Author Archives: patricewendling

ED Patients Blind to Risks of Being Overweight

American tongues start wagging whenever the latest starlet puts on a few pounds, but we appear loathe to discuss our own ever-increasing waistline.

A study of 453 adults presenting to a Florida ED found that 58.5% of overweight/obese African American and Caucasian men and women feel their weight is not a health issue AND have never discussed their weight with their healthcare provider.

The average BMI in the study was 29.5 kg/m2, mean weight 184 pounds, 61% were female and the average waist circumference an undignified 39.5 inches.

Given those stats, you’d think these patients had gotten an earful from their provider, but not so.

Overall, 38% of all patients reported their weight to be unhealthy, but only 28% recalled being told so by their provider, University of Florida emergency physician Dr. Matthew Ryan reported at the recent meeting of the Society for Academic Emergency Medicine in Chicago.

It’s possible that some physicians may be afraid to bring up weight for fear their patients will scurry off to a “kinder, gentler” provider. Others may simply be short on time. Yet even when docs did start the conversation, some patients just couldn’t make the connection between obesity and health risks.

Among patients told by their provider they were overweight, 77% believe their present weight is damaging to their health, yet 23% still believe their weight is not unhealthy.

Dr. Ryan points out there’s an obvious disconnect between patients’ perceptions of their weight and their actual weight and current health, and suggests that “the first line of action toward confronting the mounting obesity epidemic in the U.S. is clear patient-provider education.”

The chaotic environment of the ED may seem like an unlikely place to help increase patient awareness about weight-related medical issues or to provide weight-loss counseling, but there may just be something to the “Willie Sutton rule” that teaches, not just bankrobbers, but medical students to focus on the obvious.

As part of the study, the investigators also measured the prevalence of obese patients presenting to their ED in order to compare it to state and national prevalence rates. It reached a whopping 38%, towering over the already hefty 26.6% obesity rate reported for the general population in Florida in 2010 by the CDC.

To their knowledge, the authors say no studies have directly measured the obesity prevalence in the ED. Thus, the ED population may be poorly represented in existing national healthcare studies, which are largely community-based. Moreover, the obesity prevalence may be higher than indicated by studies like the CDC’s that rely on self-reported height and weight.

Given the author’s findings in the ED, that’s a very real and chilling possibility.

The research was supported by a University of Florida Clinical and Translational Science Institute grant.  Dr. Ryan reported having no conflicts of interest.

– Patrice Wendling

 

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Taking the QE? Do It PDQ!

Surgeons who delay taking the American Board of Surgery Qualifying Examination immediately after completing their residency in hopes of boning up on their skills may want to rethink the strategy.

A new analysis of 4,909 residents found that candidates who took the exam immediate after residency had an average first-time QE pass rate of 87%, compared with 57% for those who delayed 1 year and just 48% for those who delayed 2 years or more.

PATRICE WENDLING/Elsevier Global Medical News

“This idea of somehow thinking your results are going to improve if you wait a year is not borne out by the information we’ve shown,” study author and ABS associate executive director Dr. Mark Malangoni said in an interview.

While the study identified an association and not cause and effect, Dr. Malangoni and his colleagues suggest that poor performance is “most likely due to a deterioration of knowledge over time.”

That may not sit all that well with the average patient, who likes to think that physicians (like parents and even journalists) get smarter with experience.

Dr. Malangoni explained that one of two things may be going on. Roughly 80% of general surgery residents pursue a fellowship and focus on learning in a very narrow area. So, when they take the QE, which tests a very broad base of surgical knowledge, they may actually be forgetting things because of the narrow focus of their fellowships.

The second scenario is that the candidates start a practice, and the activities and stressors inherent in this new venture, may divert them from maintaining their knowledge base, he said.

Still others attending the recent Central Surgical Association meeting, where the study was presented, suggest that candidates who delay taking the QE may simply be poor learners or poor test takers.

Regression analysis, however, found that the effect was tempered but still significant after controlling for the candidate’s fund of knowledge using ABS In-Training Examination (ABSITE) scores. Undergraduate medical education and post-residency training also did not affect the results.

“There are a lot of reasons why someone might delay taking the examination and some of them are perfectly understandable,” Dr. Malangoni said. “I think the message we’d like to transmit to someone who’s thinking of delaying, is that if you’re able to adequately prepare for the examination, you should take it with that first opportunity right after completing residency because it appears, from what information we have, that that’s your greatest chance of being successful in passing the examination.”

By Patrice Wendling

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The Trauma of Politics in Medicine

It’s been a quick reversal for the Susan G. Komen for the Cure Foundation, reinstating funding some 72 hours after cutting off Planned Parenthood because of new criteria barring grants to organizations under investigation, prompted in this case, by a Republican congressman.

“We will amend the criteria to make clear that disqualifying investigations must be criminal and conclusive in nature and not political,” Komen CEO and founder Nancy Brinker said in a statement issued Friday.

The uproar brought more than $3 million in donations to Planned Parenthood in just three days, but also highlights the volatile mixture of politics and medicine.

Dr. Richard Carmona recently observed that one of the most popular presentations he made during his tenure as the 17th Surgeon General of the United States did not address emerging infections, physical trauma, or national diasters, but rather the plague of politics in medicine.

“This traumatic plague of politics is more insidious and virulent than emerging infections; has potentially more morbidity and mortality than hemorrhagic shock or blunt or penetrating trauma; has virtually no diagnostic criteria; and is resistant to all therapy, especially voices of reason, substantive discussion or positions of compromise,” he said during a memorial lecture at the recent meeting of the Eastern Association for the Surgery of Trauma.

Dr. Richard Carmona Patrice Wendling/Elsevier Global Medical News

Dr. Carmona didn’t have far to look for examples to flesh out his diagnosis.

More than a century ago, public health officials’ efforts to control the bubonic plague outbreak of 1900 in San Francisco were nearly derailed by politicians who claimed that quarantine procedures, including closing the city’s harbor to incoming ships, were an over-reaction that would impede commerce and tourism, and result in the collapse of San Francisco, and possibly California. The Surgeon General who intervened based on the scientific evidence was labeled a heretic and asked to resign.

In the 1980s, similar calls were made after former Surgeon General Dr. C. Everett Koop refused to back down from statements that HIV could be prevented. At the time, Dr. Carmona reminded the audience, senior elected officials were telling the American public that HIV was God’s way of punishing homosexuals.

In the 1990s, the tenure of Surgeon General Dr. Joycelyn Elders  was cut short after controversy erupted over a 1994 speech at the United Nations World AIDS Day that included remarks that masturbation was a normal part of sexuality and that abstinence-only education was “child abuse.”

During his own term under President George W. Bush, Dr. Carmona said, abstinence-only became the mantra of the administration, “based solely on ideological and theological concepts, and not science.

“Science had really demonstrated that abstinence alone was a failed proposition,” Dr. Carmona said. “Ironic, that an administration that was repeatedly caught up in the issue of abortion did not see the connection that comprehensive sex education was the best method to prevent STDs, unwanted pregnancies, and therefore abortions. As Surgeon General, this is a science-based position I have always held.”

Dr. Carmona, the only Surgeon General to be unanimously confirmed to the position in over 200 years, said the trauma of politics and its preventable deleterious outcomes are owned equally by politicians on both sides of the aisle.

He pointed out that over-the-counter sales of Plan B stalled under the Bush administration before gaining limited approval in December 2006, but fared no better seven years later under the more liberal Obama administration. In December 2011, HSS Secretary and Democrat Kathleen Sebelius overruled the FDA’s decision to make the emergency contraceptive available, without prescription, to girls of all childbearing ages. While Sebelius cited a lack of conclusive data, Dr. Carmona said it was the administration’s desire to avoid a political battle in the face of an upcoming election.

“The immunization for preventing the continued viralness of political trauma is transparency, full disclosure, accountability for elected officials, a citizenry that is informed and participatory, coupled with civil discourse of complex issues,” he said.

–Patrice Wendling

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Placing Central Lines and DVTs?

Does the simple act of inserting a central venous catheter induce a hypercoagulable state in patients?

Courtesy Wikimedia Commons/Jsonp/Public domain

Research presented at the Eastern Association for the Surgery of Trauma shows that central venous line insertion significantly decreases clotting time and initial clot formation time and accelerates fibrin cross-linking in both healthy swine and critically ill patients.

The findings indicate that CV catheters induce a systemic hypercoagulable state, probably because of the endothelial injury, which may explain the increased risk for venous thromboembolism associated with central venous lines, said lead author Dr. Mark Ryan, with the University of Miami School of Medicine.

The prospective, observational trial involved eight patients whose blood was drawn from an indwelling peripheral arterial catheter before and 60 minutes after central venous line catheterization and analyzed with thromboelastography (TEG). Ten swine consented to having their blood drawn as well.

The group previously reported that placing a pulmonary artery catheter in critically ill patients and healthy swine significantly decreases the time to initial fibrin formation, thereby inducing a hypercoagulable state.

WENDLING/Elsevier Global Medical News

As in the current study, however, no changes were observed in conventional coagulation parameters, raising questions as to why standard coagulation tests fail to correlate with TEG and whether the prothrombotic state identified by TEG truly indicates an increased risk for deep vein thrombosis, Dr. Ryan said.

Finally, as has been suggested by other investigators, pigs may simply have a very different hypercoagulable state than humans do. I selfishly hope so.

–Patrice Wendling

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Do Trauma Patients Need An Aspirin?

Acute traumatic injury has been shown to produce a prothrombotic state that predisposes trauma patients to an increased risk of venous thromboembolic events. But are these patients also at increased risk for stroke?

Researchers at the University of Louisville report that trauma patients were 1.6 times more likely to develop a cerebrovascular accident (CVA) after admission than medical and surgical controls matched for known CVA risk factors such as age, hypertension, diabetes, atrial fibrillation, and tobacco use.

On logistic regression, trauma was the only significant risk factor for CVA between the two groups, Dr. Jason W. Smith reported at the recent meeting of the Eastern Association for the Surgery of Trauma.

By Patrice Wendling/Elsevier Global Medical News

Dr. Smith called for more studies concerning the etiology and management of post-traumatic hypercoagulability and suggested that “CVA prophylaxis may be warranted in select trauma patients.”

The analysis identified 64 strokes after admission among 7,633 trauma admissions from 2008-2010, for an overall CVA rate of 0.8%. Out of this group, 23 strokes were found to be related to TBI and blunt cervical vascular injury, leaving 41 patients with non-injury related CVA in the analysis. The medical/surgical controls included 14,121 patients obtained from the university’s hospital database over the same time period.

When compared with a second control group of 120 trauma patients matched for Injury Severity Score and mechanism of action, the 41 trauma-related CVA patients presented with significantly more stroke risk factors, including older age, pre-existing hypertension, diabetes, and tobacco use.

Their chance of placement in an extended care facility also skyrocketed from 28% to 81%, while mortality rates more than tripled from 7% in controls to 22% in the trauma-related CVA patients, Dr. Smith and his co-authors reported.

The one bright spot was that on follow-up in the medical/surgical analysis, trauma patients had higher six-month post-CVA functional assessment compared with the controls.

–Patrice Wendling

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New Questions on Lung Cancer Screening

Would you allow patients to self-refer for a CT lung cancer screening? Would you screen a never-smoker? What size nodule would trigger a follow-up exam? What is your lower age limit and lower pack-year limit for screening?

These are just a few of the questions tackled during an interactive lung cancer screening session at the recent Radiological Society of North America meeting, and that highlight the uncharted waters physicians face in the wake of the pivotal National Lung Screening Trial.

The NLST demonstrated a 20% reduction in lung cancer mortality when low-dose CT screening was used, compared to chest X-ray, among 53,000 asymptomatic current or former heavy smokers. However, CT produced more than three times the number of positive results and a higher false-positive rate than radiography.

Without a clear plan to manage abnormal findings or a firm handle on cost, policymakers and payors are hesitant to back reimbursement for widespread lung cancer screening. Results of the ongoing NLST cost-effectiveness analysis are expected early next year. Based on already published data, however, a crude back-of-the-envelope estimate puts the incremental cost-effectiveness ratio at $38,000 per life-year gained, NLST investigator Dr. William Black told attendees.

“That actually is a pretty good deal compared to a lot of things we do in medicine, and in fact most people would put the threshold for acceptability somewhere between $50,000 to $100,000 per life-year gained,” he said. “So it certainly is feasible”

Dr. Black pointed out that low-dose CT saved one lung cancer death per 346 persons screened in NLST, which again is very favorable compared to the rate of 1 per 2,000 patients for mammography.

Although the session provided just a small snapshot in time, audience responses suggest there is much work ahead. A full 77% of attendees were not using low-dose CT to screen for lung cancer and 72% reported not being familiar with the recently published National Comprehensive Cancer Network guidelines for lung cancer screening.

One-quarter of the audience had no lower age limit for screening, and 34% said they did not provide either decision support or obtain informed consent.

Dr. Caroline Chiles. Image by Patrice Wendling/Elsevier Global Medical News

Radiologist and NLST collaborator Dr. Caroline Chiles said informed consent in NLST helped prepare patients for the potential risks of a screen, the likelihood of a positive result and that a positive result didn’t mean they had lung cancer.

“It made a huge difference once they got that letter saying they had a positive screen, because at that point you don’t want everyone rushing out to a surgeon to get that nodule resected,” she added.

What attendees and panelists could agree on is the need for smoking cessation to be included in any future lung cancer CT screening program, with 60% of attendees saying they already do so.

Dr. Chiles pointed out that 16.6% of participants in the NELSON lung screening trial quit smoking compared with 3%-7% in the general public, but that participants were less likely to stay non-smokers. She also cited a recent MMWR that found 70% of adult smokers want to quit smoking, but only about half had been advised by a health professional to quit.

“We really have to think of lung cancer screening as being a teachable moment,” she said.

She suggested physicians visit www.smokefree.gov for help in guiding their patients. Dr. Black also noted that the NLST team is working on a lung cancer screening fact sheet for physicians and patients that will be ready in a few weeks and made available on the Internet.

—Patrice Wendling

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Filed under Cardiovascular Medicine, Family Medicine, Health Policy, IMNG, Internal Medicine, Oncology, Physician Reimbursement, Practice Trends, Pulmonary Diseases and Sleep Medicine, Radiology, Surgery, Thoracic Surgery

Hypnosis Takes the Bite Out of MRI Anxiety

I’d rather have an MRI.

OK, it doesn’t have the same ring as the traditional punch line, but for many patients the fear of being slipped in a scanner surrounded by the clicking and banging sounds of an MRI ranks right up there with a root canal.

Rather than sedating these patients, a radiology group in France has been offering hypnosis on a daily basis since 2004.

Over a 15-month period, 45 patients were identified as being claustrophobic and refused the scheduled MRI, including four patients who experienced a panic attack.

All 41 patients who agreed to undergo a brief 3- to 5-minute single session of hypnosis just before the MRI completed the exam, including those with panic attacks.

Conversely, none of the four patients who refused hypnosis were able to withstand the procedure, radiologist and co-author Dr. Bruno Suarez reported at the Radiological Society of North America  meeting.

Dr. Bruno Suarez

“The more a patient is claustrophobic, the more hypnosis is efficient,” Dr. Suarez, with L’Hôpital Privé de Thiais in the outskirts of Paris, said in an interview. “For us it’s a surprise. It’s a very interesting technique.”

The technique is based on the late American psychiatrist Dr. Milton Erickson’s approach to hypnosis, but modified to integrate the repetitive noise of the MRI. Patients are given a tour of the MRI room, assured that the scanner and its magnets are safe and prompted to mentally recall a pleasant memory involving a repetitive noise while the MRI exam is performed.

During hypnosis, the brain is more susceptible to suggestions, Dr. Suarez said, noting that a Belgian study showed that hypnosis reduces the perception of pain by 50%.

Hypnosis requires a good memory and language skills, so it’s not used on those under five years of age or those with dementia or Alzheimer’s, he added.

So far, a radiologist, two MRI technicians and even the two office receptionists have been trained in the technique.

Marc Andre Fontaine (left) and Dr. Suarez

“I like the contact with the patient, and I want the best results for the patient,” MR technician and co-author Marc Andre Fontaine said in an interview.

The 45 patients in the series represent just 1.4% of the roughly 3,300 patients seen by the group over the 15 months, but the appeal of the drug-free method has attracted referrals from other centers. It’s also a big financial boon due to shorter exam times, fewer appointment cancellations and no procedural side effects, Dr. Suarez said.

A recent study by interventional radiologist and hypno-analgesia pioneer Dr. Elvira Lang reported that self-hypnotic relaxation added an extra 58 minutes to the room time for an outpatient radiologic procedure, but still saved $338 per case compared with standard IV conscious sedation.

That’s a big savings for just getting patients to relax with a few words, especially when you consider that  nine out of ten patients are probably already muttering something under their breath during their MRI.

—Patrice Wendling

Images by Patrice Wendling/Elsevier Global Medical News

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OSHA Denial Roils Resident Work-Hour Reformists

Reaction has been mixed to the Occupational Safety and Health Administration’s recent decision to deny a second petition from the Public Citizen Health Research Group and other groups to have OSHA, rather than the Accreditation Council for Graduate Medical Education, regulate resident/fellow work hours.

The American Medical Association, which had worked to keep ACGME at the helm, applauded OSHA’s decision in a recent statement .

“The ACGME is the appropriate body to regulate and monitor resident duty hours, as it is optimally suited to oversee resident and fellow physician duty hours on behalf of both the profession and the public,” AMA president Dr. Peter Carmel said. “We are pleased that OSHA agrees.”

In denying the petition, OSHA officials wrote that resident duty hour standards are “best addressed within the context of resident training and education,” and that new duty hour standards and enforcement mechanisms that took effect in July 2011 “provide an opportunity for ACGME to take meaningful steps to protect the health of resident physicians within the context of their overall residency experience.”

OSHA officials also noted that federal whistleblowers provisions protect residents and interns who voice concerns related to extended work hours.

Public Citizen fired back in a letter to OSHA that the Obama administration was rehashing “the same discredited Bush-era arguments of nine years ago when our first petition was rejected on almost identical grounds.”

The group went on to say that “OSHA has, once again, opted out of its legal obligation to protect residents from excessive work hours, deferring instead to a largely unaccountable private entity, the ACGME.”

Currently, when a resident reports work-hour violations, they risk retaliation from colleagues and put their training programs at risk for probation and even loss of accreditation, Sonia Lazreg, health justice fellow with the American Medical Student Association, said in an interview.

After the 2003 work rules were implemented, more than 80% of residents reported that their programs were in violation when they could report anonymously to an external body, she said. During the same period, ACGME resident survey reporting suggested that only 3% of programs were in violation.

“Only when we have external enforcement, beyond the ACGME, will we see true implementation of duty hours,” she added.

The AMSA co-petitioned OSHA based on what Lazreg described as overwhelming evidence that current schedules cause an increase in mood disorders, motor vehicle accidents, pregnancy complications and needle-stick injuries among residents. As the federal body tasked with ensuring employee safety and health, she said OSHA has a responsibility to intervene when evidence so strongly points to worker harm.

“OSHA’s denial translates into continued employee risk, injury and death,” Lazreg said.

With so much on the line, it’s unlikely that either side will give ground on this contentious issue any time soon. Notably, OSHA said it had received 15 letters in support of OSHA regulating resident hours and 26 letters in opposition.

 Where do you fit it? Let us know.

By Patrice Wendling

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TAVI Trek Begins

It took just two days after the Nov. 2 FDA approval of the Edwards SAPIEN transcatheter aortic valve for New York-Presbyterian Hospital/Columbia University Medical Center to claim bragging rights as the first center in the United States to implant the device as an FDA-approved standard of care.

The center will be one of four sites to train U.S. doctors in the procedure, and is promising to lead a live demonstration tomorrow (Nov. 9) at the annual Transcatheter Cardiovascular Therapeutics symposium in San Francisco for those eager to get a front row view of transcatheter aortic valve implantation (TAVI).

Courtesy Edwards Lifesciences

The FDA approval also put the U.S. in the rare position of following the footsteps of some 40 countries that have already approved the SAPIEN valve including Latvia, Iran, and Russia. This fact elicited a good laugh at the recent Heart Valve Summit 2011 in Chicago, but also prompted much dialogue about some of the thorny ethical and economical consequences that still lay ahead.

“Is anyone at the government talking about rationing of care?” asked Dr. Stephen Strelec, an anesthesiologist at University of Pennsylvania Medical Center, at the summit. It’s not just the 92-year-old who says “I want to live,” but the younger patient facing a valve procedure who decides they don’t want to be on anticoagulants and undergo surgery because they can afford this expensive new transcatheter valve in 2 years. “There’s an economic consequence to that decision as well,” he said.

Dr. Robert Bonow, director of the center for cardiovascular innovation at Northwestern, said the issue is being looked at by federal agencies and insurers, but added that it is “one of the biggest hot-button items about this whole technology because it’s not going to be cheap.”

Dr. David Adams, chair of cardiothoracic surgery at Mount Sinai Medical Center, said they’ve already had their share of 90-year-olds wheeled in from the nursing home by family members who read about TAVI in the newspaper and want mom to stay alive.

The suggestion was made that surgeons and interventional cardiologists will have to hone their skills in making the very specific diagnosis of medical futility, and that a board-certified palliative care physician will be one of the most valuable members of the multidisciplinary teams treating these patients.

“Every PARTNER site looking back over their patients can name patients that they wish they didn’t enroll in the trial and done the valve on,” said Dr. Howard Herrmann, director of interventional cardiology and cardiac catheterization at the Hospital of the University of Pennsylvania. “The question is how to recognize them up front.”

Edwards Lifesciences and the FDA are setting up an intensive training program with simulations, an expert review of cases and a proctoring system. Still, the challenge for Edwards and other companies that will follow will be enormous in terms of launching this technology outside the clinical trial setting, said Dr. Adams, co-principal investigator of Medtronic’s CoreValve trial.

“You can not overestimate the amount of company support you’re going to need to do these things safely,” he said. “This is not a new widget you can pick up in one or two tries like a new ring or new stent…It’s a whole new process.”

The European experience, albeit the initial experience, suggests there’s a distinct learning curve to TAVI. A meta-analysis of 12 TAVI trials presented at this summer’s European Society of Cardiology Congress, reported a flattening of mortality curves 8 years after the first human case in 2002, with procedural mortality decreasing from 16.7% in 2004 to 0.0-0.6% in 2010 and 30-day mortality plummeting from 67% to 11% over the same time period. The authors, led by Dr. Pablo Salinas, University Hospital La Paz, Madrid, credit technical improvements in the devices, better patient selection and on-site case proctoring as helping to shorten the learning curve.

—by Patrice Wendling

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Filed under Cardiovascular Medicine, Drug And Device Safety, Geriatric Medicine, Health Policy, Hospice and Palliative Care, Surgery, Thoracic Surgery

A.W.O.L. in the Hospital

Ask any new parent to part with her baby in the hospital for even a few moments and it’s likely to set in motion a mental high-speed, Guy Ritchie-like montage, complete with squealing tires, deranged abductors, and shadowy baby-sale rings. (Well, it did for me.)

When it comes to why children go A.W.O.L. in the hospital, however, researchers say we want to look a little closer to home.

It turns out that some parents are taking off the ID bands used to keep track of their child in the hospital.

Photos by Patrice Wendling

A learning collaborative of six hospitals found that the overwhelming (90%) reason for pediatric ID band failure was that the band was simply not in place. The most frequent reasons were that it fell off, was taken off by the parent or the patient, or was put on another object such as a crib,  Dr. Shannon Phillips and her co-authors reported at Pediatric Hospital Medicine 2011.

“A lot of times, the patients had been at the hospital for a long time and the parent would say ‘Everyone knows my child’or ‘I’m always here at the bedside,’ co-author Dr. Michele Saysana explained. “Many of the parents were taking [the ID band] off, but when we educated them on the importance of keeping the ID band on, they had a better understanding.”

In addition to family/patient education, the collaborative staged other interventions including educating front-line staff on the importance of correct ID bands as a safety strategy; conducting audits, often by night nursing administrators; and changing to softer ID bands, including luggage tag-type bands in some NICUs.

“In bigger systems with adults, you must have different bands,” said Dr. Saysana, who directs the pediatric hospitalist program at Riley Hospital for Children in Indianapolis. “The one-size-fits-all doesn’t work for the little guys.”

Dr. Michele Saysana

Post-intervention, the collaborative saw a 13% absolute reduction, corresponding to a 77% relative reduction, in pediatric band failures between September 2009 and September 2010. Their goal had been to reduce errors across the collaborative by 50% in 12 months.

The keys to sustaining this kind of success?

“The lessons learned are having leadership be involved, having continuous audits, and just doing education every time you catch something,” she said.

—Patrice Wendling

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