The headline and the details, where the devil can be found
On June 23, 2017, CBS News ran a story about the Los Angeles VA Hospital. The headline read:
"A new report by the VA inspector general shows 43 percent of the 225 patients who died between October 2014 and August 2015 at the Los Angeles VA were waiting for appointments or needed tests they never got. However, the report does not conclude these patients "died as a result of delayed consults."
If you click the link within that excerpt you are taken to the actual report from the Inspector General. I'm still reading it, but one particular section leapt off the page at me:
"For the period October 1, 2014 through August 9, 2015, we identified 225 deceased patients who had 371 open or pending consults at the time of their deaths or had discontinued consults after their deaths.
Of the 225 patients, we found 117 patients with 158 consults experienced delays in obtaining requested consults. We substantiated that 43 percent (158/371) of consults were not timely because providers and scheduling staff did not consistently follow consult policy or procedures.
We did not substantiate the allegation that patients experienced serious or severe impact with long-term consequences or organ dysfunctions or that patients died as a result of delayed consults. However, we identified two patients who experienced intermediate impact (Patient 1) or minor impact (Patient 2)."
So in only two instances was there an impact on a patient due to a delayed consult. Let's extract the two instances from that report.
* * *
Patient 1 experienced intermediate clinical impact (Level 3) from a delayed cardiothoracic (CT) surgery consult.
The patient was in his 70s with a history of valvular heart disease, heart failure, and an abnormal heart rhythm at the time of his death. In 2014, the patient was seen by a cardiologist who ordered a routine outpatient CT surgery consult for heart valve replacement.21
The patient was admitted to the facility a few weeks later to expedite the preoperative evaluation needed for heart valve surgery. During the admission, the cardiologist noted “CT surgery consulted prior. Needs [valve repair] workup.” We reviewed the EHR Consult Management Concerns, VA Greater Los Angeles Healthcare System, Los Angeles, CA dating back to 1996 and did not find any CT surgery notes regarding a valve repair. As part of the preoperative evaluation, the patient underwent a heart catheterization and was found to have coronary artery disease. He was discharge with a dental appointment to evaluation for infections that might adversely effect his surgical outcome.
After the patient failed to show for his dental appointment, dental staff made three unsuccessful attempts to reschedule his appointment. A week after the scheduled dental appointment, the patient presented to a non-VA hospital with “massive leg swelling” and was admitted for myocardial infarction (heart attack) with kidney and heart failure. Less than 12 hours after admission, he died of cardiogenic shock23 presumed to be related to a massive myocardial infarction. Facility staff did not take action on the CT surgery consult for more than 4 months, when they discontinued the consult because the patient had died.
We determined that the patient experienced an intermediate clinical impact (Level 3) from not receiving a CT surgery evaluation. The patient’s advanced age and comorbidities (coronary artery disease and an abnormal heart rhythm), increased his risk for heart failure, a known complication of valvular disease. While the EHR did not have documentation from a CT surgeon, the cardiologist had been coordinating the patient’s preoperative evaluation in preparation for a heart valve replacement. Timely consultation by a CT surgeon would not likely have prevented his death because he was receiving appropriate care from the cardiologist.
* * *
Patient 2 experienced minor or self-limited impact (Level 2) due to delayed nephrology and cardiomyopathy consults.
Nephrology Consult
The patient was in his late 60s with a history of diabetes, hypertension, heart failure, and chronic kidney disease requiring several months of dialysis in 2014 (month 1), which he received at a non-VA facility. After completion of dialysis treatments, he was seen by the VA nephrology (kidney) clinic, with a plan to follow up in 4–6 weeks. In month 10, the patient was admitted to the facility for heart failure with worsening kidney disease. In month 11, his PCP ordered laboratory tests and a routine outpatient nephrology consult to help determine the cause of the chronic kidney disease. Clinic staff approved the consult for an appointment in 3–4 weeks noting that the patient had not been followed up by nephrology clinic since a month 4 appointment. The scheduler made an appointment for month 13 after multiple scheduling attempts.
Cardiomyopathy Consult
Prior to the patient’s discharge home from his month 10 hospitalization, the hospitalist requested a routine outpatient cardiomyopathy (heart failure) clinic24 consult. The patient did not attend a scheduled month 11 appointment, so the scheduler made another appointment for the next month (month 12).
Before the scheduled appointment in month 12, a physician’s assistant in the cardiology clinic saw the patient for worsening heart failure and sent him to the ED. The ED physician treated the patient for heart failure and discharged him home with instructions to follow up with cardiology the following week. The patient did not attend the cardiomyopathy appointment but presented to a non-VA facility 2 days after the missed appointment with massive leg swelling and shortness of breath.
His kidney function had worsened but was without signs of kidney failure as indicated by normal electrolytes. He was diagnosed with heart failure and underwent dialysis to remove fluid but not electrolytes. On hospital day 3, he developed worsening shortness of breath that progressed to cardiac arrest, and died of presumed myocardial infarction. An autopsy was not performed.
We determined that the patient experienced minor clinical impact (Level 2) as a result of the delayed nephrology and cardiomyopathy consults. The patient had severe multi-organ disease. However, had the patient received the nephrology consult timely, physicians would not likely have performed any interventions as he had no signs of kidney failure. The goal of the cardiomyopathy clinic was to encourage treatment adherence, and the patient had a history of poor attendance at his cardiology appointments, including “no show” to a heart failure consultation in month 9.
* * *
So in only two of the "43% of deaths" was there any connection to the failure to receive treatment and the cause of death, according to the report being cited by the news story. In both cases, the patient missed appointments.
I hate going to the VA, or any hospital for that matter. That mindset is because I spent an entire year inside of a hospital. I sometimes rationalize my way to missing and/or rescheduling appointments. It is a habit I need to break.
Two is still two too many cases where treatment being delayed is at least partially the fault of the care provider. But the real story is not being told by the media.
Nearly 100 patients died waiting for care from Los Angeles VA
That will get your attention, especially if you're like me and get your healthcare at that very facility. Here is an excerpt from the story:"A new report by the VA inspector general shows 43 percent of the 225 patients who died between October 2014 and August 2015 at the Los Angeles VA were waiting for appointments or needed tests they never got. However, the report does not conclude these patients "died as a result of delayed consults."
If you click the link within that excerpt you are taken to the actual report from the Inspector General. I'm still reading it, but one particular section leapt off the page at me:
"For the period October 1, 2014 through August 9, 2015, we identified 225 deceased patients who had 371 open or pending consults at the time of their deaths or had discontinued consults after their deaths.
Of the 225 patients, we found 117 patients with 158 consults experienced delays in obtaining requested consults. We substantiated that 43 percent (158/371) of consults were not timely because providers and scheduling staff did not consistently follow consult policy or procedures.
We did not substantiate the allegation that patients experienced serious or severe impact with long-term consequences or organ dysfunctions or that patients died as a result of delayed consults. However, we identified two patients who experienced intermediate impact (Patient 1) or minor impact (Patient 2)."
So in only two instances was there an impact on a patient due to a delayed consult. Let's extract the two instances from that report.
* * *
Patient 1 experienced intermediate clinical impact (Level 3) from a delayed cardiothoracic (CT) surgery consult.
The patient was in his 70s with a history of valvular heart disease, heart failure, and an abnormal heart rhythm at the time of his death. In 2014, the patient was seen by a cardiologist who ordered a routine outpatient CT surgery consult for heart valve replacement.21
The patient was admitted to the facility a few weeks later to expedite the preoperative evaluation needed for heart valve surgery. During the admission, the cardiologist noted “CT surgery consulted prior. Needs [valve repair] workup.” We reviewed the EHR Consult Management Concerns, VA Greater Los Angeles Healthcare System, Los Angeles, CA dating back to 1996 and did not find any CT surgery notes regarding a valve repair. As part of the preoperative evaluation, the patient underwent a heart catheterization and was found to have coronary artery disease. He was discharge with a dental appointment to evaluation for infections that might adversely effect his surgical outcome.
After the patient failed to show for his dental appointment, dental staff made three unsuccessful attempts to reschedule his appointment. A week after the scheduled dental appointment, the patient presented to a non-VA hospital with “massive leg swelling” and was admitted for myocardial infarction (heart attack) with kidney and heart failure. Less than 12 hours after admission, he died of cardiogenic shock23 presumed to be related to a massive myocardial infarction. Facility staff did not take action on the CT surgery consult for more than 4 months, when they discontinued the consult because the patient had died.
We determined that the patient experienced an intermediate clinical impact (Level 3) from not receiving a CT surgery evaluation. The patient’s advanced age and comorbidities (coronary artery disease and an abnormal heart rhythm), increased his risk for heart failure, a known complication of valvular disease. While the EHR did not have documentation from a CT surgeon, the cardiologist had been coordinating the patient’s preoperative evaluation in preparation for a heart valve replacement. Timely consultation by a CT surgeon would not likely have prevented his death because he was receiving appropriate care from the cardiologist.
* * *
Patient 2 experienced minor or self-limited impact (Level 2) due to delayed nephrology and cardiomyopathy consults.
Nephrology Consult
The patient was in his late 60s with a history of diabetes, hypertension, heart failure, and chronic kidney disease requiring several months of dialysis in 2014 (month 1), which he received at a non-VA facility. After completion of dialysis treatments, he was seen by the VA nephrology (kidney) clinic, with a plan to follow up in 4–6 weeks. In month 10, the patient was admitted to the facility for heart failure with worsening kidney disease. In month 11, his PCP ordered laboratory tests and a routine outpatient nephrology consult to help determine the cause of the chronic kidney disease. Clinic staff approved the consult for an appointment in 3–4 weeks noting that the patient had not been followed up by nephrology clinic since a month 4 appointment. The scheduler made an appointment for month 13 after multiple scheduling attempts.
Cardiomyopathy Consult
Prior to the patient’s discharge home from his month 10 hospitalization, the hospitalist requested a routine outpatient cardiomyopathy (heart failure) clinic24 consult. The patient did not attend a scheduled month 11 appointment, so the scheduler made another appointment for the next month (month 12).
Before the scheduled appointment in month 12, a physician’s assistant in the cardiology clinic saw the patient for worsening heart failure and sent him to the ED. The ED physician treated the patient for heart failure and discharged him home with instructions to follow up with cardiology the following week. The patient did not attend the cardiomyopathy appointment but presented to a non-VA facility 2 days after the missed appointment with massive leg swelling and shortness of breath.
His kidney function had worsened but was without signs of kidney failure as indicated by normal electrolytes. He was diagnosed with heart failure and underwent dialysis to remove fluid but not electrolytes. On hospital day 3, he developed worsening shortness of breath that progressed to cardiac arrest, and died of presumed myocardial infarction. An autopsy was not performed.
We determined that the patient experienced minor clinical impact (Level 2) as a result of the delayed nephrology and cardiomyopathy consults. The patient had severe multi-organ disease. However, had the patient received the nephrology consult timely, physicians would not likely have performed any interventions as he had no signs of kidney failure. The goal of the cardiomyopathy clinic was to encourage treatment adherence, and the patient had a history of poor attendance at his cardiology appointments, including “no show” to a heart failure consultation in month 9.
* * *
So in only two of the "43% of deaths" was there any connection to the failure to receive treatment and the cause of death, according to the report being cited by the news story. In both cases, the patient missed appointments.
I hate going to the VA, or any hospital for that matter. That mindset is because I spent an entire year inside of a hospital. I sometimes rationalize my way to missing and/or rescheduling appointments. It is a habit I need to break.
Two is still two too many cases where treatment being delayed is at least partially the fault of the care provider. But the real story is not being told by the media.
posted by me at 12:31 PM
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