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MedPAC has advised Congress to extend the specialty hospital moratorium that was set to expire in the summer by 18 months, to December 2006. MedPAC also voted to reshuffle and redistribute DRG payments, which will even out the relative profitability of services at all hospitals (acute-care and specialty). MedPAC didn't broach the issue of eliminating the whole hospital exemption.

News You Can Use

The medication errors most likely to occur in the endoscopy/GI lab are over-sedation, contraindication to medication (because of pre-existing allergy), omissions of ordered medications and not having the right medication, according to the United State Pharmacopeia's (USP) medication error-reporting program. Of the 140 endoscopy medication errors reported, 5.1 percent of them resulted in harm, says Rodney W. Hicks, MPA, MSN, ARNP, research coordinator for the USP Center for the Advancement of Patient Safety. Over-sedation was commonly cited. One of the underlying causes involved syringe swaps, where one syringe contained Midazolam and the other contained fentanyl, and the wrong product was administered. Another case revealed that the institution had changed suppliers of fentanyl and the new packaging was not clearly labeled as to the total content. In another case, the physician wanted a second dose of meperidine and Midazolam given within three minutes of the first dose. Failure to titrate the medications to the patient's condition resulted in the need to provide additional airway support during the procedure.

Larger, high-volume ambulatory surgery centers (ASCs) spend less on operating costs than smaller facilities, but also generate significantly lower revenue on a per-case basis, according to a new survey by the Medical Group Management Association (MGMA). The survey, conducted with the American Association of Ambulatory Surgery Centers, found that ASCs with 5,000 or more procedures a year reported median total operating costs of $583 per case in 2003 compared with $985 for ASCs with 1,999 or fewer procedures per year. At the same time, however, total medical revenue for the larger ASCs was $809 per case, or almost 30 percent lower than the $1,147 per case reported by smaller facilities, according to the survey of about 150 facilities. Smaller ASCs generate greater per-case revenue because they tend to focus on single specialties with high-volume procedures, says the MGMA.

Preventable Errors
Could These Mishaps Ever Happen at Your Facility?
A recent rash of surgical errors serves as a reminder that even the most prepared facility is susceptible to lapses in safety protocol. Here are four incidents you and your staff can learn from.

• Malignant hyperthermia death. A 20-year-old college student died from malignant hyperthermia (MH) two days after an outpatient procedure to repair a separated shoulder. Steve Nook's body temperature began to spiral over 109 degrees when the anesthesiologist told the surgical team to end the procedure, but it was too late. Such deaths highlight the need for greater awareness of MH, says the Malignant Hyperthermia Association of the United States, which recommends these steps for handling MH:
• Screen patients. Patients who have had problems with anesthesia, or who have (or have family members who have) neuromuscular diseases might be susceptible.
• Use non-triggering anesthetics. You can perform outpatient surgery on MH-susceptible patients if you don't use general anesthesia, monitor the patient's CO2 saturation and temperature, and have dantrolene in the OR.
• Keep dantrolene and ice on hand. The $2,000 drug has a three-year shelf life; it is the only cure. You can use ice to cool the patient.

Anesthesiologists who are experts in MH staff MHAUS' 24-hour hotline (800-644-9737).

• Eyewash instead of BSS. An ophthalmologist substituted an external eyewash, Eye Stream, for balanced salt solution for intraocular irrigation, blinding seven cataract surgery patients at Barberton Citizens Hospital in Barberton, Ohio, according to a lawsuit filed against the hospital and Jeffrey T. Starkey, MD.

Alcon Laboratories, which makes Eye Stream, warns against intraocular use on the product's packaging. The hospital acknowledged its error at a December hearing before the Ohio State Pharmacy Board, which fined it $3,000 and Dr. Starkey $1,000.

When asked to comment, Melissa Reece, RN, MSN, MBA, CNOR, director of the Cedar Laser & Surgery Center in Tacoma, Wash., says, "it's a process problem. The surgeon is the one who takes all the responsibility in the OR, and he trusts that the staff he's working with has taken the right steps. He would never check a bottle in the room."

• Supply-cleaning error. Staff washed surgical supplies in hydraulic fluid instead of detergent at Durham Regional Hospital and Duke Health Raleigh Hospital, say spokeswomen for both facilities. The wrong fluid was used due to an apparent mix up with the detergent supplier for the hospitals.

Workers who were fixing an elevator at Duke Raleigh may have filled the opaque detergent drums with hydraulic fluid, says hospital spokeswoman Katie Galbraith. "We're still investigating how the drums re-entered the supply chain," she says. Both hydraulic fluid and the surgical detergent Mon-klenz are the consistency of syrup and are a dark honey color, she says. A sparse amount of hydraulic fluid was used during one step of a six-step instrument-cleaning cycle - and before the sterilization process, she says.

Ms. Galbraith says both hospitals sent a combined 4,000 letters to patients who were treated during the time of the liquid mix-up, but hospital officials believe there is a very low risk involved.

Both hospitals are now implementing a three-step process to verify delivery of the detergent. Each barrel's seal will be checked three times: when it arrives at the loading dock, at central sterile processing and again when the barrel is about to be hooked up to the instrument washer. An intact seal, says Ms. Galbraith, will show the barrels contain detergent and not a foreign liquid found in waste barrels. The hospitals will additionally take waste barrels to a floor supervisor, who will deface all labels, attach a "Do Not Use" sticker and drill holes in its bottom.

• Wrong-site surgery. "X" did not mark the spot where a New York surgeon performed knee surgery, court records show. A jury ordered Andrew Feldman, MD, the New York Rangers team doctor, and St. Vincent's Medical Center to pay $450,000 for operating on the wrong knee of Douglas Hall, 43. The jury verdict found Dr. Feldman 60 percent responsible for the injury, and his support staff and St. Vincent's liable for the other 40 percent. Mr. Hall went to St. Vincent's in November 2001 for arthroscopic surgery on his right knee. Despite marking the right knee with an X, Dr. Feldman operated on the left knee. Dr. Feldman did not return calls for comment. - Compiled by Daniel Cook

Post-operative Ileus
New Drug in Development Aimed at Preventing POI
If open abdominal surgery is part of your caseload, the common complication called post-operative ileus, or POI, has no doubt left you and your patients frustrated. A solution might soon hit the market: a drug called Entereg (alvimopan).

"It's a first-in-class drug," says Lizanne Wentz, a spokeswoman for Adolor, an Exton, Pa., pharmaceutical firm that's been developing Adolor since June 1998. "There are existing treatments for this condition, however, not very effective ones. Our drug candidate has the potential to treat the condition without affecting the analgesic qualities of the opioid."

According to experts, side effects from anesthesia and opioid analgesics are among the causes of POI. The same drugs that block pain signals in the central nervous system can also disrupt the normal function of the gastrointestinal tract. What's more, experts say, the treatments currently used against the condition - watchful waiting, cutting back on post-op opioids, nasogastric decompression or the use of prokinetic agents to promote motility - don't shorten its duration.

"When you see lots of different treatments, it's likely that none of them work well," says Conor Delany, MD, PhD, a staff surgeon at the Cleveland Clinic's Department of Colorectal Surgery and Minimally Invasive Surgery Center. "We'd ideally like to treat POI, and if we can't prevent it, we could at least minimize it."

A pharmaceutical treatment would help patients as well as the bottom line.

"It can benefit us hugely," says Dr. Delany, who has conducted a study on the use of alvimopan for POI after major abdominal surgery. Noting that the condition is the most common reason for delayed discharge of abdominal patients, he says, "That translates into massive post-operative care costs. The impact to any institution that sees a number of abdominal surgery cases is very significant."

The FDA designated Entereg as a fast track product for the management of POI in February 2004. The FDA's notification of fast track designation indicates that post-operative ileus is a serious condition for which no drugs have been approved. Still, the drug faces a few hurdles before you'll be seeing it.

While Adolor had originally anticipated an FDA decision by April, the agency has requested additional data - including the results of European trials conducted by the company's corporate partner, GlaxoSmithKline - which Ms. Wentz says might delay the agency's decision until summer.

According to published reports, the European trials did not find Entereg to have a statistically significant effect on patients' recovery of gastrointestinal function.

A few facts about POI. It is a transient impairment of gastrointestinal motility and function, resulting in abdominal distension and pain, constipation, nausea and vomiting, and a reduced desire to eat. Each year, an estimated 2 million open laparotomy patients suffer its symptoms, which can last anywhere from a couple days to more than a week.

There has been little advance in the treatment of POI since the introduction of nasogastric decompression, which has limited effectiveness and is uncomfortable for patients. There are no FDA-approved drugs for the management of POI currently available. There is a need for improved treatments because POI can have a negative impact on patient recovery and healthcare costs.

- David Bernard