Tuesday, January 15, 2013

It takes two to Tango, two to 'toast' the planet, but three to safeguard the patient.

At the height of the cold war, as well as today, two USAF Missile Officers can launch a missile resulting in a world-wide conflagration.

Imagine my surprise when I learned that one of the hospitals at which I work couldn't give tPA without three persons meeting in time and space to agree on the dose and the identity of the patient being treated with the drug.

The frustration of this situation was a 32-year old male, four weeks out from a ORIF (operative reduction and fixation) to the right lower leg, who presented to my ED with collapse, shock, syncope, and chest pain and dyspnea. A point of care echocardiogram demonstrated within one minute of his arrival in the trauma bay, acute RV pressure overload establishing the diagnosis of life threatening pulmonary embolism.

Of patient's who die of pulmonary embolism, 70% die within the 1st hour of their event. (Sadeghi, et al. Acute Massive Pulmonary Embolism: Role of the Cardiac Surgeon. Tex Heart Inst J, V32(3);2005, 430-433). Because of the massive investments in time, interest, concern and good process engineering an acute ST segment myocardial infarctions patient on their worst day will face an overall mortality rate of no more than 4-5%. The less frequent but highly lethal pulmonary embolism patient faces an overall mortality of at least 33-40% with their first episode of pulmonary embolism.

So my patient with an extreme risk of 1-hour death from his pulmonary embolism did not receive his thrombolytic drug therapy ordered by me within the 1st 5 minutes of his ED arrival until almost 1 hour and 45 minutes after his ED arrival. How was this possible?

The hospital had targeted tPA as a high risk medication and invoked safeguards to ensure its appropriate use. Therefore, byzantine processes have been implemented in order to make sure the medication is used appropriately and safely. However, the unintended consequence of this policy was to make timely administration of the medication almost impossible. As an example of the height of the ridiculousness of the process was the local requirement for three individuals, 2 independent nurses and the pharmacist to consensually agree to patient, dose of the drug, and appropriateness of the indication for the drug.

What sense is there in me having the ability to almost instantaneously make this diagnosis, if processes are put in place frustrating timely lifesaving therapy? As is too common in the patient safety area, draconian recommendations occur based on someones well intentioned idea(s) about what enhances safety without consideration of the potential downsides to the proposed policy, and without even fundamental or rudimentary studies done to demonstrate  the actual effectiveness of the 'policy.'

Again, my point is not to argue against the wisdom of the patient safety movement, but rather to argue for intelligent and thoughtful design of safety processes to ensure that safety is enhanced but that timely therapy is not compromised.

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