, solutions of various salts to increase the blood volume, drugs for nausea, pain, high blood pressure...The beeping wakes them up, but the sedatives make them sleep. They become sleep deprived. The pain medications make them goofy and constipated. The fluids discombobulate their own electrolyte levels or overload them causing swelling and oxygen deficiency. The diuretics, if we went in that direction, cause kidney injury, which is strongly associated with in hospital death. They are not fed because we do tests that require that they not eat, so if they are diabetic their blood sugars drop, and then go too high when they finally get a giant tray of food which is much different than what they eat at home.

Much of what we do to patients is based in our culture of infinite health care resources. We don't necessarily even need the IV, but put it in anyway, just in case. There is a perverse incentive to do this, since a patient on IV medications of certain types is felt by payers such as medicare to need hospitalization, and one without an IV is not. We are paid for a higher level of care if a patient is getting opiate pain medications by the IV route.We don't do these things just to make more money, but we are also not immune to perverse incentives. We sometimes do tests without thinking whether they are necessary. We try to avoid fluid overload or dehydration but we don't necessarily watch people as closely as we should.

Being in a hospital is dangerous. It is also sometimes necessary, and sometimes more dangerous to not be in a hospital. Still. The science of patient safety could link itself more effectively to cost effective care. I would bet that there is actually not one patient admitted to the hospital who does not have a health care associated complication, if we keep in mind that things as seemingly trivial to providers as damage to veins from IVs and blood draws and financial ruin related to hospital costs are truly significant to the patients in our care. We need to be attentive to the fact that every little thing we do, from ordering a medication to ordering a test, carries with it a significant risk, and notice that some portion of our patients' medical problems stem directly from our best intentions.

Sunday, January 6, 2013

Small hospitals, the bystander effect and a hospital that works well

I just finished another week of hospitalist shifts at a small hospital in Alaska. It was a good week. People worked well together, the patients were well served and seemed to feel good about their care and, since I had been at this hospital for several weeks, I noticed some of the things that really worked.

The hospital is a member of the "Planetree Alliance" which works with member hospitals to make them more sensitive to how patients experience things, and also works to increase efficiency so energy and money can be directed in the right way. I read some things about this group. Apparently it was started by a woman after she had a terrible dehumanizing hospital experience and now started an organization to make hospitals less unpleasant. In some places it works, and in others it does not. It sounds like that has to do with whether the nurses are genuinely overextended. Planetree hospitals look better, with fish tanks and waterfalls and nice lounges, and have services like massage and therapeutic touch. Staff members do retreats to help them learn about what patients experience and to absorb the new care model. Some nurses have expressed that they feel like scripted automatons and couldn't possibly be expected to take care of really sick people and also act like day spa hostesses. In my hospital they seemed to be doing fine, and, because it's Alaska, they probably chucked the script but kept the waterfalls and the general attitude.

What I noticed about this hospital is that the doctors work well together (generally) and the nurses take initiative to make sure patients get the care they need. I usually find at least one nurse when I work at a hospital who says something or does something that reveals a deep misunderstanding of human physiology and makes me really nervous to leave a patient in his or her care. The nurses were all good and they acted like members of a team that took care of patients rather than being disgruntled or subservient. This can only come from not having been yelled at by physicians for asking about treatment choices or lab results. The nurses were always busy, but did not seem terribly harried, which bespeaks adequate staffing ratios.

Every morning Monday through Friday I would sit down, as hospitalist, with the social workers, physical therapists, nutritionists and nurse discharge planners and discuss all of my patients and what we needed to achieve success. Because it was a small hospital in a small town usually somebody at the table knew more about the patient than I did in ways that would explain how the patient came to be so sick and what hurdles they had to jump over in order to get home. They might tell me that the husband had been abusive or that the caregiver was actually a schizophrenic daughter or that the patient had huge financial resources which opened up many new options. They might know that less than civil behavior was the norm for this patient. They might have stories of how the patient almost died a few years ago and that it is amazing that they are independent and working now. Since there were lots of Alaskan Native patients people who had lived there for years would explain to me how their families and culture affected things. Since it was a small hospital we could talk about all of my patients every day and someone would volunteer to take care of details like obtaining expensive medications or contacting caregivers so that I could take care of medical problems and not get overwhelmed (very often).

Nurses also had these Vocera walkie talkie things so I didn't have to go wandering all over the ward to talk to them, which made me much more likely to be able to come up with a plan that both of us

The fact that this hospital was small was very important in making it good. Small hospitals get a bad rap when it comes to taking care of certain life threatening emergencies. If you have an acute heart attack and need to get an artery opened up pronto to save your life, you want to be right next door to a major metropolitan hospital. Our emergency department flies such patients to the nearest major hospital, which can be achieved in less than an hour, weather permitting. The patients who stay, though, get care from a set of doctors who usually know each other well, are used to working together and are right there when you need them. Since there are a limited number of specialists available, patients don't usually have a large and unwieldy entourage of physicians confusing the nurses and pharmacists with conflicting orders. It would be nice to have all of those endocrinologists, oncologists, rheumatologists, cardiologists and vascular surgeons (to name a few) available, but for that loss, something is gained in consistency and familiarity. The coordinating hospitalist has to actually think rather than call a specialist for each offending organ, which is good.

I read an article in the New England Journal of Medicine about the "bystander effect" in medical care in a large university medical center. The bystander effect was coined after a much publicized rape/murder in New York City during which none of a number of people intervened to save a young woman. Psychological studies have investigated what variables make us unable to do the right thing when faced with an event that clearly needs action. Social norms that work in other situations sometimes make us stupid. We assume, in a large group, that someone else is more qualified to act than we are. We pay less attention in places where we are overstimulated. It's inexcusable, but occasionally Chinese toddlers run into traffic unheeded and the injured or ill lie in public, unattended. The author of the article was a specialist helping care for a person in the intensive care unit of a major hospital and noticed that the patient was getting sicker and sicker with nobody out of scores of doctors taking responsibility for making important decisions until the patient nearly died. He noted that bystander effect researchers have found that when the bystanders are friends, they are more likely to take action. He suggested that fostering friendship among doctors in a setting like that would be good for patient care. I agree, and would add that there might be other good reasons to be friends as well. In my little Alaska hospital I noticed the opposite of a bystander effect. Everyone seemed to have an opinion and told me about it. All of the patients seemed to be being stealthily watched by multiple caregivers all the time. It was very nice.

Another thing I noticed about this hospital was that the doctors were really good. A couple of the internists were the former chief residents of their well respected training programs. A young anesthesiologist had trained at Harvard and the Mayo Clinic. People were still psyched to take care of patients. I'm not sure how this happened, but I think that a couple of decades ago some good doctors fell in love with the area and decided that they would make it medically excellent. They called their friends and their friends moved there and they trained medical students and medical residents and kept up their enthusiasm for teaching and learning. I think that's what happened. There might be some other factors involved. I'm not entirely sure of the ingredients or how the recipe was put together but the final product is excellent.