Secondary Logo

Emergentology: How Much Does ‘Never Ever’ Cost

Walker, Graham MD

doi: 10.1097/01.EEM.0000411486.99392.5d


If you've at all traveled by plane in the past five years, you know how draconian, Big Brotherish, and downright ridiculous security screenings have become. “Please take off your shoes and belt, have your liquids measured out ounce-by-ounce, and prepare for the diagnostic radiation!” is, I think, what they yelled out last time I boarded. (I personally prefer the opt-out protocol.)

But where did all this security theatre come from?

Never again!”

Never forget!”

Now 10 years out from 9/11, many of us have come to wonder, “Has all this screening done us any good?” I'm sure it's an unpatriotic question to ask, but at the same time, I get it, TSA. With Americans scared that their neighbor is a terrorist and clamorings that we should never, ever, under no circumstances let another 9/11 happen no matter what, what would you have the TSA do? Of course, they're going to be as secretive and drastic as possible. Of course, they're going to go overboard. They're not allowed to miss anything. Ever. Cross their heart and hope to die. With a cherry on top.

It's the same way I sometimes feel about evaluating disease in the ED (you knew there was a segue coming, didn't you?). Working in the uncertainty-based specialty in which we do, where it now almost feels like the standard is a zero-percent miss rate for MI, PE, or any other potentially life- or limb-threatening disease, can you blame an emergency physician for going overboard in the testing arena just like the TSA? For working up stuff that really just needs patient reassurance?

Because … what if? What if the 26-year-old with chest pain and a normal EKG ends up having an MI? What if the minor head injury patient ends up having a subdural? What if the kid with vomiting ends up having a perforated appendicitis?

We've all seen these cases. We've all gotten the “Hey, remember that patient…” line from our colleagues. But should we be basing our practice on them? And if we do more testing, can we miss fewer things? (Some evidence suggests no.) A zero miss rate is a lofty goal but at what cost?

I could very easily never miss a subdural. I would just scan every single patient who walked through the door with any complaint. “Ankle sprain? Maybe you hit your head, and you don't remember. Let's just make sure.” Now, for the person with the subdural that would have gone missed, this strategy would be great, but no one in his right mind would follow this algorithm. It would harm far too many more patients than it would help in any number of ways: unnecessary radiation, increased health care costs, mostly false-positive tests that then get further tests and interventions, or an overutilized CT scanner that would cause waits for other patients who need it.

Now take that hyperbole, muddy the water a bit, and you have today's medicolegal climate. How thorough is too thorough? How cautious is too cautious? How cavalier is too cavalier? Just because we can do the test in everyone, should we? (I believe the answer is no.)

Unfortunately, while we in the ED have trouble toeing the line of what defines an appropriate workup, our inpatient colleagues are already starting to deal with some clear boundaries of acceptable and unacceptable practice, known and set by Medicare as “never events.” I think they're perfectly suitable goals (events that should never happen), but just like our ED diagnostic conundrum, achieving that zero-point-zero-zero rate comes with some major costs. I worry we'll soon be seeing plenty of unintended consequences of trying to prevent:

  • Patient death associated with a fall while being cared for in a health care facility. Easy enough. Demented patients sundowning at night or agitated and confused patients? Just tie them down, and load them up on antipsychotics and benzos to keep them in their beds. No danger there. They definitely won't fall.
  • Surgical site infection following certain orthopedic procedures, bariatric surgery, or CABG. Piece of cake. Just give everyone amp/gent, meropenem, and flagyl before and after surgery. This will clearly have no impact on rates of C. difficile or on the development of local antibiotic resistance.
  • Catheter-associated urinary tract infection. Duh! Just let the incontinent patients who need strict Ins and Outs (or those with hip fractures) urinate on themselves!

Ironically, the reason emergency physicians struggle to define an “appropriate workup” is the same reason that these “never events” will never stop happening: variation, idiosyncrasy, human individuality, deviation from the mean. Each patient is unique, and each physician approaches each patient differently. My costochondritis might be your pleuritic chest pain. And similarly, different patients bring different risk factors to the table when we're faced with “never events.” Even on the best of days, at least one of the immunosuppressed cancer patients with a pathologic fracture is going to get a surgical infection. It's. Just. Going. To. Happen.

Our specialty should lead the medical field, and apply the same standard many of our pediatric colleagues have applied to ionizing radiation: as little as reasonably achievable (ALARA). It acknowledges that we simply can't — and shouldn't — hit zero percent, but that we should aim for it. We should have metrics to compare similar EDs and hospitals, and come up with a low range of miss rates and almost never event rates that we acknowledge as acceptable, given the consequences. And hospitals that have consistently low rates should be rewarded, and share their secrets with everyone else.

We owe it to our patients to always do our best. Put our best foot forward. (And I believe that we can always, always do better.) But even hinting at the word never in a system as complex as health care dooms you to failure. It'd be like outlawing Colles' fractures on the monkey bars: Yes, certainly, put padding on the ground, maybe lower the height a bit, but I don't care how soft the Tempur-Pedic below, some kid is going to find a way to break his arm. But we shouldn't outlaw monkey bars. How else would the pediatric orthopedists stay in business?

Click and Connect!Access the links in this article by reading it

Dr. Walker

Dr. Walker

Back to Top | Article Outline

In Brief

Louisiana CAH Achieves Stage 1 Criteria

Bunkie General Hospital, a 32-bed critical access hospital in Louisiana has met and attested to Stage 1 meaningful use criteria for Medicare and Medicaid. The hospital utilized CMR, an emergency department information system, version 3.3, which is certified by the U.S. Office of the National Coordinator-Authorized Testing and Certification Body.

Bunkie consequently received more than $800,000 in incentive payments. “We have been using CMR since April of 2007,” said Linda Deville, CEO of Bunkie General Hospital. “Achieving Stage 1 meaningful use is vital to our success.”

© 2012 Lippincott Williams & Wilkins, Inc.