Hospitals Need to Test More for Diabetes

Hospitals are being urged to test people for diabetes while in the hospital. Patients with high blood sugar and no known history of diabetes were five times more likely to leave the hospital with a diagnosis if given a standard test. Researchers say the high rate of hospital patients with high blood sugar diagnosed with diabetes who had no known history of the condition suggests increased screening is necessary to catch these patients.

Researchers at Touro University and Ohio University found a high rate of missed diabetes diagnoses were caught in the hospital, which they say suggests changes to hospital protocol and increased screening for the condition is necessary. The HbA1C test is used to measure average blood glucose level over the previous 8 to 12 weeks (The test actually measures blood glucose levels for the previous 16 weeks or four months). Often, it detects hyperglycemia, or high blood sugar, which can be ascribed to physiologic stress, illness or medications.

Hyperglycemia is often detected in hospital patients during treatment for conditions such as sepsis or heart attack, and the recent study showing a high proportion of these patients having diabetes or prediabetes suggests there is more doctors can do.

Dr. Jay Shubrook, a researcher at Touro University California, in a press release said, "We are missing opportunities to detect diabetes and initiate treatment for those patients to help manage that disease, which can reduce their long-term cost of care and disease burden."

For the study, published in the Journal of the American Osteopathic Association, the researchers reviewed medical records for 348 hospital patients with hyperglycemia in the hospital.

"From the osteopathic perspective of early detection equals better outcomes, it's easy to make a case for hospital protocols to trigger an HbA1C test when hyperglycemia is detected to distinguish between transient hyperglycemia and chronic disease," Shubrook said.

Pilot Program on Food-Insulin Gap Helpful

This is great news and I hope hospitals are paying attention. Two articles on the same topic – here and here. Again communication is the key and this is often lacking across hospital departments as they think (more like don't) the other department is on top of things. It is surprising what a little cooperation does for the health of patients with diabetes. If you, as the patient, have been allowed to manage your own diabetes, then this study will not benefit you.

This also brings up an idea for another study while thinking about studies. I would like to see a study where the patients that are capable, emphasis on capable, are allowed to manage their own diabetes while in the hospital. Some hospital kitchens are capable of providing a list of the foods on the tray and the carb count of each food item. This would allow those on oral medications to medicate accordingly and those patients on insulin would be able to inject appropriately. This study could be done in hospitals that have an endocrinology department with specialists in diabetes employed by the hospital or attached to the hospital. I dare say that the patients would be more satisfied and not under the stress normally felt when the blood glucose is allowed to run above 180 mg/dl to 220 mg/dl that most hospitals allow.

Back to the study. Dr. Dace Trence, who was not involved in the study, carefully pointed out, “Hospitals may be motivated to do so because they could face penalties from Medicare if they do not. Hyperglycemia in the hospital is now a [national hospital inpatient quality measure], so you can imagine how important it is to try not only to prevent hypoglycemia, but also hyperglycemia."

Considering Dr. Trence's statement adds value to this study and may make hospitals consider this necessary. Shwetha Mallikarjuna, MD, an endocrinology fellow at Southern Illinois University (SIU), Springfield, presented the study at the American Association of Clinical Endocrinologists 2013 Scientific & Clinical Congress in Phoenix.

Often it is the simple interventions are the best medicine, like telling floor nurses that meals are on the way so they can coordinate insulin dosing for hospitalized diabetics.  The study demonstrated that patients received prandial insulin on time with significantly greater frequency when food service and nurses coordinated care (50.4% versus 35.5%). When patients are forced to let hospitals dictate when insulin is injected, the idea of injecting after a meal is a common practice and when a nurse can count carbs and know how many units to inject; this will help prevent a hypoglycemic episode. This is good for the patient and the hospital.

Mallikarjuna did note that their study was limited by a low sample size and low power. She said the study was also limited by poor patient matching. She said that a larger follow-up study is ongoing.

I see a few positives from this study and the potential for good being part of the penalty system being put in place by the Centers for Medicare and Medicaid Services. How much this will benefit patients still is to be determined.

A Guide for Hospital Discharge Planning

I could not have ended this year with a better topic. Hospital discharge planning is not something to be ignored, but often it is, much to the detriment of the patient and their safety after being discharged. Therefore, if you are expecting to have this happen to you, or you are a caregiver for someone being discharged from a hospital, take time to read this and I mean really digest the contents. Then you can print out a copy to have with you to remind you of important points.

Not all hospitals are equal and some do very good at discharging patients. It is the hospitals that are not doing things properly that need to be challenged. The high points of this guide are:

1. What is discharge planning?

2. Why is good discharge planning so important?

3. The caregiver's role in the discharge process

4. Getting help at home

5. Discharge to a facility

6. Paying for care after discharge

7. What if you feel it's too early for discharge?

8. Improving the system

9. Conclusion

Below the conclusion is some information for caregivers. Some may seem overkill, but to make this adaptable for many people, this section needs to be large.

The other website that is so important is this one - http://www.nextstepincare.org./

Do not allow hospitals to discharge you without knowing your rights and procedures that hospitals need to follow to see that you receive the proper care after discharge.

Think Your Hospital Is Looking Out for You?

If you think when you are in the hospital that the hospital is looking out for you, you are in the minority. Day after day, we see news of people that have stories to tell that are not showing hospitals in a good light. We hear of friends or relatives of friends that have died because of medication errors, errors in medical judgment, and errors in operations performed on the wrong patient. It will soon be apparent to even the most careful of patients that they will need a patient advocate if they are to be admitted to a hospital.

Even then, patient advocates will have a difficult time. Hospitals do not like patient advocates and do their best to work around them or even conceal what is happening. Yes, several decades ago, there were accidents and errors, but not at the ratio of today. We had doctors that spent time with patients and checked in regularly. We had nurses that knew what to do and communicated with the patient’s doctor(s) and the patients. They would alert doctors of changes in a patient's condition and test results.

Then came larger hospitals and more lawsuits. To protect their profit margin, nurses were marginalized, doctors restricted in their duties by the hospitals. Patients in the hospitals are being seen less often and not by their own physician. Is it any wonder there are more errors and improper medications given? Allergies are not checked and communications are limited.

This article in a Diabetic Connect newsletter says a lot and lays out many of the problems we encounter as people with diabetes. This from the article needs to be quoted, “The problem with hospitals is that they standardize care much more than they individualize care. This is due in large part to the huge volume of patients they service, and the need for general protocols. General protocols, however, do not work all the time for patients with diabetes. If you have never used insulin and the plan is to give you insulin in the hospital, work with your health care team to understand what to expect. I would advise family members to carry blood glucose meters with them and have them available for a quick check if necessary so that you can alert the hospital of a potential problem with high or low blood sugars.”

These general protocols can make it impossible to manage blood glucose levels in the range that you are accustomed to. Most hospitals do not want you to use your pump if you use one. They even discourage continuous glucose monitors. Occasionally you will find a hospital that will allow the patient to manage their diabetes while in the hospital, but this is rare and must be decided upon before admission. I would even suggest getting it in writing.

Another issue the article raises that I can appreciate is some hospitals are giving rapid-acting insulin after a meal. This surprisingly allows the patient to not eat the food that you will be served and/or eat what you think will be sufficient for your needs. Then the amount of insulin can be adjusted for the food eaten. Most hospital food is not very enticing and is loaded with carbohydrates. This is because of the dietitian mandate that people with diabetes should have 60 grams of carbohydrates at every meal.

I do appreciate the author's comment and I quote, “I do not in any way want this to scare you, but rather to encourage you to be an active participant in your healthcare. Any and all family members and loved ones should be involved as well.”

Hospitals need to learn how to treat people with diabetes. This will mean every family member will need to be on board and maybe even a diabetes patient advocate. If the patient is going to be incapable for any period of time and a family member is unable to be present, even a medical power of attorney will get their attention as long as the persons present are listed on the document. Even then, many hospitals will try to circumvent this document.

If you are the patient, make sure that you dot all “I's” and cross all “T's” and that your wishes are known, if possible, before admission to the hospital. Remember that the hospital protocols may not be in your best interests for diabetes management. Hospitals have protocols that are in their interest to protect their profit margin and prevent lawsuits.

Hospitals Now Are More Monopolistic

Medical practice is nearing a crossroad and not the road everyone is talking about. This is the legal mess of monopolistic medicine that many patients are starting to wonder if this is in their best interest. While it is true that we will continue to need hospitals, the size and dictatorial power they will possess may not be in the best interest of medicine. A hospital monopoly combined with the insatiable appetite for profits may create problems in patient care with too many patients being ignored and euthanized to preserve the almighty profit.

Hospital CEOs will demand higher and higher salaries and bonuses and as such, it will become second nature to end life for patients needing care that is more expensive. This drain of financial expenditures will be unacceptable for these hospitals and we know what this will mean for the patient. If you want an example, read this article of what is being allowed in Britain. Follow the link provided for the chilling details. Don't wonder how or if this will happen in the USA, but be concerned about when.

Under the Patient Protection and Affordable Care Act (ACA), the rising cost of medical care will become a priority and euthanasia will become a fact of everyday cost cutting.  When the ACA was first enacted, it was thought that physicians and hospital accountable care organizations (ACOs) would be approximately proportionate. I don't think the early prognosticators had counted on hospitals having almost the entire lock on ACOs. It is now speculated (unfortunately no official studies) that doctors were not creative enough and lacked leadership skills to organize ACOs. Hospitals were willing to seize the opportunity and take advantage of doctor indecision to hire a majority of doctors. Hospitals thereby garnered most doctors leaving too few capable of forming ACOs.

Up until June 28, 2012, there was more speculation than fact about what would happen to ACOs, but now we know which way the arrow is pointing. I suspect there will be many lawsuits trying to break the monopolies that hospitals will be creating. We have seen hospitals also merging and becoming larger and larger. Size and scale will create some savings, but not enough to make up for the increase in expenses and inefficiencies generated by bloated overhead and massive referrals internally.

In addition to the mandate to cut expenses (creating more euthanasia), we will soon see the medical insurance industry supporting euthanasia as a method of keeping their profits on the rise. These two profit minded organizations will be able to eliminate many costs but supporting each other and still have the financial ability to fight the lawsuits bound to happen for unwarranted euthanasia.

A study that is going to create some controversy around the country is this one. I am seeing some of this in my own community and surrounding communities and if people could read about this study, many might not be so happy. Yes, there is some need in Iowa's rural communities for better medical care, but are we really obtaining it. In many cases, much of this may go unnoticed because to the protection that is being given ACOs from antitrust and other benefits. The current administration is promoting the formation of ACOs and shielding them from antitrust laws.

The further I get into some of the new law and the discussions, blogs, and articles that I read, the more I have some real concerns about the impending abuse and fraud that will accompany the Accountable Care Organizations. I am now even more concerned because of the Supreme Courts action.

Because of all the concern being raised, we will have of course more abuse and fraud as the different departments, the Department of Human and Health Services, the Federal Trade Commission, and the Department of Justice, under the direction of the White House, have been and will be granting more waivers, safety zones, and guidance to providers.

It is unclear if the law, the Affordable Care Act provides for waivers and the legality of these waivers. An ACO, as defined by ACA, is an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare patients for whom they provide the bulk of primary care services. With hospitals having all but eliminated private medical practice in some areas of the country, they will continue their efforts in the rest of the country.

Although I have seen no discussions yet on the independence of the different medical associations, if a majority of doctors are hospital employees, does it not seem reasonable that the hospitals will soon be making their agenda felt in the medical associations. I think we have seen this in the quick response of the American Diabetes Association to the Supreme Court decision.

I have pulled many different areas together for this blog. I am working on more now that the Supreme Court has ended the ambiguity.

Nursing Shortages – Oh Really?

Nursing shortage seems like another myth. In some areas of the USA, this is true. In other areas, there is an honest shortage, but it may not last long. What are some of the factors affecting the field of nursing? There are some obvious answers and some almost obscure answers.

Two of the most telling answers are one; older nurses are not retiring because of the economy and may well have a spouse without a job. The second and more frightening answer is hospitals are just not replacing nurses as they leave. Why you might ask? The reduction in profits is largely to blame and increases in hospital administrator salaries are adding to this pressure.

Although many hospitals have positions for nurse aids, more hospitals are adding them in place of nurses. This will increase the workload for remaining nurses, but the hospitals are striving to keep profits increasing. How are the hospitals determining this? They have people patrolling the floors of the hospitals, counting patients, watching nurse activities and other variables. These people report to the administration about their observations.

This may sound cruel, but many nurses have brought this on themselves by their actions or maybe I should say lack of doing their duties. I have been in a few hospitals and actually seen this and wondered how the hospital could make money with the nurses sitting around the nursing station. In one visit to a friend, the five hours I was there they sat and never made rounds. Call buzzers would go off and still they did not move. They would send an aid to check and only leave the nurse's station if it was something urgent. The patient I was visiting needed a shot every four hours, but while I was visiting, no shots were given.

Even a trip to the nurse station did not get a shot. In this case, I called the doctor and explained what had happened. The doctor said he would be there in a few minutes and he was. He came in an entrance away from the nurse's station and came directly to the room. He checked the chart and asked how long I had been there. Next, he headed to the dispensary to get the medication for the shot and the syringe. He asked why his patient had not been given a shot on time. The answer was it was not listed on the patient file. He came to the room, gave the shot, and then went back to the station with the patients chart in his hand.

I don't know more as visiting hours were over and the nurses were checking every room and making sure all visitors were leaving. The whole time I had been there, no rounds had been made by the nurses, but the aids had come and gone rather regularly. From what I observed, the five nurses had a gab fest the whole time and I don't think four had gone anywhere except to use the ladies' room and one to the cafeteria to bring back food for all.

In another hospital, I knew there were very few patients on that level, but the nurses were constantly checking rooms and I very seldom heard a call bell (or buzzer) sounding. About every 15 to 20 minutes, a nurse would be in to check on my wife, checking pulse and blood pressure and moistening her lips with water on a cloth. When shift time came, one of the day nurses stayed and two others reported in plus a couple of aids. Even they were making rounds and checking on the few patients. A very clear contrast when compared to my visit to a friend.

From the second article, this seems to be the case I have described above and varies from hospital to hospital. Some nurses are extremely busy and at some hospitals, it is difficult to see nurses at work. Even patients are complaining at these hospitals. Although this is seldom talked about, hospitals that have strong unions are where the most complaints originate. Others say it depends on the strength of the director of nursing. And, it may be a combination of these.

Either way there are several scenarios that may play out in the next few years. I disagree with the scenarios discussed in this blog, but he may be right as he is an insider and I am a patient. I suspect there will not be an oversupply of nurses because many will leave for employment that is more lucrative. Hospitals will work diligently to reduce the nursing staff and replace many with nurse aids to reduce labor costs and at the same time bring in pharmacists to administer medications and manage inhouse pharmacies. Unions will be either forced out or greatly weakened all as a means of increasing profits.

Watch What Hospitals Do With MRSA

This is not unexpected. What was called MRSA for infections acquired by patients while in the hospital has now been termed HAIs (hospital acquired infections). I like the title given to the article in Medscape, “Medicare Reimbursement Change Spurs Prevention, Work-Arounds.” Work-arounds is what we can expect from hospitals so that they will be reimbursed for something Medicare has deemed non-reimbursable.

Approximately half of the hospitals participating in a report published in the May issue of the American Journal of Infection Control increased their attention of how such infections (HAIs) were coded for billing. Instead of doing increasing measurers to prevent HAIs, coding for other billable infections was where they paid attention. It is no wonder that people are concerned about hospital safety since the hospitals care only about the profits they can accumulate.

I quote from the article, “"Our findings were generally positive, suggesting the policies have led not only to an enhanced focus on targeted HAIs with greater efforts toward surveillance and education but also to changes in practice from front-line staff as reported by infection preventionists," the authors write.

However, the results also include persuasive evidence of hospitals "gaming the system," according to Peter Pronovost, MD, PhD, director of the Armstrong Institute for Patient Safety and Quality and Johns Hopkins Medicine Senior Vice President for Patient Safety and Quality, Baltimore, Maryland.”

It is disturbing as a patient to see statements like “gaming the system.” This means that the coding is apparently working for them to obtain reimbursements they would otherwise be denied by Medicare. Read the article here.

I will now get into another even more disturbing aspect that this causing. I had intended on writing about this from another perspective. However, this does explain why the hospitals have through the American Hospital Association, sent a formal letter to the Centers for Medicare and Medicaid Services asking that delays be granted in meeting the “Meaningful Use” criteria that is scheduled to begin later this year.

The “Meaningful Use” came into existence as apart of a government program (the American Recovery and Reinvestment Act of 2009 (ARRA)) in which billions of dollars were set aside to aid medical providers shift from paper records to electronic records. When the providers could prove they had reached certain stages of meaningful use, they would receive reimbursement from the government to cover the expense of implementation.

During stage one of meaningful use providers needed to demonstrate that an interface was in place so patients could access their own medical records, via the internet, securely and privately. For hospitals, that access needed to be provided within four days of a patient's discharge. Read the AHA communication here in a PDF file. (Adobe Reader required)

Now that it is almost ready for stage two (starts Jan 2013), patients have asked for quicker access, meaning within at least 24 hours for theirs, their spouses, or their childrens records. We want to know what took happened, with whom, and how it happened. This is important if post discharge problems occur and we want to discern where the problems may have arisen from and who may be responsible. However, the American Hospital Association if attempting to delay these provisions and has asked for a 30 day limit for patient access. The AHA also wants three years to each stage instead of the two years currently mandated.

Fortunately, it is easy to figure out why they want the 30 day window. They want the extra time to “doctor” the records to “game the system”, prevent things from being available to the patients, and thus their lawyers, for events that should have been reported, but weren't. They need time to hide these and more. Yes, the hospitals are nefarious for misdirection and covering up what should have been reported. This is why when you are hospitalized, if you are able, record everything, or have another family member record what they observe. Hospitals count on this not happening because they know most patients do not have this mind-set.

Hospitals also need the time to recode and balance bill. They are sure to increase a number here and there for items seldom, if ever counted. Hospitals also have become adept at changing a coding number to get more money than should be charged. Therefore, if they deliver the records to you as soon as you are discharged, they will not have time to make all the changes they want. Plus an event that needs to be hidden may be in plain site. If by chance, the AHA request for 30 days is denied, you may end up in the hospital for a day or two more than normal while they adjust your records. Excuses for additional time in the hospital can be easily fabricated. Remember, the profit margin needs to be met for each patient as well as preventing future problems from your records.

Read the article here by Trisha Torrey. Then follow the links provided by here to others that are pointing out problems. I must also encourage you to read this blog from The Health Care Blog. This also takes you to other blogs that you should read.  Carefully follow the link to the letter from Trisha's blog.  I admit I cannot get it to work for me otherwise.

If you do not follow Regina Holliday, she has a lot to say about the current disaster in our hospitals and obtaining the medical records for her deceased husband. Her situation should make you desire to take action. Read these three blogs by Regina, one, two, and three.

If it takes some time to read all this, then you should have had time to consider your course of action. I have sent my emails to my congressional people.

Most Adverse Events in Hospitals Go Unreported

I am not sure how to react to this report. Yes, I believe the study and I am surprised it is not more of a horror story. Having experienced a few incidents first hand which I doubt were reported, anything is possible. Some hospitals are indeed better than others are, but I believe this comes from the top down. If the head of the hospital is conscientious and concerned, generally he will employ physicians and nursing staff that are concerned. Anyone can hire a bad apple, but it is the hospital administrator that sets the tone. In some cases, it is the hospital board of directors that establishes the standards.

The study reports that about 86 percent of patient mishaps in hospitals go unreported and are not entered into any incident database. Whether better reporting will improve the quality of care or patient safety remains to be seen. A big surprise in a way is that 62 percent of adverse and “temporary harm” events that were not reported were believed not reportable by hospital staff.

The Office of Inspector General (OIG) in the US Department of Health and Human Services (HHS) recommends that the Centers for Medicare and Medicaid Services (CMS) collaborate with the federal Agency for Healthcare Research and Quality and develop a master list of potentially reportable events. Then hospitals and other healthcare providers could use this list to eliminate any confusion. Presently, the three organizations that accredit hospitals - the Joint Commission, the American Osteopathic Association, and Det Norske Veritas Healthcare — do not have standardized lists of reportable patient incidents.

I seriously wonder if there will be any changes made, as you have to think that hospitals will continue on the present path. If nothing more than to minimize lawsuits, they will resist reporting adverse events. With hospitals now employing many doctors, they will continue to be profit motivated to a fault and to avoid legal problems. Nurses will continue to be dismissed when they do their job and counsel patients to the detriment of potential profits.

You may read the study here and the situation about the nurse here.

Hospital and Medical Mismanagement of Diabetes

Some people with diabetes are being medically mismanaged while in the hospitals in the USA. Why? Because of lack of diabetes education by the hospital staff and outdated hospital management rules for diabetes. Scott Johnson posted an excellent example of this on his blog scottsdiabetes and you should take time to read it now. Some of the comments also bring out some of the problems faced by people with diabetes in the hospital setting.

Disturbing? Most definitely! Why is this happening? In addition to the above reason, patients also need to shoulder some of the blame. Most are not aware that there are patients' rights that must be adhered to by hospitals and many hospitals ignore these rights and enforce their own rules and regulations which most often are not in favor of the patient and the patients' rights. When the day comes that these hospitals are sued for patient neglect and failure to serve the patients and their rights, then maybe, just maybe, some of these highhanded hospitals will get the wake-up call they so desperately deserve.

When I wrote about this back on July 19, 2010, I had not anticipated the extent of medical malpractice that exists in some of our hospitals when dealing with patients with diabetes – and not just those with Type 1 diabetes. Fortunately, not all hospitals are this bad, and some are very accommodating to people with diabetes. Therefore, if at all possible, you need to do your homework before entering the hospital yourself or if a family member or relative with diabetes enters a hospital.

Learn from the experience of others like Scott Johnson writes about. Then talk to your doctors, preferable you should have an endocrinologist, but many people do not. Learn about your patient rights by reading this and related articles this article refers to. Make sure that you ask your doctor for a "self-management order," a document that will permit you to take care of your own testing and diabetes management if you are capable during your stay in the hospital.

If you know when you are entering the hospital, be sure that the hospital will accept the self-management order and that you are capable of using your own testing supplies and medications. I urge you to take time to read my previous blog above as there are some important points in it.

Now is also an excellent time to determine if you have a family member(s) or a trusted friend(s) that will be able to advocate for you if you are admitted to the hospital under emergency circumstances and make them aware of your needs and the paperwork they need to have available. This would include a limited medical power of attorney, a self-management order when you become capable of managing your own care. Do not leave this step unattended to as you cannot know when an emergency will arise.

A little planning now can actually get you better care when you desperately need it. Do not wait for mistakes and mismanagement of your health care to happen when in a hospital, it can and does happen more than we would like. Take time to read the referenced articles and blogs above to avoid many of the problems. Get the necessary paperwork completed and copies available to those that may need it!

I realize that many people will still not have taken these steps to assure their hospital stay is handled properly and I sincerely hope that I will not continue to read many more of these disturbing problems for others with diabetes that happen while in the hospital.