CPOE is an Independent Risk Factor for Death?

A nice entry from Dr. Andy: Uh oh Computerized Physician Order Entry

Computerized physician order entry (CPOE) is looked on as a panacea which will decrease medical error, improve efficiemcy, and improve patient safety. Only it looks like it has some major, unintended consequences, like increasing death according to an article titled “Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System: in this months Pediatrics.

Anyway, the findings were suprising and alarming:

Among 1942 children who were referred and admitted for specialized care during the study period, 75 died, accounting for an overall mortality rate of 3.86%. Univariate analysis revealed that mortality rate significantly increased from 2.80% (39 of 1394) before CPOE implementation to 6.57% (36 of 548) after CPOE implementation. Multivariate analysis revealed that CPOE remained independently associated with increased odds of mortality (odds ratio: 3.28; 95% confidence interval: 1.94–5.55) after adjustment for other mortality covariables.

Put in plain English, kids transported after implementation of CPOED has a more than 3 fold increased risk of death. Ouch.

(Emphasis mine). Ouch, indeed.

My response is in the comments of Dr. Andy’s post.

“Best” Bad Santa Photo

Several years ago, our younger family made a Ritual Trek to a Mall to ‘See Santa’! The older kids were too old for the experience, and were there mainly because they had to go, and they wanted to see the littlest with the Big Guy.

Youngest daughter was then more than a little skittish and risk-averse, so why we thought this would go well is, in retrospect, completely beyond me.

Here’s how it went:

Sanat wants to cry, too

In discussing this with friends and family over the years, kid meltdowns with Santa seem to very frequent. If you’d like to share your Bad Santa Picture, send me a link (or send me the pic and the story).

Be nice to the Santa surrogates, they earn their pay.

Update! Thanks to reader Celsey, here’s a gallery of 42 Bad Santa photos from SouthFlorida.com

December 7th is Pearl Harbor Day

Pearl Harbor Day

Thank a Pearl Harbor vet. They’re getting hard to find.

MedBlogs Grand Rounds 2:11

The Examining Room of Dr. Charles: Grand Rounds 211

Welcome to Grand Rounds, the weekly highlight show of medical blogging. You will be inspired, discouraged, and enlightened by these unique pieces as contributed this week by doctors, nurses, patients, and healthcare professionals who’ve got something to say.

Tales of the Examining Room And, he has a book out, which would be a good Christmas present.

Coffee and Your Liver

Again, coffee is found to be good for you. This from the Washington Post:

Study Suggests Caffeine Can Help Liver

Reuters
Monday, December 5, 2005; Page A06

Coffee and tea may reduce the risk of serious liver damage in people who drink too much alcohol, are overweight or have too much iron in the blood, researchers reported yesterday.

The study of nearly 10,000 people showed that those who drank more than two cups of coffee or tea per day developed chronic liver disease at half the rate of those who drank less than one cup each day.

ABEM: EM Docs Not Participating in Life Long Self Assessment

The American Board of Emergency Medicine (ABEM) is the Board Certifying organization in Emergency Medicine for those who are residency trained, which is the current standard for Emergency Physicians. Therefore, the ABEM is Important, and is charged with initial and recurrent certification of EM docs.

In the good old days, a residency grad would get Board Certified initially, then retest every ten years (and most specialty boards still do that). ABEM is one of the first to embrace Lifelong Learning and Skills Assessment (LLSA), which in the current iteration means reading several articles and then taking an online, open book test. Not scary, and probably a good idea (the articles chosen so far are pretty good, though the timing of the Nesiritide article could have been better).

So, it’s been in place for nearly two years. How’s it going? Here’s how:

Well. Not good. Not good at all.

Yes, diplomates can wait 8 years and take all the tests at once (which is against the spirit of the arrangement but still legal), and that’s stupid, frankly. I have no idea why the numbers are this low, and I guarantee 80% of the currently board certified docs aren’t intending to just give up their board certification at the end of their 10 years.

My personal opinion is that the horrible completion rates are a mixture of lazyness and hope (and that’s just a guess, I have no independent polling). Lazy so they don’t have to read the articles assigned and figure out how to get to the site, pay the money and take the test, and hope that if enough diplomates don’t play the Board will be forced to rescind the whole system. I think that’s dreaming and isn’t going to happen.

I also predict that my current study manuals will find some very receptive buyers in about 6 years, as the dawn occurs to a lot of EP’s.

For the record, I passed 2004 and have registered for the 2005 test, but haven’t finished it.
Update: I finished it.

AAEM Reviews Cases, and Names Names

I’ve written before that one of the things we, as a Profession need to do to decrease meritless malpractice cases is to put our own house in order as regards expert witness testimony. I do not advocate a wall of silence or a parroting of the ‘party-line’, but I’m all for exposing our erstwhile ‘colleagues’ who will give expert testimony that’s at odds with provable standards and actual practices.

AAEM has decided to join the party, explaining it thusly:

In order to file a malpractice claim, many states require plaintiffs to have an opinion from an expert that malpractice has occurred. A number of these so-called experts are physicians who seem willing to make any statement, no matter how outrageous, in support of a malpractice claim. These physicians can profit handsomely from their willingness give such testimony.

Alarmingly, a number of leaders in our specialty have chosen to supplement their income by giving “expert” testimony that is unfounded in current medical standards and practice.

AAEM has responded to suggestions by several members by creating this web site. It is designed to bring to light testimony by expert witnesses that is remarkable either because of its spurious nature or because it is particularly helpful to the emergency physician defendant. It is hoped that by publicizing such testimony, and the individuals who offer it, emergency physicians may find some measure of relief from the ongoing crisis.

Unlike the ACEP review, AAEM is naming names. AAEM has helpfully included the name of the plaintiff’s expert witness (which I’m going to leave out of this post, for now).

A look at the testimony in the case does make me, as a practicing EM physician, say “huh?” Here’s some of it:

Page 33 – line 11:

Question: “And have you treated patients like Mrs. Walker who have come here with these kind of symptoms with tPA?”
Answer: “All the time. I mean, unfortunately, it’s all the time. Not daily, but probably three or four times a week.”
Comment: The reviewers were surprised that a physician would claim to give tPA so frequently. Giving it at such a rate would probably exceed the usage at the busiest centers in the world. This seems like a wild exaggeration.

My ED sees about 75,000 a year and we don’t give tPA for stroke 4 times a month, let alone any one physician giving tPA for stroke 4 times a week.

Want to keep the roaches down? Turn on the lights. They don’t like the exposure, and for that reason ACEP and AAEM are to be commended for their efforts.

RSNA: Coffee Boosts Short Term Memory

Another reason to have a cup:

CHICAGO, Nov. 30 – A cup of coffee is good for the memory, at least the short term memory, according to research reported today.

In a study of 15 healthy men ages 26 to 47, functional magnetic resonance imaging (fMRI) detected significant activity in the brain’s memory centers 20 minutes after the men consumed 100 mg of caffeine, according an Austrian study reported at the Radiological Society of North America meeting here.

The activity was significantly greater than men who were imaged after consuming a matched placebo (P<0.05), said Florian Koppelstatter, M.D., of the University Hospital Innsbruck.

He said the fMRI scan detected activity in the anterior cingulate cortex of the brain, which is responsible for some short-term memory functions.

This was by the Radiological Society of North America, and not Folgers, so you know it’s good.

Bird Flu Symptoms

Just so you know: there have not been any cases of bird flu in the US. That having been said, there’s a lot of work going on to get ready for it.

Today: how to tell if you have bird flu

Center for Disease Control has released a list of symptoms of bird flu. If you experience any of the following, please seek medical treatment immediately:

1. High fever

2. Congestion

3. Nausea

4. Fatigue

5. Aching in the joints

6. An irresistible urge to crap on someone’s windshield.

Heh.

via Dear Aunt Sue